Pratibha Reebye

Relation Between Prenatal Maternal Mood and Anxiety and Neonatal Health

Objective: To examine the relation between the mood and anxiety of pregnant, psychiatrically treated women and neonatal health outcomes after birth. Method: We prospectively assessed 46 women treated with psychotropic medications for anxiety and depression during pregnancy. We compared measures of maternal mental health with infant outcomes, in particular, the outcomes of infants with symptoms of poor neonatal adaptation. Results: The mothers of babies who demonstrated poor neonatal adaptation reported higher levels of anxiety and depression at study entry than did the mothers of healthy babies. This relation was not related to the presence or absence of treatment with clonazepam, an anxiolytic used to treat symptoms of anxiety. Further, increased psychiatric comorbidity in the mother was associated with a greater likelihood of transient symptoms in the newborn. Conclusions: Despite psychiatric treatment, the intensity and degree of comorbid symptoms appear to be related to poor transient neonatal health outcome. Our data suggest that, in addition to the impact of pharmacologic factors, maternal psychiatric status influences infant outcomes.

Conduct disorder and substance use disorder : comorbidity in a clinical sample of preadolescents and adolescents

Objective To examine the rate of comorbidity between conduct disorder and substance use disorder in a clinical sample using the Diagnostic Interview for Children and Adolescents - Revised. Method Examined the pattern of conduct disorder symptoms, including type, number, and severity, in conduct-disordered youth diagnosed with, and without a comorbid substance use disorder. Results The examination revealed no significant differences in the incidence of comorbidity between younger (aged 10 to 13) and older (above age 13) youth. Among youth who met criteria for conduct disorder, 52% also met criteria for a substance use disorder. Odds ratios indicated that the probability of comorbidity of conduct and substance use disorders was higher in the younger group. Conclusion Substance abuse and dependence tend to develop rapidly following first use, suggesting that a slim window of opportunity exists to prevent substance disorders once drug use has begun.

Symptoms of posttraumatic stress disorder in adolescents with conduct disorder: Sex differences and onset Patterns

Objective: To examine sex differences in the rate and symptoms of posttraumatic stress disorder (PTSD), trauma exposure, and onset patterns in youth with conduct disorder (CD). Method Youth admitted to a clinical facility for severe behaviour problems completed the Diagnostic Interview for Children and Adolescents – Revised (DICA-R) to assess the presence of CD and PTSD. Results Over one-half of CD youth reported exposure to trauma, yet only 17% met criteria for PTSD. PTSD was more frequent in CD girls (28%) than in boys (10%), and girls experienced greater symptom intensity and anhedonia, difficulty feeling love or affection, and disturbance of sleep and concentration. Girls more frequently reported sexual assault, while boys were more likely to report accidents, physical assaults, and witnessing the death of a loved one. Retrospective reports indicated that PTSD tended to develop subsequent to CD. Conclusions Exposure to trauma is common among CD youth; however, diagnostic procedures should be adapted for increased sensitivity to PTSD. The development of CD may increase the risk for PTSD, particularly in girls, by exposing youth to situations in which they are traumatized. The role of trauma in CD should be routinely examined by clinicians and warrants further research.

Affect Expression and Self-Regulation Capacities of Infants Exposed in utero to Psychotropics

This study explored the affect expression and self-regulation capacities of 8-month-old infants exposed in utero to psychotropic medications. This was a continuation of our previous study conducted on the same cohort when the infants were 3 months old. Psychotropics implicated included selective serotonin reuptake inhibitors (SSRIs), and a benzodiazepine derivative anxiolytic (clonazepam). The three comparison groups were: control (n = 23; infants not exposed to psychotropics in utero), SSRI-alone (n = 22; infants exposed to SSRIs only and having mothers who had a primary diagnosis of depressive disorder without having comorbid anxiety disorder), and SSRI+ group (n = 15; infants gestationally exposed to SSRIs and clonazepam and having mothers that had both clinical depression and anxiety disorder). Using the Parent–Child Early Relational Assessment Scale, infants were assessed in a dyadic context during free play and a structured task. There were significant differences in psychotropic exposed and non-exposed dyads regarding infant negative affect management. There were significant associations between the SSRI+ group of mothers and infant negative affect. This group of mothers also showed significant associations with infants’ averting and avoiding behaviors in both play situations. The SSRI-alone group was similar to the control group and showed variable associations with infant’s positive, negative, and sober moods unlike the SSRI+ group. There were no differences in infants’ capacity for self-regulation in psychotropic exposed and non-exposed groups. Increased awareness of these vulnerable subgroups (SSRI-alone and SSRI+) is needed, in order to safeguard these dyads through better support systems and improved management.

