Anxiety Disorders: March JS

Compton SN, Kratochvil CJ, March JS. · Pediatric Psychiatry, Duke University Medical Center, DUMC Box 3527, Durham, NC 27710, USA. · Pediatr Ann. · Pubmed #17910206 No free full text.

This publication has no abstract.

Compton SN, March JS, Brent D, Albano AM, Weersing R, Curry J. · Department of Psychiatry and Behavioral Psychology, Duke University Medical Center, Durham, NC 27710, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #15266189 No free full text.

Abstract: OBJECTIVE: To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and depressive disorders within the conceptual framework of evidence-based medicine. METHOD: The psychiatric and psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to pediatric anxiety and depressive disorders. RESULTS: For both anxiety and depression, substantial evidence supports the efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active control conditions suggest medium to large effects for symptom reduction in primary outcome domains. CONCLUSIONS: From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitive-behavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven treatments to divergent settings and patient populations.

Franklin M, Foa E, March JS. · Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. · J Child Adolesc Psychopharmacol. · Pubmed #12880499 No free full text.

Abstract: Obsessive-compulsive disorder (OCD), which has a prevalence of 1 in 200 in children and adolescents, carries with it significant functional morbidity. A growing empirical literature supports the efficacy of short-term treatment with OCD-specific cognitive-behavior therapy (CBT) or medication management with a selective serotonin reuptake inhibitor. These and other studies also identify a substantial probability of partial response and, possibly, differences in durability when treatment is discontinued between medication and CBT. The Pediatric OCD Treatment Study is a multicenter, randomized, masked clinical trial designed to evaluate the relative benefit and durability of four treatments for children and adolescents with OCD: sertraline, CBT, combination of sertraline and CBT, and pill placebo. Stage 1 (12 weeks) is a balanced randomized comparison of these four treatments. Responders at the end of stage 1 advance to 4 months of open follow-up in their assigned arm during which all treatment is discontinued. At the end of stage 2 (if not before), nonresponders to any treatment at the end of stage 1, any patient relapsing in stage 2, and all stage 1 placebo patients receive open treatment that is tailored to the patient's needs. A volunteer sample of 120 subjects between the ages of 7 and 17 inclusive with a primary Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of OCD enters the study. All patients, regardless of responder status, return for all scheduled assessments. This report describes the design of the trial, the rationale for the design choices made, and the methods used to carry out the trial.

March JS. · Child and Family Study Center, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA. · Biol Psychiatry. · Pubmed #12725973 No free full text.

Abstract: There is little empirical support for the diagnosis of acute stress disorder (ASD) in children and adolescents. Most reports treat ASD as "provisional posttraumatic stress disorder (PTSD)" (meaning that children evidence ASD on the way to a formal diagnosis of PTSD), while speculating on factors that might moderate or mediate the transformation of ASD into PTSD. This report briefly reviews the literature on ASD in the context of presenting a testable, multivariate model for understanding acute stress responses in youth.

Kratochvil CJ, Harrington MJ, Burke WJ, March JS. · Department of Child and Adolescent Psychiatry, University of Nebraska Medical Center, 44th and Emile, Omaha, NE 68198, USA. · Curr Psychiatry Rep. · Pubmed #12126594 No free full text.

Abstract: Anxiety disorders are among the most common psychiatric disorders of childhood, yet limited data is available regarding the use of psychotropic medications for these conditions. Until recently, much of the data on the pharmacologic treatment of pediatric anxiety disorders has consisted of case reports and small open-label studies, with the exception of pediatric obsessive-compulsive disorder (OCD), which has had a comparatively rich literature consisting of several double blind trials. This void has been lessening, however, with four double blind, placebo-controlled studies published in the past year alone. Although the majority of pharmacologic studies of pediatric anxiety continue to focus on the treatment of OCD, additional reports on treatment of generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder have recently been published. This article will review significant pharmacologic studies published in the prior year, and the role of pharmacotherapy in the treatment of pediatric anxiety disorders.

March JS, Vitiello B. · Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, USA. · Int J Neuropsychopharmacol. · Pubmed #11466164 No free full text.

