TS+, The Tourette Syndrome "Plus" Blog

Autism Linked to Superior Information Processing Skills

Leslie E. Packer PhD — Sun, 25 Mar 2012 23:03:44 +0000

Rick Nauert, PhD writes:

New research from the UK suggests people with autism have a greater than normal capacity for processing information.

This aptitude is evident even when the presentation is presented rapidly. Autistic individuals are also better at detecting information defined as ‘critical.’

Investigators believe the findings may help to explain the apparently higher than average prevalence of people with autism spectrum disorders in the IT [information technology] industry.

Possible causes of sudden onset OCD in kids broadened

Leslie E. Packer PhD — Sat, 24 Mar 2012 23:03:30 +0000

Criteria for a broadened syndrome of acute onset obsessive compulsive disorder (OCD) have been proposed by a National Institutes of Health scientist and her colleagues. The syndrome, Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), includes children and teens that suddenly develop on-again/off-again OCD symptoms or abnormal eating behaviors, along with other psychiatric symptoms – without any known cause.

PANS expands on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), which is limited to a subset of cases traceable to an autoimmune process triggered by a strep infection. A clinical trial testing an immune-based treatment for PANDAS is currently underway at NIH and Yale University (see below).

“Parents will describe children with PANS as overcome by a ‘ferocious’ onset of obsessive thoughts, compulsive rituals and overwhelming fears,” said Susan Swedo, M.D., of the NIH’s National Institute of Mental Health (NIMH), who first characterized PANDAS two decades ago. “Clinicians should consider PANS when children or adolescents present with such acute-onset of OCD or eating restrictions in the absence of a clear link to strep.”

Swedo, James Leckman, M.D., of Yale University, and Noel Rose, M.D., Ph.D. of Johns Hopkins University, propose working criteria for PANS in February 2012 in the open source journal Pediatrics & Therapeutics.

“As the field moves toward agreement on this broadened syndrome, affected youth will be more likely to receive appropriate care, regardless of whether they are seen by a neurologist, pediatrician or child psychiatrist,” said NIMH Director Thomas R. Insel, M.D.

Differing causes sharing a “common presentation”

The PANS criteria grew out of a PANDAS workshop convened at NIH in July 2010, by the NIMH Pediatric and Developmental Neuroscience Branch, which Swedo heads. It brought together a broad range of researchers, clinicians and advocates. The participants considered all cases of acute-onset OCD, regardless of potential cause.

Clinicians reported that evaluations of more than 400 youth diagnosed with PANDAS confirmed that affected boys outnumbered girls 2:1, with psychiatric symptoms, always including OCD, usually beginning before 8 years.

Although debate continues about the fine points, the field is now of one mind on the core concept of “acute and dramatic” onset of a constellation of psychiatric symptoms. There is also broad agreement on the need for a “centralized registry” that will enable the research community to analyze evidence from studies that will eventually pinpoint causes and treatments. Such a registry is currently under development by members of the International Obsessive Compulsive Foundation (IOCDF).

Since a diagnosis of PANS implies no specific cause, clinicians will have to evaluate and treat each affected youth on a case-by-case basis.

“PANS will likely turn out to include a number of related disorders with different causes that share a common presentation,” explained Swedo.

The authors propose that a patient must meet 3 diagnostic criteria for a diagnosis of PANS:

Abrupt, dramatic onset of OCD or anorexia.
Concurrent presence of at least two additional neuropsychiatric symptoms with similarly severe and acute onset. These include: anxiety; mood swings and depression; aggression, irritability and oppositional behaviors; developmental regression; sudden deterioration in school performance or learning abilities; sensory and motor abnormalities; somatic signs and symptoms.
Symptoms are unexplainable by a known neurologic or medical disorder.

Among the wide range of accompanying symptoms, children may appear terror stricken or suffer extreme separation anxiety, shift from laughter to tears for no apparent reason, or regress to temper tantrums, “baby talk” or bedwetting. In some cases, their handwriting and other fine motor skills worsen dramatically. Leckman’s team at the Yale Child Study Center is in the process of developing assessment tools for diagnosing the syndrome.

