Jeffrey A. Bridge

Psychometric Properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A Replication Study

OBJECTIVE To replicate and extend work on the psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED), a child and parent self-report instrument used to screen for children with anxiety disorders. METHOD The 41-item version of the SCARED was administered to a new sample of 190 outpatient children and adolescents and 166 parents. The internal consistency, discriminant, and convergent validity were assessed. In addition, using discriminant function analysis, a briefer version of the SCARED was developed. RESULTS Using item analyses and factor analyses on the 41-item version, 5 factors were obtained: panic/somatic, generalized anxiety, separation anxiety, social phobia, and school phobia. In general, the total score and each of the 5 factors for both the child and parent SCARED demonstrated good internal consistency and discriminant validity (both between anxiety and depressive and disruptive disorders and within anxiety disorders). A reduced version of the SCARED yielded 5 items and showed similar psychometrics to the full SCARED. CONCLUSIONS In a new sample, the authors replicated their initial psychometric findings that the SCARED is a reliable and valid instrument to screen for childhood anxiety disorders in clinical settings. Furthermore, pending future research, the 5-item SCARED appears to be a promising brief screening inventory for anxiety disorders in epidemiological studies.

Age- and Sex-Related Risk Factors for Adolescent Suicide

OBJECTIVE To examine the impact of age and sex on adolescent suicide risk. METHOD A standard psychological autopsy protocol was used to compare 140 suicide victims with 131 community controls. The risk factors for older (> or = 16 years) and younger, and for male and female suicide were compared. RESULTS Mood disorders, parental psychopathology, lifetime history of abuse, availability of a gun, and past suicide attempt conveyed significant risk for suicide across all 4 demographic groups. Psychopathology, particularly substance abuse (alone and comorbid with mood disorder), was more common and conveyed a much higher risk for suicide in the older versus younger adolescents. Younger suicide victims showed lower suicidal intent. Males chose more irreversible methods, and conduct disorder was both more prevalent and a more significant risk factor in males. CONCLUSIONS The increased rate of suicide in older versus younger adolescents is due in part to greater prevalence of psychopathology, namely substance abuse, and greater suicidal intent in the older population. The increased rate in males is less easily explained, but it may stem from method choice and the greater prevalence of and risk conveyed by conduct disorder in males.

Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression.

OBJECTIVE To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response. METHOD One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared. RESULTS Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBTs performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors. CONCLUSION Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

Fluoxetine for the Treatment of Childhood Anxiety Disorders

OBJECTIVE To assess the efficacy and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder, and/or social phobia. METHOD Anxious youths (7-17 years old) who had significant functional impairment were randomized to fluoxetine (20 mg/day) (n = 37) or placebo (n = 37) for 12 weeks. RESULTS Fluoxetine was effective in reducing the anxiety symptoms and improving functioning in all measures. Using intent-to-treat analysis, 61% of patients taking fluoxetine and 35% taking placebo showed much to very much improvement. Despite this improvement, a substantial group of patients remained symptomatic. Fluoxetine was well tolerated except for mild and transient headaches and gastrointestinal side effects. Youths with social phobia and generalized anxiety disorder responded better to fluoxetine than placebo, but only social phobia moderated the clinical and functional response. Severity of the anxiety at intake and positive family history for anxiety predicted poorer functioning at the end of the study. CONCLUSIONS Fluoxetine is useful and well tolerated for the acute treatment of anxious youths. Investigations regarding the optimization of treatment to obtain full anxiety remission and the length of treatment necessary to prevent recurrences are warranted.

Sleep disturbance preceding completed suicide in adolescents.

We examined sleep difficulties preceding death in a sample of adolescent suicide completers as compared with a matched sample of community control adolescents. Sleep disturbances were assessed in 140 adolescent suicide victims with a psychological autopsy protocol and in 131 controls with a similar semistructured psychiatric interview. Rates of sleep disturbances were compared between groups. Findings indicate suicide completers had higher rates of overall sleep disturbance, insomnia, and hypersomnia as compared with controls within both the last week and the current affective episode. Group differences in overall sleep disturbance (both within the last week and present episode), insomnia (last week), and hypersomnia (last week) remained significant after controlling for the differential rate of affective disorder between groups. Similarly, overall sleep disturbance (last week and present episode) and insomnia (last week) distinguished completers in analyses accounting for severity of depressive symptoms. Only a small percentage of the sample exhibited changes in sleep symptom severity in the week preceding completed suicide, but of these, a higher proportion were completers. These findings support a significant and temporal relationship between sleep problems and completed suicide in adolescents. Sleep difficulties should therefore be carefully considered in prevention and intervention efforts for adolescents at risk for suicide.

