Shekhar P. Seshadri

A prospective study of bipolar disorder in children and adolescents from India

Bipolar disorder in adults is known to run an episodic course. However, little information exists on the long‐term naturalistic course of bipolar disorder in juvenile populations. The present study was undertaken with the objectives of (i) documenting the rates of recovery and relapse, (ii) identifying the predictors of recovery and relapse and (iii) assessing the rates of comorbid conditions. A total of 30 subjects with onset of bipolar illness (according to DSM‐III‐R criteria) in childhood and adolescence were assessed systematically at baseline and 4 to 5 years later. All 30 subjects (100%) had recovered from their index episodes and none had exhibited chronicity. Twenty of the 30 subjects (67%) had relapsed, with most relapses occurring within 2 years of recovery from index episodes. No predictors of recovery and relapse could be identified. Conduct disorder was the only comorbid diagnosis in two subjects (7%). The main implication of our study, in view of the high rates of relapse in the crucial developmental phase of a young individual, is that long‐term maintenance medication should be considered in juvenile bipolar patients, even if it is a first episode.

Risperidone-Induced Priapism in a 12-Year-Old Boy with Schizophrenia

OBJECTIVE To examine whether adverse perinatal experiences of children are associated with obsessive compulsive disorder (OCD) in youth. METHODS Subjects were 130 children and adolescents with OCD recruited from a family genetic study of pediatric OCD and 49 matched controls from a contemporaneous family case-control study of attention-deficit/hyperactivity disorder (ADHD). Subjects were comprehensively assessed in multiple domains of function. A systematic history of pregnancy, delivery, and infancy complications was obtained. RESULTS Compared to normal controls, children with OCD had mothers with significantly higher rates of illness during pregnancy requiring medical care (chi(2) +/- 8.61, p +/- 0.003) and more birth difficulties (induced labor, forceps delivery, nuchal cord, or prolonged labor) (chi(2) +/- 7.51, p +/- 0.006). Among the OCD-affected children, we found several significant associations between adverse perinatal experiences and earlier age at onset, increased OCD severity, and increased risk for comorbid ADHD, chronic tic disorder, anxiety disorder, and major depressive disorder. CONCLUSION Although exploratory, our analyses found that children with OCD had higher rates of several adverse perinatal experiences compared with controls. Among OCD-affected children, comorbid psychopathology was predicted by specific perinatal risk factors. Prospective studies of perinatal adverse events that minimize potential recall bias and type I errors are needed.

The Index Manic Episode in Juvenile-Onset Bipolar Disorder: The Pattern of Recovery

Objective: Recent studies of patients with juvenile bipolar disorder report low rates of recovery and high rates of chronicity. However, we lack data on the short-term outcome. This study examines the pattern of recovery from the index episode in an aggressively treated juvenile sample. Method: We assessed 25 subjects (< 16 years) with a diagnosis of mania, using the Diagnostic Interview for Children and Adolescents-Revised) (DICA-R), Young Mania Rating Scale (YMRS), and Childrens Global Assessment Scale (CGAS) at intake and at 3 and 6 months. We studied the time taken to recover from the index episode, the level of functioning, and the factors predicting them. Results: After 6 months, 24 (96%) subjects had recovered from the index manic episode. The median time to recovery was 27 days. Total episode length was significantly longer among those with previous affective episodes. Conclusions: The findings suggest that juvenile-onset mania has high rates of recovery and low rates of chronicity. These differences from the existing literature need further exploration.

Review of electroconvulsive therapy practice from a tertiary Child and Adolescent Psychiatry Centre

AIMS AND OBJECTIVES The use of electroconvulsive therapy (ECT) in children and adolescents is a controversial issue. This study was done to examine the pattern and practice as well as the outcome of electroconvulsive therapy administered to children and adolescents admitted to a tertiary care centre. METHODOLOGY A 10 year retrospective chart review of all children and adolescents (up to 16 years of age) admitted in the Child and Adolescent Psychiatry Centre, National Institute of Mental Health and Neurosciences (NIMHANS) who had received at least 1 session of ECT was done. Information regarding diagnosis, reasons for prescribing electroconvulsive therapy, details regarding the procedure and outcome variables was collected from the records. Clinical Global Impressions (CGI) scale rating of the severity of illness and improvement seen were done by 2 trained psychiatrists independently. RESULTS 22 children and adolescents received electroconvulsive therapy over 10 years. There were an equal number of boys and girls. All received modified ECT. Most patients who received electroconvulsive therapy were severely ill. Catatonic symptoms 54.5% (12) were the most common reason for prescribing electroconvulsive therapy. It was efficacious in 77.3% (17) of the patients. Electroconvulsive therapy was relatively safe, and most experienced no acute side effects. 68.2% (15) who were on follow up and did not experience any long term side effects due to the electroconvulsive therapy. CONCLUSIONS Electroconvulsive therapy has a place in the acute management of severe childhood psychiatric disorders. Further long term prospective studies are required.