PANDAS treatment study targets errant antibodies

Meanwhile, Swedo, Leckman, and Madeleine Cunningham of the University of Oklahoma, and colleagues, are collaborating on a new, multi-site placebo-controlled study, testing the effectiveness of intravenous immunoglobulin (IVIG) for reducing OCD symptoms in children with PANDAS.

Previous human and animal research suggested mechanisms by which strep-triggered antibodies mistakenly attack specific brain circuitry, resulting in obsessional thoughts and compulsive behaviors.

“Strep bacteria has evolved a kind of camouflage to evade detection by the immune system,” Swedo explained. “It does this by displaying molecules on its cell wall that look nearly identical to molecules found in different tissues of the body, including the brain. Eventually, the immune system gets wise to this ‘molecular mimicry,’ recognizes strep as foreign, and produces antibodies against it; but because of the similarities, the antibodies sometimes react not only with the strep, but also with the mimicked molecules in the human host. Such cross-reactive ‘anti-brain’ antibodies can cause OCD, tics, and the other neuropsychiatric symptoms of PANDAS.”

IVIG, a medication derived from normal antibodies, neutralizes such harmful antibodies, restoring normal immune function. It is used to treat other autoimmune illnesses and showed promise in a pilot study with PANDAS patients.

“We predict that IVIG will have striking benefits for OCD and other psychiatric symptoms, and will prove most effective for children who show high levels of anti-brain antibodies when they enter the study,” said Swedo.

Prospective study participants are first screened by phone by investigators at the NIH or the Yale Child Study Center. Those who meet eligibility requirements are then randomized to receive either active IVIG or a placebo procedure during a brief inpatient stay at the NIH Clinical Center. The researchers remain blind to which children received the active medication; after 6 weeks of placebo control, they give any children whose symptoms fail to improve the option to receive open-label active treatment.

In addition to assaying for antibodies that attack brain cells, the researchers use magnetic resonance imaging to see if the treatment reduces inflammation in an area of the brain known as the basal ganglia, which is thought to be the target of the errant antibodies. They also analyze levels of immune system chemical messengers (cytokines) in cerebrospinal fluid and blood – with an eye to identifying biomarkers of disease activity and potential predictors of treatment response.

The study was launched with support from the NIH Clinical Center’s Bench to Bedside program, which encourages such intramural-extramural collaborations in translational science.

Children with PANS and PANDAS sometimes experience sudden loss of fine motor skills.
Source: Susan Swedo, M.D., NIMH Pediatric and Developmental Neuroscience Branch

Reference:

Swedo, SE, Leckman JF, Rose, NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). Feb 2012, Pediatrics & Therapeutics.

Source: National Institute of Mental Health

Recruiting Participants for Study on the Benefits of Exercise on Childhood Tourette syndrome and Obsessive-Compulsive Disorder Symptoms

Leslie E. Packer PhD — Thu, 22 Mar 2012 21:30:54 +0000

I’m re-posting a recruitment notice as slots are still available if you want to enroll your child in the study described below, which has received Institutional Review Board approval:

Participants sought for a study exploring the possible benefits of aerobic exercise on children and adolescents with Tourette syndrome (TS) and Obsessive-Compulsive Disorder (OCD). The study has received Institutional Review Board approval from Hofstra University, New York.

Children and adolescents ages 8-16 diagnosed with both TS and OCD are eligible to participate in a 6-week, 12-session aerobic exercise program. All sessions will be conducted in the participants’ home for ease and convenience.

Each exercise session will take approximately 30 minutes. Two-three 15-minute interviews will be conducted prior to beginning the exercise intervention, and one interview will be conducted one month after the end of the exercise intervention.

Participants who complete the study and follow-up will receive $250.

Participants can be on medication, but cannot be undergoing medication changes during the study.

Study Location: Long Island, New York

For additional information or to sign up, contact Loren Packer-Hopke, M.S. via telephone: 516-359-0859 or e-mail: lpackerhopke@yahoo.com

And yes, in the interests of full disclosure: the doctoral candidate is related to me, but the study is her own and has been approved by her university. Also, you do not have to be on Long Island to participate as sessions can be conducted by Skype.