Abstract: This Special Section of Int J Neuropsychopharmacol highlights current progress in paediatric neuropsychopharmacology. Combining critical reviews and, in some cases, new data, specific topics include: biological findings in major depression, sleep dysregulation in depressed youth, cardiovascular and ventilatory dysregulation in panic disorder, paediatric autoimmune neuropsychiatric disorder associated with strep (PANDAS), age of onset as a subtype marker in tic and obsessive--compulsive disorders (OCD), functional and pharmaconeuroanatomy of OCD and the behavioural pharmacokinetics of methylphenidate. In this introductory section, these articles are placed in the context of the state-of-the field and, more specifically, within the framework of recent NIMH initiatives in paediatric neuropsychopharmacology.

March JS, Franklin M, Nelson A, Foa E. · Department of Psychiatry, Duke University Medical Center, Box 3527, Durham, NC 27710, USA. · J Clin Child Psychol. · Pubmed #11294080 No free full text.

Abstract: Discusses the cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder (OCD). Over the past 15 years, cognitive-behavioral psychotherapy has emerged as the psychosocial treatment of choice for OCD across lifespan. Unlike other psychotherapies that have been applied usually unsuccessfully to OCD, cognitive-behavioral treatment (CBT) presents a logically consistent and compelling relationship between the disorder, the treatment, and the specified outcome. Nevertheless, despite a consensus that CBT is usually helpful, clinicians routinely complain that patients will not comply with behavioral treatments and parents routinely complain that clinicians are poorly trained in CBT, with the result that many if not most children and adolescents are denied access to effective psychosocial treatment. This unfortunate situation may be avoidable, given an increased understanding regarding the implementation of CBT in children and adolescents with OCD. To this end, we review the principles and the practical aspects of the cognitive-behavioral treatment of OCD in youth, move on to discuss empirical studies supporting the use of CBT in the pediatric age group, and conclude by discussing directions for future research.

Donnelly CL, Amaya-Jackson L, March JS. · Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA. · J Child Adolesc Psychopharmacol. · Pubmed #10521013 No free full text.

Abstract: OBJECTIVE: To review the current knowledge of pharmacotherapy in the treatment of Post-traumatic Stress Disorder (PTSD) as it applies to children and adolescents and to provide a rational approach to medication use in Pediatric PTSD. METHOD: The literature on the psychopharmacology of Pediatric PTSD is reviewed. Additionally, literature is reviewed on the neurobiological systems presumptively involved in trauma as well as studies in the pharmacology of adult PTSD, as they pertain to the treatment of Pediatric PTSD. RESULTS: There are too few studies in the current Pediatric PTSD literature to confirm treatment recommendations. Downward extrapolation from the adult literature combined with an understanding of the neurobiology of PTSD and its comorbid conditions may serve as the basis for a rational pharmacotherapy of PTSD in childhood. The effectiveness of targeting pharmacological agents at PTSD symptom clusters and associated comorbid conditions remains to be verified in controlled clinical trials. CONCLUSIONS: The state of psychopharmacology for Pediatric PTSD is in its earliest stages. While there are insufficient numbers of controlled pharmacological trials to make firm recommendations, the field requires a starting point for a rational psychopharmacological approach. Pharmacotherapy may provide symptom relief of both the debilitating primary symptoms and the comorbid conditions in children suffering from PTSD.

Riddle MA, Bernstein GA, Cook EH, Leonard HL, March JS, Swanson JM. · Division of Child and Adolescent Psychiatry, Johns Hopkins Medical Institutions, Baltimore, MD, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #10230186 No free full text.

Abstract: OBJECTIVE: To review extant data on the efficacy and safety of anxiolytic medications (benzodiazepines, buspirone, and other serotonin 1A agonists), adrenergic agents (beta-blockers and alpha 2-adrenergic agonists clonidine and guanfacine), and the opiate antagonist naltrexone that have been used to treat various psychopathologies in children and adolescents. To identify critical gaps in our current knowledge about these agents and needs for further research. METHOD: All available controlled trials of these medications in children and adolescents published in English through 1997 were reviewed. In addition, selected uncontrolled studies are included. RESULTS: The major finding, that there are virtually no controlled data that support the efficacy of most of these drugs for the treatment of psychiatric disorders in children and adolescents, is both surprising and unfortunate. For some drugs, e.g., buspirone and guanfacine, this is because no controlled studies have been carried out in children and/or adolescents. For other drugs, e.g., clonidine and naltrexone, most of the placebo-controlled studies have failed to demonstrate efficacy. CONCLUSIONS: The strongest recommendations for controlled studies of safety and efficacy in children and adolescents can be given for the following drugs: benzodiazepines for acute anxiety; buspirone (and newer serotonin 1A agonists as they become available) for anxiety and depression; beta-blockers for aggressive dyscontrol; guanfacine for attention-deficit/hyperactivity disorder; and naltrexone for hyperactivity, inattention, and aggression in autistic disorder.

