Flemming Graae

Fluoxetine in children and adolescents with OCD: a placebo-controlled trial.

OBJECTIVE To examine the safety and efficacy of fluoxetine in child and adolescent obsessive-compulsive disorder (OCD). METHOD Between 1991 and 1998, 43 patients were randomly assigned to fluoxetine or placebo for 8 weeks. Dosing was fixed for the first 6 weeks (up to 60 mg/day) and then could be increased to 80 mg/day. Responders entered an 8-week maintenance phase. The primary outcome measures were the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impression-Improvement (CGI-I) scale. Analyses were done on the intent-to-treat sample. RESULTS Fluoxetine patients (n = 21) had significantly lower CY-BOCS scores than placebo patients (n = 22) after 16 (but not 8) weeks. Fluoxetine responders (n = 11) had significantly lower CY-BOCS scores than placebo responders (n = 7) after an additional 8 weeks of treatment. After 16 weeks, 57% of fluoxetine (versus 27% of placebo) patients were much or very much improved on the CGI-I scale (p <.05). No patient terminated the study because of adverse medication effects. CONCLUSION Fluoxetine was well tolerated and effective for the treatment of child and adolescent OCD, but fluoxetines full effect took more than 8 weeks to develop.

Clonazepam in childhood anxiety disorders.

OBJECTIVE There is evidence for the efficacy and safety of clonazepam (CZP) in adult anxiety disorders, but no formal studies to substantiate clinical reports of similar benefit in children with anxiety disorders. METHOD In this double-blind pilot study, 15 children, aged 7 to 13 years, entered a randomly assigned, double-blind crossover trial of 4 weeks of CZP (up to 2 mg/day) and 4 weeks of placebo. RESULTS Twelve children completed the trial. All but 1 had a diagnosis of separation anxiety disorder, and all but 2 had comorbid diagnoses. Nine children appeared to have moderate to significant clinical improvement, but statistical comparisons on several ratings failed to confirm a trend in favor of CZP. Side effects of drowsiness, irritability, and/or oppositional behavior were notable in 10 children in the CZP phase compared with 5 in the placebo phase. CONCLUSIONS Clonazepam was believed to have clinical benefit for some children, but this was not confirmed statistically in this small sample. Problematic side effects of drowsiness and disinhibition were common and possibly were due to rapid titration.

Demographic predictors of treatment attendance among adolescent suicide attempters

The relationship between age and gender and treatment attendance was prospectively examined among a consecutive series of 143 adolescent emergency room attendees referred for outpatient therapy after a suicide attempt. Consistent with previous reports, nonadherence was high. Over 40% of patients had their cases terminated because of nonattendance; on average, however, patients received almost 6 sessions of treatment and 91% attended at least 1 therapy session. Adolescents terminated from treatment for nonadherence were significantly older than those completing treatment. Younger male patients were scheduled for significantly more therapy sessions than older male patients and kept significantly more scheduled sessions than did older male and female patients. Vigorous case-tracking procedures may have a significant impact on treatment attendance. Nevertheless, therapists must design strategies to increase treatment adherence among older adolescent, especially male, patients.

Brief Cognitive-Behavioral Treatment for Adolescent Suicide Attempters and Their Families

OBJECTIVE This article describes a brief, standardized, cognitive-behavioral treatment program for adolescent suicide attempters and their families. METHOD Successful Negotiation Acting Positively (SNAP) treatment consists of a series of structured activities that create a positive family atmosphere, teach problem-solving skills, shift the familys understanding of their problems to troublesome situations rather than difficult individuals, and build confidence in the treatment professional, thereby reducing conditions associated with future attempts. RESULTS SNAP treatment has been systematically administered to more than 100 suicidal adolescents and their families as part of an ongoing treatment study. Although these results are not yet available, our initial experience suggests that SNAP treatment can be delivered in a reliable fashion and is well accepted by both patients and therapists. CONCLUSIONS Although suicidality in youth constitutes a major public health problem, few therapeutic interventions have been developed specifically for suicidal adolescents. SNAP treatment addresses a number of issues critical to successful interventions with this population, including their historically poor treatment compliance, the need for family involvement in treatment, and an emphasis on coping and problem-solving strategies. Moreover, the brief, structured format of SNAP treatment is consistent with the growing trend toward standardized, empirically tested, and cost-efficient interventions.