Placebo Response in Randomized Controlled Trials of Antidepressants for Pediatric Major Depressive Disorder

OBJECTIVE The authors examined characteristics and predictors of response to placebo in all available reports of short-term randomized controlled trials of antidepressants for pediatric major depressive disorder. METHOD Response, defined as a score <or=2 on the improvement item of the Clinical Global Impression scale, and potential predictors were extracted from 12 published and unpublished randomized controlled trials of second-generation antidepressants in participants 6-18 years of age with major depression. RESULTS The single best predictor of the proportion of patients taking placebo who responded to treatment was the number of study sites. Baseline severity of illness also emerged as a significant inverse predictor of placebo response, although the strength of this relationship was diminished when number of sites was controlled for. After one large fluoxetine trial was excluded, younger participants showed a higher placebo response rate than older adolescents. Higher placebo response rates in more recent studies were explained by an increasing trend toward large multisite trials and by publication delays and failures to publish some negative trials. CONCLUSIONS The recent shift toward large multisite trials of antidepressant medications for pediatric major depression may be contributing to an increasing incidence of response to placebo. Pharmacotherapy studies of pediatric depression that carefully recruit patients with at least moderately severe depression may be more informative and efficient than many trials conducted to date. Such studies should have sufficient power to determine whether age moderates medication and placebo response.

A Preliminary Study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children Mania Rating Scale for Children and Adolescents

OBJECTIVE To construct a mania rating scale designed for children and adolescents. METHODS Fourteen questions from the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode (K-SADS-P) 1986 version plus a new item assessing mood lability were used to construct a clinician-rated mania rating scale (K-SADS-MRS). Interrater reliability was determined prospectively with 22 patients from a bipolar outpatient clinic. Sensitivity to treatment effects was determined in a separate cohort of 23 patients. RESULTS Internal consistency (Cronbachs alpha = 0.94) and interrater reliability (intraclass correlation coefficient = 0.97 between two raters) were high. Convergent validity with the Clinical Global Impressions-Severity scale (bipolar version) was good (r(s)= 0.91, p < 0.001). Treatment responders had significantly greater reduction in K-SADS-MRS scores than nonresponders (-15.6 +/- 8.7 vs. 0.3 +/- 8.8), t(21) = 4.2, p < 0.001. The K-SADS-MRS scores differentiated bipolar patients who had clinically significant manic symptoms from those who did not, with a sensitivity of 87% and a specificity of 81%. CONCLUSION The K-SADS-MRS shows promise as a rating scale for measuring manic symptom severity in pediatric bipolar patients.

Use of methylphenidate in the treatment of children with autistic disorder

The use of psychostimulants in autistic disorder has not received extensive evaluation. Furthermore, their use for the symptomatic control of autistic disorder has been felt to be contraindicated. This study investigates the use of methylphenidate (MPH) for the treatment of selected symptoms of autistic disorder. Ten children, ages 7–11, with a DSM-III-R diagnosis of autistic disorder participated in a double-blind crossover study using placebo and two MPH doses (10 mg or 20 mg bid). Subjects showed modest but statistically significant improvement on MPH over placebo. No significant side effects including worsening stereotypic movements occurred on either dose. Improvement in hyperactivity and lack of adverse effects suggest that MPH may be useful in the treatment of hyperactive autistic children.

Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation.

The specificity of cognitive and family therapies, and potential treatment mediators and moderators, was examined in a randomized clinical trial for adolescent depression. After acute treatment, cognitive-behavioral therapy (CBT) exerted specific effects on cognitive distortions relative to either systemic-behavioral family therapy (SBFT) or nondirective supportive therapy (NST). At 2-year follow-up, SBFT was found to impact family conflict and parent-child relationship problems more than CBT; NST and CBT tended to show a greater reduction in anxiety symptoms than SBFT. Nonspecific therapist variables qualified few outcome analyses. No measures of cognitive distortion or family dysfunction mediated or moderated treatment outcome. As in adult studies, relatively few areas of treatment specificity or mediation were identified. The implications of these findings for clinical treatment and research in adolescent depression are discussed.

The familial aggregation of adolescent suicide attempts

The objective of this study was to determine whether the familial aggregation of suicidal behaviour is explained by the familial aggregation of personality disorder and aggression. The relatives of 62 clinically referred adolescent suicide attempters were compared with 70 never‐suicidal psychiatric controls. The first‐degree relatives of the suicide attempters had a higher rate of suicide attempts/completion than those of the psychiatric controls. This rate remained significantly higher after controlling for Axis I and II differences in the probands and the relatives, but familial personality disorder was significantly associated with suicidal risk in probands. Among the adolescent attempters, high scores on a measure of assaultiveness were associated with significantly higher familial rates of suicide attempts/completion. Our results support the hypothesis that suicidal behaviour may be transmitted as a trait independent of Axis I and II psychopathology but that, in addition, personality disorder has a role in the transmission of suicidal behaviour. An interrelationship between proband assaultiveness and the familial aggregation of suicidality was noted.