Joseph L. Woolston

Fluoxetine Treatment of Children and Adolescents with Tourette's and Obsessive Compulsive Disorders: Preliminary Clinical Experience

Fluoxetine hydrochloride is the first selective serotonin uptake inhibitor introduced commercially in the United States. This report describes preliminary clinical experience with fluoxetine in 10 children and adolescents, aged 8 to 15 years, with primary obsessive compulsive disorder (OCD) or Tourettes syndrome (TS) plus OCD. In general, fluoxetine, which was administered from 4 to 20 weeks at a dosage of 10 or 40 mg per day, was well tolerated. Adverse effects included behavioral agitation/activation in four patients and mild gastrointestinal symptoms in two patients. No abnormalities were noted in the seven children who had follow-up EKGs. Five of the 10 patients (50%) were considered responders; their obsessive-compulsive symptoms decreased substantially during treatment with fluoxetine. Responder rates were similar in the primary OCD (two of four, 50%) and TS + OCD (three of six, 50%) groups. In conclusion, short-term fluoxetine administration appears to be safe in children and adolescents. Placebo-controlled trials are needed to further assess the efficacy of fluoxetine.

FAMILY ACCOMMODATION IN PEDIATRIC ANXIETY DISORDERS

Family accommodation has been studied in obsessive compulsive disorder using the Family Accommodation Scale (FAS) and predicts greater symptom severity, more impairment, and poorer treatment outcomes. However, family accommodation has yet to be systematically studied among families of children with other anxiety disorders. We developed the Family Accommodation Scale—Anxiety (FASA) that includes modified questions from the FAS to study accommodation across childhood anxiety disorders. The objectives of this study were to report on the first study of family accommodation across childhood anxiety disorders and to test the utility of the FASA for assessing the phenomenon.

Childhood comorbidity of anxiety/affective disorders and behavior disorders.

Considerable data have been reported concerning comorbidity of various individual psychiatric disorders in children within the diagnostic supradomains of affect/anxiety disorders and behavior disorders as well as between these supradomains. To further examine such comorbidity, 35 psychiatrically hospitalized children were studied in terms of the prevalence of comorbidity, demographic and cognitive characteristics, adaptive functioning and maladaptive behaviors. The prevalence of comorbid behavior + affect/anxiety disorders exceeded 50% of the samples. Children with such comorbidity were similar to children with Behavior only diagnoses in terms of demographic and cognitive characteristics but differed in terms of adaptive functioning and maladaptive behaviors.

Desipramine Treatment of Boys with Attention-Deficit Hyperactivity Disorder and Tics: Preliminary Clinical Experience

Abstract About 50% of children referred for clinical evaluation of Tourettes syndrome (TS) also meet criteria for attention-deficit hyperactivity disorder (ADHD). Standard treatment of ADHD with CNS stimulants results in an exacerbation of the tic symptoms in 20 to 50% of these patients. Symptoms of ADHD were treated with desipramine (DMI) in seven boys with chronic tic disorders, aged 7 to 11 years. Five patients (71%) had a moderate or marked reduction in their ADHD symptoms on a clinicians global improvement rating and on parent and teacher rating scales. There was no change in the severity of tic symptoms during DMI treatment in six patients. An intermittent eyeblink became persistent during DMI treatment in one patient. Mild tachycardia was the most common side effect. DMI appears to be safe and effective for children with ADHD and tics or a family history of TS.

Fluoxetine Overdose in an Adolescent

The response to and management of an acute ingestion of a large quantity of fluoxetine hydrochloride in a 13-year-old boy with Tourettes syndrome and obsessive compulsive disorder is described. The patients symptomatic course following the ingestion included a grand mal seizure, depressed ST segments on EKG, nausea, dizziness, and headache. In general, the fluoxetine was well tolerated: all of the symptoms and signs remitted spontaneously.

Predictors of Treatment Attrition Among an Outpatient Clinic Sample of Youths With Clinically Significant Anxiety

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5–18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process.

Case Study: Carbamazepine Treatment of Juvenile-Onset Bipolar Disorder

The literature devoted to juvenile-onset bipolar disorder has rapidly expanded in the past 5 years with an emphasis on new concepts of prevalence and comorbid conditions. In the process of enlarging the knowledge base about the phenomenology of juvenile-onset bipolar disorder, this new literature has generated considerable controversy but has provided little information about pharmacotherapy. In the following case series, carbamazepine appeared to be a safe and effective treatment for juvenile-onset bipolar disorder. Controlled studies are necessary before any definitive conclusions can be reached about the efficacy of carbamazepine in the treatment of this form of bipolar disorder.

Eating disorders in infancy and early childhood.

The eating disorders in infancy and early childhood are delineated by an overview of the relevant literature. The special methodological problems which impede reserch in this area of study are described. Pilot data concerning one specific eating disorder, nonorganic failure to thrive (NFTT), is presented to illustrate new research approaches and heuristically intersting findings. Specifically, a formula for estimation of degree of protein calorie malnutrition predicts the caloric supplementation required for catch up growth. This estimate of malnutrition can become a useful tool to investigate the relative contribution of inadequate nutrition and inadequate psychosoical stimulation in NFTT.

Combined pharmacotherapy: Pitfalls of treatment

Combined pharmacotherapy (Wilens et al., 1995) has become an important and innovative component in the therapeutic armamentarium in child and adolescent psychiatry. Published reports (Conner et al., 1997; Kaplan et al., 1994) indicate that a substantial proportion of seriously disturbed children are treated simultaneously with several psychotropic medications. Despite this clinical enthusiasm for combined pharmacotherapy and despite the publications of rational algorithms for its use (Spencer et al., 1995; Vitiello, 1997; Walkup, 1995), there is a growing body of literature on adverse drug reactions to single and combined psychotropics in children (Bhatara et al., 1996; Cantwell et al., 1997; Fenicel, 1995; Popper et al., 1995). In addition to the caveats implicit in these adverse drug reaction reports, several published letters (Behr, 1998; Budman et al., 1995; Markowitz and Patrick, 1996; Preda et al., 1998) indicate that some children are being treated with irrational, ineffective, and potentially dangerous combinations of psychotropic medications. This article will offer a clinical perspective on the potential pitfalls associated with combined pharmacotherapy. Possible risks of, and reasons for, inappropriate combined pharmacotherapy include a number of possible causative factors (Jellinek, 1998; Woolston and Caracansi, 1999), several of which will be enumerated in this article. As with any complex phenomenon, any one of these factors may be relatively benign alone, but when they occur simultaneously, they can produce an effect that is considerably more deleterious than the simple sum of their contributions. Perhaps most important, pitfalls in pharmacotherapy are likely to occur in clusters because they are the result of systematic, rather than idiosyncratic, practice forces.

Salivary Cortisol: A Nontraumatic Sampling Technique for Assaying Cortisol Dynamics

Abstract Changes in cortisol dynamics are important correlates of various psychophysiological states in children. The two most important measures of the cortisol dynamics are changes in plasma cortisol concentrations at predetermined times and the dexamethasone suppression test (DST). Unfortunately, much restandardization of adult norms is required before these tests can be applied to infants. Measurements of salivary cortisol appear to be a reliable, accurate and nontraumatic sampling technique for assaying cortisol dynamics. Salivary cortisol values should provide a noninvasive method in the application of the DST to the investigation of psychophysiological states in infants and children.