Mona Potter

Pharmacologic Treatments for Pediatric Bipolar Disorder: A Review and Meta-Analysis

OBJECTIVE A growing body of literature has documented pediatric bipolar disorder to be a severely impairing form of psychopathology. However, concerns remain as to the inadequacy of the extant literature on its pharmacotherapy. Furthermore, treatment studies have not been systematically reviewed for treatment effects on core and associated symptoms. Thus, a systematic evaluation and synthesis of the available literature on the efficacy of antimanic pharmacotherapy for pediatric bipolar disorder on symptoms of mania, depression, and attention-deficit/hyperactivity disorder was undertaken. METHOD A systematic search was conducted through PubMed from 1989 through 2010 for open-label and randomized controlled trials published in English on the pharmacotherapy of pediatric mania. RESULTS There have been 46 open-label (n = 29) and randomized (n = 17) clinical trials of antimanic agents in pediatric bipolar disorder encompassing 2,666 subjects that evaluated a range of therapeutic agents, including traditional mood stabilizers, other anticonvulsants, second-generation antipsychotics, and naturopathic compounds. This literature has documented that the available armamentarium has different levels of efficacy in the treatment of pediatric mania. Because all psychotropic classes are associated with important adverse effects, a careful risk-benefit analysis is warranted when initiating pharmacologic treatment with any of these compounds. In the limited data available, the effects of antimanic agents on depression and symptoms of attention-deficit/hyperactivity disorder have been, in general, modest. Few studies have evaluated the effects of antimanic agents in children younger than 10 years. CONCLUSIONS A substantial body of scientific literature has evaluated the safety and efficacy of various medicines and drug classes in the treatment of mania in pediatric bipolar disorder. More work is needed to assess the safety and efficacy of psychotropic drugs in children younger than 10 years, to further evaluate the efficacy of naturopathic compounds, and to further evaluate the effects of antimanic treatments for the management of depression and attention-deficit/hyperactivity disorder.

Prescribing Patterns for Treatment of Pediatric Bipolar Disorder in a Specialty Clinic

OBJECTIVE The aim of this study was to describe prescribing practices in the treatment of pediatric bipolar disorder in a university practice setting. METHOD A retrospective chart review was performed on 53 youths diagnosed using Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV), criteria with bipolar spectrum disorder under the active care of child psychiatrists practicing in a pediatric psychopharmacology specialty clinic. Current medications, doses, and related adverse events were recorded. Clinicians were asked to provide a target disorder (bipolar mania/mixed state, depression, attention deficit hyperactivity disorder [ADHD], or anxiety) for each medication to the best of their ability. The Clinical Global Impressions-Severity (CGI-S) scale was used to measure severity of each disorder before treatment and the Clinical Global Impressions-Improvement (CGI-I) was used to quantify the magnitude of improvement with treatment. Meaningful improvement of the disorder was defined by CGI-I score of 1 or 2. RESULTS The mean number of psychotropic medications per patient was 3.0 +/- 1.6. A total of 68% of patients were treated for co-morbid disorders; 23% of patients were treated with monotherapy, primarily with second-generation antipsychotics. Mania improved in 80% of cases, mixed state improved in 57% of cases, ADHD improved in 56% of cases, anxiety improved in 61% of cases, and depression improved in 90% of cases. CONCLUSION The management of pediatric bipolar disorder often requires multiple medications. For the treatment of mania/mixed states, clinicians prescribed second-generation antipsychotics more frequently than mood stabilizers, especially in the context of monotherapy. Co-morbidity was a frequent problem with moderate success obtained with combined pharmacotherapy approaches. Further psychosocial strategies to augment pharmacotherapy may improve outcome while reducing the medication burden in pediatric bipolar disorder.

Alternative treatments in pediatric bipolar disorder.

There has been growing interest in the use of complementary and alternative treatments in pediatric bipolar disorder (BPD). There are limited data, however, regarding the safety and efficacy of these treatments. This article discusses select complementary and alternative treatments that have been considered for use in pediatric BPD and/or depression, including omega-3-fatty acids, inositol, St. Johns wort, SAMe, melatonin, lecithin, and acupuncture. Background information, reference to available adult and pediatric data, proposed mechanisms of action, dosing, side effects, and precautions of these treatments are included. Across the board, more research is necessary and warranted regarding the long-term safety and efficacy of available complementary and alternative treatments for the management of pediatric BPD.

Being Present at School Implementing Mindfulness in Schools

Developmentally sensitive efforts to help students learn, practice, and regularly use mindfulness tactics easily and readily in and beyond the classroom are important to help them manage future stresses. Mindfulness emphasizes consciously focusing the mind in the present moment, purposefully, without judgment or attachment. Meditation extends this to setting aside time and places to practice mindfulness, and additionally, yoga includes physical postures and breathing techniques that enhance mindfulness and meditation. Several mindfulness programs and techniques have been applied in schools, with positive benefits reported. Some elements of these programs require modifications to be sensitive to the developmental state of the children receiving mindfulness training.

Educational Impacts of the Social and Emotional Brain

Advances in neuroscience related to social and emotional development have significant implications for educational practice. The human brain cannot fully dissociate cognitive from emotional events, and therefore educational programming that recognizes the importance of social-emotional development also facilitates academic achievement. The ideal learning environment encourages the development of social-emotional and academic neuronal pathways. Taking advantage of the emerging understanding of the developing brain offers opportunities to facilitate greater academic gains.

Treatment Overview of an Intensive Group Outpatient Cognitive-Behavioral Therapy for Youth Anxiety Disorders and Obsessive-Compulsive Disorder

ABSTRACT Evidence-based outpatient treatment protocols for anxiety disorders and obsessive-compulsive disorder have been demonstrated to be helpful for about half of children; however, a significant portion of treatment-seeking youth remain symptomatic and with impaired functioning. Innovations in the delivery of cognitive-behavioral treatments may allow for enhanced effectiveness. This article describes the design and implementation of an intensive, group-based cognitive-behavioral therapy program with a focus on exposure and response prevention for youth (ages 7–19) with anxiety disorders and obsessive-compulsive disorder. The multicomponent treatment involves psychoeducational groups, graduated in vivo exposure, family sessions, parent guidance groups, and psychopharmacologic consultation. Youth participate in treatment 4 times per week (3 group days and 1 family treatment day), for 2½ to 3 hr per day, for at least 4 weeks. In this article we provide preliminary outcomes and describe plans for evaluating the treatment more comprehensively.