March JS, Entusah AR, Rynn M, Albano AM, Tourian KA. · Department of Psychiatry, Duke University Medical Center, Durham, North Carolina 27710, USA. · Biol Psychiatry. · Pubmed #17553467 No free full text.

Abstract: BACKGROUND: Social anxiety disorder, which occurs in 2% to 5% of children and adolescents, is associated with significant distress and functional impairment. METHODS: The objective of the randomized, masked controlled trial conducted in 48 academic and community centers in the United States was to evaluate the efficacy of venlafaxine ER in children and adolescents with generalized social anxiety disorder. A volunteer sample of 293 outpatients, age 8 to 17, who met diagnostic criteria for social anxiety disorder and were enrolled between February 2000 and March 2003 participated. Venlafaxine ER or placebo was titrated from a starting dose of 37.5 mg to a maximum dose of 225 mg over 16 weeks. The primary dependent measures were the Social Anxiety Scale, child or adolescent version (SAS-CA) and for responder analysis, a (dichotomized) Clinical Global Impressions-Improvement (CGI-I) score. RESULTS: Compared with placebo, intent-to-treat random regression analyses indicated a statistically significant advantage for venlafaxine ER (p = .001) on the SAS-CA. On the CGI-I responder analysis, 56% (95% confidence interval [CI], 47%-64%) of venlafaxine ER treated subjects responded, which was statistically superior to placebo (37% [95% CI, 29%-45%]). Three venlafaxine ER and no placebo patients developed treatment-emergent suicidality; there were no completed suicides. CONCLUSIONS: Venlafaxine ER is an effective and reasonably well-tolerated treatment for generalized social anxiety disorder in children and adolescents. As with other antidepressants, careful clinical monitoring for adverse events, including treatment-emergent suicidality, is essential.

Barrett P, Healy-Farrell L, March JS. · School of Applied Psychology, Griffith University, Australia. · J Am Acad Child Adolesc Psychiatry. · Pubmed #14691360 No free full text.

Abstract: OBJECTIVE: To evaluate the relative efficacy of (1) individual cognitive-behavioral family-based therapy (CBFT); (2) group CBFT; and (3) a waitlist control group in the treatment of childhood obsessive-compulsive disorder (OCD). METHOD: This study, conducted at a university clinic in Brisbane, Australia, involved 77 children and adolescents with OCD who were randomized to individual CBFT, group CBFT, or a 4- to 6-week waitlist control condition. Children were assessed before and after treatment and at 3 months and 6 months following the completion of treatment using diagnostic interviews, symptom severity interviews, and self-report measures. Parental distress, family functioning, sibling distress, and levels of accommodation to OCD demands were also assessed. Active treatment involved a manualized 14-week cognitive-behavioral protocol, with parental and sibling components. RESULTS: By an evaluable patient analysis, statistically and clinically significant pretreatment-to-posttreatment change occurred in OCD diagnostic status and severity across both individual and group CBFT, with no significant differences in improvement ratings between these conditions. There were no significant changes across measures for the waitlist condition. Treatment gains were maintained up to 6 months of follow-up. CONCLUSIONS: Contrary to previous findings and expectations, group CBFT is as effective in reducing OCD symptoms for children and adolescents as individual treatment. Findings support the efficacy and durability of CBFT in treating childhood OCD.

Cook EH, Wagner KD, March JS, Biederman J, Landau P, Wolkow R, Messig M. · Department of Psychiatry and Pediatrics, University of Chicago, IL 60637, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #11589530 No free full text.

