Anthony Spirito

The Children's Depression Inventory: A Systematic Evaluation of Psychometric Properties.

Community Mental Health Center, Yorkville, New YorkThis article presents data from a series of studies designed to determine thepsychometric properties of the Childrens Depression Inventory (GDI). A total of294 school children and 269 children who were psychiatric inpatients served assubjects. Reliability studies were conducted with both normal and clinicalpopulations. Good internal consistency was documented, but test-retest data werevariable across populations and test-retest intervals. Validity studies indicate thatthe GDI can distinguish children with general emotional distress from normalschool children. However, differences between GDI scores of depressed (bysymptom checklists from the Diagnostic and Statistical Manual of MentalDisorders, DSM-1II; American Psychiatric Association, 1980) and nondepressedchildren were not significantly different. There was a good correspondencebetween the GDI and self-report measures of self-concept. Our data suggestedthat the GDI measures a multidimensional construct that overlaps with otherchildhood disorders, particularly anxiety. Findings are reviewed and discussedrelative to data presented by Kovacs, Kazdin, and others. Although the GDI maystill be the best researched instrument available to measure depression from thechilds viewpoint, more work is needed before it can be interpreted withconfidence in clinical and research settings.

Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department.

This study evaluated the use of a brief motivational interview (MI) to reduce alcohol-related consequences and use among adolescents treated in an emergency room (ER) following an alcohol-related event. Patients aged 18 to 19 years (N = 94) were randomly assigned to receive either MI or standard care (SC). Assessment and intervention were conducted in the ER during or after the patients treatment. Follow-up assessments showed that patients who received the MI had a significantly lower incidence of drinking and driving, traffic violations, alcohol-related injuries, and alcohol-related problems than patients who received SC. Both conditions showed reduced alcohol consumption. The harm-reduction focus of the MI was evident in that MI reduced negative outcomes related to drinking, beyond what was produced by the precipitating event plus SC alone.

Sleep habits and sleep disturbance in elementary school-aged children.

&NA; Relatively little is known about sleep habits, sleep disturbances, and the consequences of disordered sleep in school‐aged children. This descriptive study examined a variety of common sleep behaviors in a group of 494 elementary school children, grades kindergarten through fourth, using a battery of sleep questionnaires that included parent, teacher, and self‐report surveys. The prevalence of parent‐defined sleep problems ranged from 3.7% (Sleep‐Disordered Breathing) to 15.1% (Bedtime Resistance), with 37% of the overall sample described as having significant sleep problems in at least one sleep domain. Younger children were more likely than older children to have sleep problems noted by parents (particularly bedtime struggles and night wakings), as well as by teacher and self‐report. Children tended to identify more sleep problems by self‐report, particularly sleep‐onset delay and night wakings, than did their parents. Overall, approximately 10% of the sample was identified by all three measures as having significant problems with daytime sleepiness. The results of this study emphasize the importance of screening for sleep disorders in this age group in the clinical setting. The need for consensus regarding the use of sleep screening instruments and the definition of “problem” sleep in school‐aged children is also discussed.

Switching to Another SSRI or to Venlafaxine With or Without Cognitive Behavioral Therapy for Adolescents With SSRI-Resistant Depression: The TORDIA Randomized Controlled Trial

CONTEXT Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy. OBJECTIVE To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006. INTERVENTIONS Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy. MAIN OUTCOME MEASURES Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Childrens Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time. RESULTS Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment. CONCLUSIONS For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00018902.

Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study

OBJECTIVE To evaluate the clinical and prognostic significance of suicide attempts (SAs) and nonsuicidal self-injury (NSSI) in adolescents with treatment-resistant depression. METHOD Depressed adolescents who did not improve with an adequate SSRI trial (N = 334) were randomized to a medication switch (SSRI or venlafaxine), with or without cognitive-behavioral therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period. RESULTS Of the youths, 47.4% reported a history of self-injurious behavior at baseline: 23.9% NSSI alone, 14% NSSI+SAs, and 9.5% SAs alone. The 24-week incidence rates of SAs and NSSI were 7% and 11%, respectively; these rates were highest among youths with NSSI+SAs at baseline. NSSI history predicted both incident SAs (hazard ratio [HR]= 5.28, 95% confidence interval [CI] = 1.80-15.47, z = 3.04, p = .002) and incident NSSI (HR = 7.31, z = 4.19, 95% CI = 2.88-18.54, p < .001) through week 24, and was a stronger predictor of future attempts than a history of SAs (HR = 1.92, 95% CI = 0.81-4.52, z = 2.29, p = .13). In the most parsimonious model predicting time to incident SAs, baseline NSSI history and hopelessness were significant predictors, adjusting for treatment effects. Parallel analyses predicting time to incident NSSI through week 24 identified baseline NSSI history and physical and/or sexual abuse history as significant predictors. CONCLUSIONS NSSI is a common problem among youths with treatment-resistant depression and is a significant predictor of future SAs and NSSI, underscoring the critical need for strategies that target the prevention of both NSSI and suicidal behavior. CLINICAL TRIAL REGISTRATION INFORMATION Treatment of SSRI-Resistant Depression in Adolescents (TORDIA). URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00018902.