Prevalence and Characteristics of Self-Harm in Adolescents: Meta-Analyses of Community-Based Studies 1990–2015

OBJECTIVE To provide meta-analytic estimates of self-harm from all community-based studies of adolescents from 1990 through 2015, estimates of suicidal risk, and characteristics including age profile, frequency, types, seeking help, and reasons. METHOD Databases, bibliographies, and the internet were searched for cross-sectional and cohort studies of 12- to 18-year-olds. Meta-analytic estimates of the prevalence and characteristics of self-harm, risk of suicidal behaviors, and rates comparing different methods were calculated. RESULTS One hundred seventy-two datasets reporting self-harm in 597,548 participants from 41 countries were included. Overall lifetime prevalence was 16.9% (95% CI 15.1-18.9), with rates increasing to 2015. Girls were more likely to self-harm (risk ratio 1.72, 95% CI 1.57-1.88). The mean age of starting self-harm was 13 years, with 47% reporting only 1 or 2 episodes and cutting being the most common type (45%). The most frequent reason was relief from thoughts or feelings. Slightly more than half sought help, but for most this was from a friend. Suicidal ideation (risk ratio 4.97) and attempts (risk ratio 9.14) were significantly higher in adolescents who self-harmed, but this was higher with more frequent self-harm. Methodologic factors also were associated with higher rates of self-harm. CONCLUSION Interventions that can lower suicidal risk should be made available to adolescents who self-harm frequently as soon as possible. Preventative interventions that help adolescents deal with negative feelings should be instituted at the onset of puberty. Because friends are frequently asked for support, interventions also should be developed for peer groups.

Clinical Home Visitation for Children With Externalizing Disorders: A Randomized Study

ABSTRACT Clinical home visitation (CHV) was empirically tested in a randomized study to determine if it could reduce a childs externalizing behaviors while alleviating parental stress. Clinic-referred waitlisted young children (n = 33) with symptoms suggesting an externalizing disorder were randomly offered a CHV intervention composed of a developmentally guided dyadic-centered syllabus. Families were recruited to participate in an experimental (n = 21) or control group (n = 12). Mothers completed the Parenting Stress Index (PSI) and the Child Behavior Checklist. Results of paired-samples t-tests indicated that postintervention aggression scores were significantly different from the pretest scores for the entire sample. The Difficult Child domain was the only significant PSI subscale. The results did not support definitive conclusions about CHV as an effective intervention to reduce an externalizing disorder or to alleviate parenting stress. Future research should include larger numbers of children with externalizing disorders pooled from the clinic-referred and community samples. To address the complexities involved in treating externalizing disorders, CHV could be offered as part of a multimodal intervention (e.g., CHV combined with parent and family education).

Review: evidence on the comparative effectiveness and adverse effects of antipsychotics in young people is limited.

ED FROM Seida JC, Schouten JR, Boylan K, et al. Antipsychotics for children and young adults: a comparative effectiveness review. Pediatrics 2012;129:e771–84. Correspondence to: Jennifer Seida, 4-488B Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, Alberta, T6G 1C9, Canada; jennifer.seida@ualberta.ca Sources of funding The Agency for Healthcare Research and Quality (AHRQ) and US Department of Health and Human Services. ▸ References are available online at http://ebmh.bmj.com/content/early/recent OM M EN TRY In the context of ongoing widespread expansion of antipsychotic drug usage, Seida et al present a meticulous review of antipsychotic trials in children, adolescents and the oft-forgotten age group of young adults. Including this group is important, since research shows brain development continues until approximately age 25. This age group is in transition from childhood to adulthood and medication response and adverse effects may more closely resemble observed paediatric patterns, than in adults (up to age 65) with whom they are typically lumped together in clinical trials. The authors reviewed 30 comparisons across six therapeutic categories covering major areas of antipsychotic use. In the majority of comparisons, a low strength of evidence (SOE) rating was assigned, and none of the comparisons had high SOE ratings. This is dismaying but not unexpected. Until recently, very few randomised controlled trials were conducted beyond the realm of attention deficit/hyperactivity disorder in paediatric psychopharmacology. Space limitations notwithstanding, adverse events are presented by drug class on the assumption that adverse events will occur regardless of indication. However, this ignores the dose-related nature of most adverse effects (eg, antipsychotic dosing is typically higher in schizophrenia compared with disruptive behaviour disorders), and complex drug-disease interactions (eg, the observed association of metabolic syndrome with bipolar disorder could modify a drug’s adverse effect profile in this population, but these factors may not be present in patients with disruptive behaviour disorders). 8 week median study duration is not long enough to fully assess the metabolic effects of these medications. Researchers can reduce potential for bias in future research by providing better descriptions of allocation concealment, blinding procedures and funding sources. While risk of bias in the trials was high due to industry funding (resulting in lower SOE ratings), one should consider there would be very little data to discuss, if industry funded research was not permitted. Pratibha N Reebye, Dean Elbe :Children’s & Women’s Mental Health Programs, BC Children’s Hospital, Vancouver, Canada:Department of Pharmacy, BC Children’s Hospital, Vancouver, Canada Competing interests None. EBMH August 2012 Vol 15 No 3 79 Therapeutics

Book Review: Child Psychiatry: The Infant and Family in the Twenty-First CenturyThe Infant and Family in the Twenty-First Century. Gomes-PedroJoao, NugentJ Kevin, YoungJ Gerald, BrazeltonT Berry, editors. New York: Brunner-Routledge; 2002. 343 p. US

This book is the first volume in the new Mentor series on topics of current interest in child and adolescent psychiatry. The editors attempt to maintain the title theme—the infant and family in the 21st century—throughout. All 16 authors are either well-known authorities in the infant health field or distinguished researchers in infant development. In this review, I adhere to the book’s thematic model and do not refer specifically to individual authors and their contributions.