Abstract: OBJECTIVE: To evaluate the safety and effectiveness of sertraline in the long-term treatment of pediatric obsessive-compulsive disorder (OCD). METHOD: Children (6-12 years; n= 72) and adolescents (13-18 years; n = 65) with DSM-III-R-defined OCD who had completed a 12-week, double-blind, placebo-controlled sertraline study were given open-label sertraline 50 to 200 mg/day in this 52-week extension study. Concomitant psychotherapy was allowed during the extension study Outcome was evaluated by the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), National Institute of Mental Health Global Obsessive-Compulsive Scale, and Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) scores. RESULTS: Significant improvement (p < .0001) was demonstrated on all four outcome parameters on an intent-to-treat analysis for the overall study population (n = 132), as well as the child and the adolescent samples. At endpoint, 72% of children and 61% of adolescents met response criteria (>25% decrease in CY-BOCS and a CGI-I score of 1 or 2). Significant (p < .05) improvements were also demonstrated from the extension study baseline to endpoint on all outcome parameters in those patients who received sertraline during the 12-week, double-blind acute study. Long-term sertraline treatment was well tolerated, and there were no discontinuations due to changes in vital signs, laboratory values, or electrocardiograms. CONCLUSION: Sertraline (50-200 mg/day) was effective and generally well tolerated in the treatment of childhood and adolescent OCD for up to 52 weeks. Improvement was seen with continued treatment.

Compton SN, Grant PJ, Chrisman AK, Gammon PJ, Brown VL, March JS. · Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #11349701 No free full text.

Abstract: OBJECTIVE: The aim of this open-label study was to assess the therapeutic benefits, response pattern, and safety of sertraline in children with social anxiety disorder. METHOD: Fourteen outpatient subjects with a primary Axis I diagnosis of social anxiety disorder were treated in an 8-week open trial of sertraline. Diagnostic and primary outcome measures included the Anxiety Disorders Interview Schedule for Children, Clinical Global Impressions scale (CGI), Social Phobia and Anxiety Inventory for Children, and a standardized behavioral avoidance test. RESULTS: As measured by the CGI (Improvement subscale), 36% (5/14) of subjects were classified as treatment responders and 29% (4/14) as partial responders by the end of the 8-week trial. A significant clinical response appeared by week 6. Self-report and behavioral measures showed significant clinical improvement into normal range across all domains measured. The mean dose of sertraline was 123.21+/-37.29 mg per day. Sertraline was generally well tolerated. CONCLUSION: In open treatment, sertraline resulted in significant improvement in symptoms of childhood social anxiety disorder. Absolute response rates varied depending on rating scales used. Findings from this study are sufficiently strong to warrant a future multisite, randomized, double-blind, placebo-controlled trial of sertraline for treatment of childhood social anxiety disorder.

Jensen PS, Hinshaw SP, Swanson JM, Greenhill LL, Conners CK, Arnold LE, Abikoff HB, Elliott G, Hechtman L, Hoza B, March JS, Newcorn JH, Severe JB, Vitiello B, Wells K, Wigal T. · Center for the Advancement of Children's Mental Health, Department of Child Psychiatry, NYSPI/Columbia University, New York, New York 10032, USA. · J Dev Behav Pediatr. · Pubmed #11265923 No free full text.

Abstract: In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), secondary analyses revealed that Comb had a significant incremental effect over MedMgt (with a small effect size for this comparison) when categorical indicators of excellent response and when composite outcome measures were used. In addition, children with parent-defined comorbid anxiety disorders, particularly those with overlapping disruptive disorder comorbidities, showed preferential benefits to the Beh and Comb interventions. Parental attitudes and disciplinary practices appeared to mediate improved response to the Beh and Comb interventions.

Wilens TE, Biederman J, March JS, Wolkow R, Fine CS, Millstein RB, Faraone SV, Geller D, Spencer TJ. · Department of Psychiatry, Massachusetts General Hospital, Boston 02114, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #10230189 No free full text.

Abstract: OBJECTIVE: In a 12 week, placebo-controlled, parallel-design, multicenter study of sertraline for obsessive-compulsive disorder in 107 children and 80 adolescents, the authors prospectively assessed cardiovascular effects to doses of sertraline of < or = 200 mg/day. METHOD: Vital signs (blood pressure and heart rate) and electrocardiograph parameters (ECGs) were systematically evaluated at baseline and again throughout treatment. RESULTS: There were no clinically significant cardiovascular adverse events in any of the subjects enrolled in the study. Moreover, compared with baseline and placebo, sertraline treatment at an average dose of 167 mg did not result in any clinically meaningful changes in any ECG indices (PR, QRS, and QTc intervals), cardiac rhythm, blood pressure, or heart rate. CONCLUSIONS: These prospectively derived results support the cardiovascular safety of sertraline at doses up to 200 mg in children and adolescents.

Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC. · Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287, USA. · N Engl J Med. · Pubmed #18974308 links to  free full text

Abstract: BACKGROUND: Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. METHODS: In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. RESULTS: The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. CONCLUSIONS: Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)

March JS, Franklin ME, Leonard H, Garcia A, Moore P, Freeman J, Foa E. · Department of Psychiatry, Duke University Medical Center, Durham, North Carolina 27710, USA. · Biol Psychiatry. · Pubmed #17241830 No free full text.

Abstract: BACKGROUND: The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS: Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS: Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS: In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.

Kondo DG, Chrisman AK, March JS. · Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27705, USA. · Psychopharmacol Bull. · Pubmed #14608237 links to  free full text

Abstract: Psychiatrists need to update their skills to incorporate advances in psychiatric practice and to do so "at the bedside."To this end, evidence-based medicine (EBM), which is widely used as an educational heuristic in other areas medicine and has begun to make inroad in psychiatry training programs, provides practical methods to access, evaluate, and interpret the medical literature regarding disease causation, prognosis, diagnostic tests, and treatment strategies.With respect to treatment, EBM asserts the primacy of randomized, controlled trials for demonstrating efficacy, and, in some cases, the use of meta-analytic or systematic literature reviews conducted according to pre-specified criteria. Using the common clinical problem of when and how to combine drug and psychosocial interventions at the level of the individual patient, this article illustrates the principles of EBM as they pertain to how best to combine drug and psychosocial treatments for children and adolescents with ADHD.

Barrett P, Healy L, March JS. · School of Applied Psychology, Griffith University, Mount Gravatt, Queensland, 4122, Australia. · Am J Psychother. · Pubmed #12647571 No free full text.

Abstract: Obsessive-compulsive disorder (OCD) is one of the most debilitating of the anxiety disorders. As our knowledge about this childhood condition continues to grow, there is a need for controlled treatment-outcome trials with precise assessments that are sensitive to treatment change, to guide the development of effective interventions. To evaluate the efficacy of a treatment protocol, it is necessary to have reliable and sensitive measures of OCD symptoms, including measures of obsessions, compulsions, and related levels of distress and avoidance. Whilst structured diagnostic interviews, semistructured clinical interviews, and self-report measures have been widely used in the assessment of childhood OCD, related levels of behavioral distress and avoidance have not been measured in treatment-outcome trials. This study investigated the sensitivity of a behavioral avoidance test (BAT), conducted in the home environment, in assessing treatment-outcome effects for children and adolescents with OCD following a 14-week cognitive-behavioral therapy (CBT) family intervention, in comparison to children in an 8-week "waitlist" control group. The results of the current study strongly support the sensitivity of a standardized BAT in assessing treatment-related changes in children and adolescents with OCD. Implications and future directions for research are discussed.

Costello EJ, Pine DS, Hammen C, March JS, Plotsky PM, Weissman MM, Biederman J, Goldsmith HH, Kaufman J, Lewinsohn PM, Hellander M, Hoagwood K, Koretz DS, Nelson CA, Leckman JF. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA. · Biol Psychiatry. · Pubmed #12361667 No free full text.