Sleep and Daytime Behavior in Children With Obstructive Sleep Apnea and Behavioral Sleep Disorders

Objective. The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS. Methods. Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains. Results. Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness. Conclusions. The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.

Longitudinal Trajectories and Predictors of Adolescent Suicidal Ideation and Attempts Following Inpatient Hospitalization

Remarkably little is known regarding the temporal course of adolescent suicidal ideation and behavior, the prediction of suicidal attempts from changes in suicidal ideation, or the prediction of suicidal attempts after accounting for suicidal ideation as a predictor. A sample of 143 adolescents 12-15 years old was assessed during psychiatric inpatient hospitalization and again at 3, 6, 9, 15, and 18 months postdischarge through a series of structured interviews and parent- and adolescent-reported instruments. Symptoms of depression, posttraumatic stress disorder, externalizing psychopathology, hopelessness, and engagement in several forms of self-injurious/suicidal behaviors (i.e., suicide threats/gestures, plans, nonsuicidal self-injury [NSSI]) were assessed. Latent growth curve analyses revealed a period of suicidal ideation remission between baseline and 6 months following discharge, as well as a subtle period of suicidal ideation reemergence between 9 and 18 months postdischarge. Changes in suicidal ideation predicted suicide attempts. After accounting for the effects of suicidal ideation, baseline suicide threats/gestures also predicted future suicide attempts. Higher adolescent-reported depressive symptoms, lower parent-reported externalizing symptoms, and higher frequencies of NSSI predicted weaker suicidal ideation remission slopes. Findings underscore the need for more longitudinal research on the course of adolescent suicidality.

Attempted suicide in adolescence: A review and critique of the literature

Abstract Attempted suicide among adolescents is a significant public health concern due to its frequency, coexisting physical and psychiatric problems, and economic toll. Attempters are also a high-risk group for eventual completed suicide. This review covers three major areas pertinent to attempted suicide in adolescence: characteristics of the attempt (lethality, intent, and precipitants), psychological factors associated with suicidal behavior, and follow-up course. Findings suggest there exists a significant degree of individual and family dysfunction among a large proportion of adolescent suicide attempters. However, strong evidence for the specificity of this dysfunction to suicide attempts, rather than to general emotional disturbance, was found only for hopelessness, family conflict, and contagion. In addition, the ability to devise effective interventions for adolescent suicide attempters is significantly compromised by limited knowledge of the natural course following a suicide attempt. Therefore, the need for comprehensive follow-up studies of suicide attempters should be the immediate focus of research efforts with this high-risk group.

Reasons for adolescent suicide attempts: associations with psychological functioning.

OBJECTIVE To determine reasons for suicide attempts in adolescents and to examine the relationship between these reasons and psychological functioning. METHOD Self-reported reasons for suicide attempts and psychological functioning were examined in 120 adolescent suicide attempters who presented to a pediatric general hospital. RESULTS Consistent with prior research, the most frequently endorsed motives for self-harm were to die, to escape, and to obtain relief. More manipulative reasons for overdose (such as making people sorry) were endorsed less frequently. Adolescents who cited death as a reason for their suicide attempt reported more hopelessness, socially prescribed perfectionism, depression, and anger expression. Discriminant function analyses indicated that high levels of depression and anger expression predicted a self-reported wish to die, and high levels of depression and socially prescribed perfectionism predicted death as the primary reason reported for the suicide attempt. CONCLUSIONS Systematic assessment of the reasons for a suicide attempt is a useful tool for clinicians in determining recommendations for follow-up treatment.

Peer Functioning, Family Dysfunction, and Psychological Symptoms in a Risk Factor Model for Adolescent Inpatients' Suicidal Ideation Severity

Examined models of suicidal ideation severity that include two psychosocial risk factors (i.e., peer and family functioning) and four domains of psychological symptoms (i.e., generalized anxiety, depression, conduct problems, and substance abuse/dependence). Participants were 96 psychiatric inpatients (32 boys, 64 girls), ages 12 to 17, who were hospitalized because of concerns of suicidality. Adolescents completed a structured diagnostic interview, measures of suicidal ideation, and several dimensions of family and peer functioning. Results supported a model in which greater levels of perceived peer rejection and lower levels of close friendship support were associated directly with more severe suicidal ideation. In addition, indirect pathways included deviant peer affiliation and global family dysfunction related to suicidal ideation via substance use and depression symptoms. The results are among the first to demonstrate relations between suicidal ideation and several areas of adolescent peer functioning, as well as divergent processes for peer and family predictors of suicidal ideation.