Microanalysis of Adolescent Suicide Attempters and Ideators During the Acute Suicidal Episode

OBJECTIVE To compare psychological and event-related contingencies that characterize and differentiate adolescent suicidal ideation and attempts. METHOD Thirty-five ideators and 32 attempters (aged 12 to 17 years) consecutively referred to the suicide disorders clinic were evaluated with a semistructured interview about current and past emotional, cognitive, and behavioral states. RESULTS Before the precipitant stressor (baseline), attempters reported significantly more hopelessness than ideators (odds ratio [OR] = 4.2, p < .05). During the suicidal episode, attempters, relative to ideators, spent more time ideating (OR = 4.3, p < .05), were more likely to isolate themselves (OR = 5.8, p < .01), and were less likely to tell anyone what they were thinking (OR = 4.5, p < .05). In contrast, ideators reported significantly more residual anger after the episode than did attempters (OR = 4.0, p < .05). All the episodes of ideation and attempts were preceded by a stress event. No differences were found between the groups on Beck Depression inventory scores. CONCLUSIONS Preexisting hopelessness, a tendency toward isolation, not talking about ideation, and longer length of time ideating during suicidal episodes discriminated suicide attempters from suicide ideators. Knowledge of these factors may be helpful in preventive and treatment efforts with suicidal adolescents.

Abnormality of EEG alpha asymmetry in female adolescent suicide attempters

Abnormal electroencephalographic (EEG) activity has been associated with various psychiatric disorders and behaviors, including depression, suicide, and aggression. We examined quantitative resting EEG in Hispanic female adolescent suicide attempters and matched normal controls. Computerized EEG measures were recorded at 11 scalp sites during eyes open and eyes closed periods from 16 suicide attempters and 22 normal controls. Suicide attempters differed from normal controls in alpha asymmetry. Normal adolescents had greater alpha (less activation) over right than left hemisphere, whereas suicidal adolescents had a nonsignificant asymmetry in the opposite direction. Nondepressed attempters were distinguished from depressed attempters in that they accounted for the preponderance of abnormal asymmetry, particularly in posterior regions. Alpha asymmetry over posterior regions was related to ratings of suicidal intent, but not depression severity. The alpha asymmetry in suicidal adolescents resembled that seen for depressed adults in its abnormal direction, but not in its regional distribution. Findings for suicidal adolescents are discussed in terms of a hypothesis of reduced left posterior activation, which is not related to depression but to suicidal or aggressive behavior.

Outpatient behavioral treatment of child and adolescent obsessive compulsive disorder

Abstract Although several studies have shown behavioral treatment to be effective for adults with OCD, there are relatively few reports of this treatment in younger populations. This paper describes a standardized outpatient program for the behavioral treatment of child and adolescent OCD. Three case reports are presented to illustrate several unique features of the treatment, including a built-in reward program and concurrent family treatment sessions. Two patients responded well to the treatment and maintained their gains over a one-year follow-up interval, but the third patient, whose treatment was complicated by severe familial dysfunction, showed only minimal to moderate improvement. The importance of expanding available treatments to address the specific needs of OCD youngsters and the need for standardized treatments to facilitate systematic comparison of different treatment modalities are addressed.

The Children's Yale-Brown Obsessive-Compulsive Scale: Item Structure in an Outpatient Setting.

The Childrens Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is one of the most popular measures of symptom severity for childhood obsessive-compulsive disorder (OCD). This study describes the factor structure of the CY-BOCS. A total of 233 children diagnosed with OCD were evaluated with the CY-BOCS. The results indicated that 2 alternate 2-factor solutions (obsessions and compulsions; severity and disturbance) fit the data set best. The results also suggested that items assessing resistance to obsessions and compulsions provide unreliable evaluations of these symptoms in children with OCD. Recommendations for modifications to the CY-BOCS as well as clinical applications and for future research with the measure are made.