Abstract: To expand and accelerate research on mood disorders, the National Institute of Mental Health (NIMH) developed a project to formulate a strategic research plan for mood disorder research. One of the areas selected for review concerns the development and natural history of these disorders.The NIMH convened a multidisciplinary Workgroup of scientists to review the field and the NIMH portfolio and to generate specific recommendations. To encourage a balanced and creative set of proposals, experts were included within and outside this area of research, as well as public stakeholders.The Workgroup identified the need for expanded knowledge of mood disorders in children and adolescents, noting important gaps in understanding the onset, course, and recurrence of early-onset unipolar and bipolar disorder. Recommendations included the need for a multidisciplinary research initiative on the pathogenesis of unipolar depression encompassing genetic and environmental risk and protective factors. Specifically, we encourage the NIMH to convene a panel of experts and advocates to review the findings concerning children at high risk for unipolar depression. Joint analyses of existing data sets should examine specific risk factors to refine models of pathogenesis in preparation for the next era of multidisciplinary research. Other priority areas include the need to assess the long-term impact of successful treatment of juvenile depression and known precursors of depression, in particular, childhood anxiety disorders. Expanded knowledge of pediatric-onset bipolar disorder was identified as a particularly pressing issue because of the severity of the disorder, the controversies surrounding its diagnosis and treatment, and the possibility that widespread use of psychotropic medications in vulnerable children may precipitate the condition. The Workgroup recommends that the NIMH establish a collaborative multisite multidisciplinary Network of Research Programs on Pediatric-Onset Bipolar Disorder to achieve a better understanding of its causes, course, treatment, and prevention. The NIMH should develop a capacity-building plan to ensure the availability of trained investigators in the child and adolescent field.Mood disorders are among the most prevalent, recurrent, and disabling of all illnesses. They are often disorders of early onset. Although the NIMH has made important strides in mood disorders research, more data, beginning with at-risk infants, children, and adolescents, are needed concerning the etiology and developmental course of these disorders. A diverse program of multidisciplinary research is recommended to reduce the burden on children and families affected with these conditions.

Giulino L, Gammon P, Sullivan K, Franklin M, Foa E, Maid R, March JS. · Child and Family Study Center, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27705, USA. · J Child Adolesc Psychopharmacol. · Pubmed #12188984 No free full text.

Abstract: The diagnosis of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) requires a prospectively determined association between group A beta-hemolytic streptococcal (GABHS) infection and obsessive-compulsive disorder (OCD) or tic disorder. Screening for GABHS infection imposes a significant burden on both patient and clinician. To heighten the index of suspicion for PANDAS, it would be useful to know if parent-reported upper respiratory infection (URI) is associated with PANDAS symptoms or associated characteristics. Eighty-three consecutive, clinically referred patients aged 6 to 17 years with a primary diagnosis of OCD and their primary caregivers were asked about URI signs and symptoms at the time of OCD onset, PANDAS symptoms, OCD and tic symptoms, comorbidity, and putative PANDAS risk factors. Specific inquiry regarding URI symptoms proved more informative than general inquiry. In the URI present versus URI absent group, more patients experienced a sudden rather than insidious onset of symptoms. Additionally, more patients with a URI plus sudden onset exhibited a comorbid tic disorder. Until validated biomarkers permit retrospective diagnosis, a history that OCD began around the time of a URI should clue the clinician to look prospectively for PANDAS. Additional research is required to define the boundaries of PANDAS and to develop psychometrically reliable and valid diagnostic strategies.

Abikoff HB, Jensen PS, Arnold LL, Hoza B, Hechtman L, Pollack S, Martin D, Alvir J, March JS, Hinshaw S, Vitiello B, Newcorn J, Greiner A, Cantwell DP, Conners CK, Elliott G, Greenhill LL, Kraemer H, Pelham WE, Severe JB, Swanson JM, Wells K, Wigal T. · New York University School of Medicine, New York, USA. · J Abnorm Child Psychol. · Pubmed #12109488 No free full text.

Abstract: Examined hypothesized gender and comorbidity differences in the observed classroom behavior of children with attention deficit hyperactivity disorder (ADHD). The behavior of 403 boys and 99 girls with ADHD, ages 7-10, was compared (a) to observed, sex-specific classroom behavior norms, (b) by sex, and (c) by comorbid subgroups. Boys and girls with ADHD deviated significantly from classroom norms on 15/16 and 13/16 categories, respectively. Compared to comparison girls, girls with ADHD had relatively high rates of verbal aggression to children. Boys with ADHD engaged in more rule-breaking and externalizing behaviors than did girls with ADHD, but the sexes did not differ on more "neutral," unobtrusive behaviors. The sex differences are consistent with notions of why girls with ADHD are identified and referred later than boys. Contrary to hypothesis, the presence of comorbid anxiety disorder (ANX) was not associated with behavioral suppression; yet, as hypothesized, children with a comorbid disruptive behavior disorder (DBD) had higher rates of rule-breaking, and impulsive and aggressive behavior, than did children with ADHD alone and those with ADHD+ANX. Elevated rates of ADHD behaviors were also observed in children with comorbid DBD, indicating that these behaviors are truly present and suggesting that reports of higher ADHD ratings in this subgroup are not simply a consequence of negative halo effects and rater biases.