Heart Rate Variability in Children with Attention-Deficit/Hyperactivity Disorder: A Pilot Study.

Background: Attention deficit/hyperactivity disorder (ADHD) is a common childhood neuropsychiatric disorder. Autonomic nervous system plays a vital role in attention, self-regulation, emotional stability and social affiliation, which are affected in ADHD. The prefrontal cortex, which is vital for attention, motor control, emotional regulation and higher order autonomic control, is hypofunctional in ADHD. In addition, catecholamine dysregulation is there. Purpose: We hypothesized that there is autonomic dysfunction: reduction in overall heart rate variability (HRV) and sympathovagal imbalance in children with ADHD. Methods: Study criteria were drug-naïve ADHD children who were 7-12 years of age of either gender who fulfilled DSM-IV criteria for ADHD and did not have any associated comorbid psychiatric/neurological/medical disorders. Two hundred and seventy ADHD children were screened out of which only 12 were found eligible and 10 participated. Sample size was 20 (cases = 10, age- and gender-matched healthy controls = 10). Short-term HRV of both time and frequency domains were assessed by recording lead II electrocardiogram after using Tell-Show-Do, a behavior shaping technique. Comparison between groups was done using Mann-Whitney and Wilcoxon test. Demographic variables like age, height, weight and body mass index were similar between groups. Results: Among time domain parameters, SD of all NN intervals, square root of the mean of the sum of squares of differences between adjacent NN intervals and percentage of count of number of pairs of adjacent NN intervals differing by more than 50 ms were reduced in ADHD group with p < 0.05. Among frequency domain parameters, total power was reduced in ADHD group with p < 0.05, high frequency power (HF) was reduced in ADHD group with p < 0.01 and low frequency power to HF ratio was higher in ADHD group with p < 0.01. Conclusion: There is autonomic dysfunction in children with ADHD - reduction in overall HRV with sympathovagal imbalance with sympathetic dominance.

Childhood Autism Spectrum Disorders With and Without Epilepsy Clinical Implications

This prospective cross-sectional study compared 25 children with pervasive developmental disorder and epilepsy and 25 children having pervasive developmental disorder without epilepsy on pervasive developmental disorder scores, Childhood Autism Rating Scale scores, language disability, presence of regression, and epileptiform abnormalities. Epilepsy phenotype was also studied. Children with pervasive developmental disorder and epilepsy had higher pervasive developmental disorder scores (P = .001), higher Childhood Autism Rating Scale scores (P = .016), and lower social quotient (P = .09). More than 50% of children with pervasive developmental disorder and epilepsy and 12% of children having pervasive developmental disorder without epilepsy had epileptiform abnormalities in electroencephalography (EEG). Regression of milestones was significantly associated with epilepsy and epileptiform abnormalities. Children with pervasive developmental disorder and epilepsy might have a worse developmental trajectory requiring intensive management. A behavioral phenotype of autism may coexist often in children with epilepsy, EEG abnormalities, and regression. Seizures might be difficult to control in these children despite adequate compliance. Studies with larger sample size and longitudinal follow-up will provide better understanding.

‘Ego-dystonicity’ in homosexuality: An Indian perspective

Background: Homosexual persons are targets of verbal and physical abuse, discrimination and face legal disadvantages in many countries, including India. These external factors could play a role in determining discomfort with their sexuality. Aims: We ascertained the association between ego-dystonicity of sexual orientation and indices of perceived acceptance, stigma and awareness of possible normative lifestyles. Methods: Fifty-one self-identified adult homosexual men were assessed using online questionnaires that covered information including their socio-demographic details; a Visual Analog Scale (VAS) that measured their degree of discomfort with their sexuality; Reactions to Homosexuality Scale, Perceived Acceptance Scale, Modified China Men Who Have Sex with Men (MSM) Stigma scale; and trait version of the Positive and Negative Affect Scale. The participants were also asked to provide a written narrative of their experiences which influenced their comfort with their sexuality. Results: Discomfort with sexuality significantly correlated with education, acceptance by friends and family, legal disadvantages, awareness and accessibility to non-heteronormative lifestyles and support systems and trait affect. Only acceptance by friends and awareness showed significance on linear regression. Qualitative analyses revealed external attributions for discomfort. Conclusions: Modifying external factors, reducing legal restrictions and improving societal acceptance and support systems could reduce ‘ego-dystonicity’. ‘Ego-dystonicity’ as a determinant for psychiatric classification and intervention needs to be reexamined.