Waters TL, Barrett PM, March JS. · School of Applied Psychology, Griffith University, Mount Gravatt, Queensland, 4122, Australia. · Am J Psychother. · Pubmed #11641879 No free full text.

Abstract: The effectiveness of a 14-week cognitive-behavioral family treatment protocol for childhood obsessive-compulsive disorder (OCD) was piloted using a volunteer sample of seven children aged 10-14 years. The primary outcome measures were diagnostic status, symptom severity, and global functioning which were assessed at pre- and post-treatment, and at three-month follow-up. A series of self-report measures assessing obsessive-compulsive symptomatology, depression, and family factors were also completed at pre- and post-treatment. The results indicated that six participants no longer met criteria for OCD at post-treatment, with a mean reduction of 60% in symptom severity. Self-reported obsessive-compulsive symptomatology and family involvement in the disorder also significantly decreased across time. The findings support the efficacy of cognitive-behavioral treatment with a structured family component for childhood OCD. Further research investigating the comparative efficacy of treatment with and without family involvement is warranted.

Jensen PS, Hinshaw SP, Kraemer HC, Lenora N, Newcorn JH, Abikoff HB, March JS, Arnold LE, Cantwell DP, Conners CK, Elliott GR, Greenhill LL, Hechtman L, Hoza B, Pelham WE, Severe JB, Swanson JM, Wells KC, Wigal T, Vitiello B. · Center for the Advancement of Children's Mental Health, Columbia University/NYSPI, 1051 Riverside Drive, Unit 78, New York, NY 10032, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #11211363 No free full text.

Abstract: OBJECTIVES: Previous research has been inconclusive whether attention-deficit/hyperactivity disorder (ADHD), when comorbid with disruptive disorders (oppositional defiant disorder [ODD] or conduct disorder [CD]), with the internalizing disorders (anxiety and/or depression), or with both, should constitute separate clinical entities. Determination of the clinical significance of potential ADHD + internalizing disorder or ADHD + ODD/CD syndromes could yield better diagnostic decision-making, treatment planning, and treatment outcomes. METHOD: Drawing upon cross-sectional and longitudinal information from 579 children (aged 7-9.9 years) with ADHD participating in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), investigators applied validational criteria to compare ADHD subjects with and without comorbid internalizing disorders and ODD/CD. RESULTS: Substantial evidence of main effects of internalizing and externalizing comorbid disorders was found. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to the MTA behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to MTA medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. CONCLUSIONS: Findings indicate that three clinical profiles, ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder (ADHD + ANX), ADHD co-occurring with ODD/CD but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes different from "pure" ADHD with neither comorbidity. Future clinical, etiological, and genetics research should explore the merits of these three ADHD classification options.

Compton SN, Nelson AH, March JS. · Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #10939233 No free full text.

Abstract: OBJECTIVE: To examine the developmental progression and pattern of self-reported symptoms of social phobia (SP) and separation anxiety (SA) in community (n = 2,384) and clinical (n = 217) samples of children and adolescents, using a cross-sectional method. METHOD: Subjects were cross-classified by age, gender, and race. Using mean scores on the SP and SA subscales of the Multidimensional Anxiety Scale for Children, 4 categories of children were established: HighSP/HighSA, HighSP/LowSA, LowSP/HighSA, and LowSP/LowSA. Data were analyzed using a generalized logit model. RESULTS: Community sample: Preadolescents and females reported more symptoms of HighSP/HighSA and LowSP/HighSA than adolescents and males. White children reported more symptoms of HighSP/LowSA, while the opposite pattern was found among African-American children. Clinical sample: Similar to the community sample, preadolescents reported more symptoms of HighSP/HighSA. However, clinical males reported more symptoms of LowSP/HighSA than clinical females. CONCLUSIONS: In general, adolescents endorsed more symptoms of SP and fewer symptoms of SA than preadolescent children. Irrespective of age, white children endorsed more symptoms of SP and fewer symptoms of SA than African-American children. In the community sample, preadolescent boys endorsed more symptoms of SA and fewer symptoms of SP, suggesting a possible referral bias.