A comparative study of pathways to care for children with specific learning disability and mental retardation

Context: Early intervention in specific learning disability (SpLD) results in better outcome and prevents comorbidity. Understanding the pathways is therefore important. Aims: To study and compare the pathways to care for children with SpLD and mental retardation (MR) before reaching a tertiary care center. Settings and Design, Material and Methods: A cross-sectional study was conducted for pathways to care of two groups: SpLD and MR with 50 children in each group from 8 to 16 years. MINI-KID for comorbidity and Goldbergs pathway to care instrument was used. The groups were divided into early contact (up to three carers) and late contact (more than three carers) and compared. Statistical Analysis: Data were analyzed using Statistical Packages for Social Sciences (SPSS) version 10.0 software. Results: Majority (n = 24 or 48%) of SpLD children visited “others” (teachers, neighbors, relatives, and guardians of fellow classmates) as first carer. Allopathic practitioners were the first choice for MR children (n = 31 or 62%). Six children (12%) in SpLD group and 10 of MR (20%) group have seen either traditional practitioner or healer as first carer. Maximum referral to the tertiary center in both groups was done by others (62% in SpLD and 56% in MR group). Early contacts in SpLD group belonged to younger age group (P = 0.01). While comparing both groups on the basis of early and late contact, mothers education was found to be significant in early contact group (P = 0.036) and having comorbidity was significant among late contacts (P = 0.038). Conclusions: The pathways to care for SpLD children are more or less similar to MR children whose parents recognize MR late. Both the groups visit multiple carers including traditional healers substantiating the strong belief for supernatural causation of developmental disorders in India.

Clinical characteristics of aggression in children and adolescents admitted to a tertiary care centre

BACKGROUND AND NEED FOR THE STUDY Identification and management of aggression is a major mental health priority in hospitalised patients. However, no such studies have been done in child and adolescent in-patients in India. OBJECTIVES To study the clinical and demographic features; characteristics of the aggression and methods employed to manage aggression in child and adolescent in-patients. MATERIALS AND METHODS Child and adolescent in-patients between the ages of 4 and 16 years who were aggressive were included. The tools used were the MINI-International Neuropsychiatric Interview (M.I.N.I) KID, Overt Aggression Scale (OAS), Childrens Global Assessment Scale (CGAS), and a Semi-structured interview regarding each aggressive episode. RESULTS 31 patients displayed aggressive behaviour out of the 131 patients who were admitted during the study period. Aggressive acts were more common in males, those with academic difficulties, who had a past history of aggression, with suicidal ideation or suicidal attempts. Aggression occurred across diagnostic categories but a significant proportion was diagnosed to have Disruptive Behaviour Disorders either as a primary diagnosis or as comorbidity. 90.6% were on psychotropic medication prior to admission. Around 2/3rd of aggressive episodes occurred in the evening and family members (85.7%) were the most common targets of aggression. CONCLUSION There are a few factors that can possibly help identify and predict aggression in children and adolescents in a hospital setting. More research is required to understand aggression in clinical settings.

Are anxiety disorders associated with a more severe form of bipolar disorder in adolescents

Background: Anxiety disorders are common among children and adolescents with bipolar disorder. Among adults, anxiety disorder comorbidity is associated with a more severe form of bipolar disorder and a poorer outcome. There is limited data on the effect of comorbid anxiety disorder on bipolar disorder among children and adolescents. Aim: To study the prevalence of anxiety disorders among adolescents with remitted bipolar disorder and examine their association with the course and severity of illness, global functioning, and quality of life. Materials and Methods: We evaluated 46 adolescents with DSM IV bipolar disorder (I and II) who were in remission, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. We measured quality of life using the Pediatric Quality of Life Inventory and global functioning using the Childrens Global Assessment Scale, and then compared these parameters between adolescents with and without current anxiety disorders. We also compared the two groups on other indicators of severity such as number of episodes, suicidal ideation, presence of psychotic symptoms, and response to treatment. Results: Among the 46 subjects, the prevalence of current and lifetime anxiety disorders were 28% (n=13) and 41% (n=19), respectively. Compared with others, adolescents with anxiety had more lifetime suicidal ideation, more number of episodes, lower physical, psychosocial, and total subjective quality of life, and lower global functioning. Conclusions: Among adolescents with bipolar disorder, anxiety disorders are associated with a poorer course, lower quality of life, and global functioning. In these subjects, anxiety disorders should be promptly recognized and treated.