Seminar: Moving On: Preparing Students with Autism, Asperger’s and Learning Differences for College

Leslie E. Packer PhD — Thu, 22 Mar 2012 16:56:07 +0000

If you are the parent of a high school student, you’ll want to know about this event sponsored by The Yale Child Study Center:

Moving On: Preparing Students with Autism, Asperger’s and Learning Differences for College

This full day seminar is designed to assist college-bound students on the autism spectrum (and their parents) cope with expectations and pressures, and understand their domestic and academic responsibilities. Topics include identifying the right program/institution, social and communication supports, and managing anxiety, among others.

Sunday, April 22, 2012, 10:00 a.m. – 4:00 p.m.
Yale University, School of Medicine
333 Cedar Street, New Haven, CT
Harkness Auditorium

You can download the workshop agenda here and find more information on the workshop here.

Columbus School District Sued Over Accusations of Locking Disabled Students in Padded Rooms

Leslie E. Packer PhD — Sun, 18 Mar 2012 03:17:28 +0000

Molly Bloom reports on a lawsuit over seclusion:

…. the Ohio Legal Rights Service says it has initiated a “district-wide investigation of abuse, neglect and/or significant rights violation” in Columbus, Ohio’s largest school district.

The investigation came about after the mother of an autistic student contacted the agency about her son being placed seclusion room — which she called a “closet” — more than once, according to the lawsuit. The mother said that her son, who is autistic, “had urinated in the room, was lying on the floor, and contracted a staph infection,” according to the lawsuit.

An agency investigator visited the school and described the seclusion room as a “a padded room with a metal door that had two peep holes and a foot latch lock,” according to the lawsuit. The agency said in the lawsuit that they believe at least four Columbus elementary schools have these kinds of rooms.

Read more about the case on NPR, where you can also read a copy of the lawsuit.

Update on Bizarre Outbreak of Tourette-like Symptoms in New York

Leslie E. Packer PhD — Sun, 18 Mar 2012 02:47:58 +0000

Back in November, I noted that there was a bizarre outbreak of Tourette-like symptoms in a number of high school girls in LeRoy, New York. Since that time, the number of people affected has increased, and controversy has continued to swirl around that cause of the outbreak. While some have argued that the cases are due to conversion disorder (“mass hysteria”), others have sought a more organic basis. Erin Brockovich has been conducting her own investigation into the possibility that environmental contaminants are responsible. As of today, there is no evidence that environmental contaminants are the likely cause, but investigations are not complete. Others have claimed that PANDAS (now called PANS) is the cause (i.e., an autoimmune response to infection gone awry). An article by Alison Motuk in Nature provides some of the background on this case and the possibilities that are being explored. The following segment and other news clips linked at the end of the segment give a sense of how complicated this situation has been:

On a positive note, although the cause of the mystery is still unresolved, some of those affected are now getting better.

Climate Change Obsessions?

Leslie E. Packer PhD — Sun, 18 Mar 2012 02:22:53 +0000

Sarah Harvey reports that doctors in New Zealand have observed that some patients with OCD are getting developing obsessions and compulsions relating to climate change:

More than a quarter of patients with obsessive compulsive disorder (OCD) in a recent study in Australia were found to have obsessions which directly related to climate change. The majority were male.

The patients were found to be carrying out rituals, such as checking lights, stoves and taps were turned off, so they could reduce their global footprint.

[...]

Two participants were convinced increased air temperatures would result in rapid evaporation of the water leading to their pets dying of thirst if they didn’t check that the water bowls were full.

Another patient was continually checking skirting boards, pipes, roofs and wooden structures for problems they were convinced were caused by global warming.

Study authors Mairwen Jones, Bethany Wootton, Lisa Vaccaro and Ross Menzies said: “While these behaviours are not particularly unusual for people with this condition, it was the rationale they provided for carrying them out that was surprising.

“Instead of checking and rechecking so as to prevent fire or flood, the rituals were specifically performed so as to reduce their global footprint, or respond to climate change-induced negative events.

“While it is not particularly surprising that some people with OCD may have concerns related to climate change, what is surprising is the extent of these concerns.”

The Benefits of Exercise on OCD Symptoms

Leslie E. Packer PhD — Sun, 18 Mar 2012 01:49:17 +0000

Noted in The Yeshiva World:

In a review of three separate meta-analyses, investigators at Arizona State University found that patients who participated in at least 21 minutes daily of aerobic exercise experienced a reduction in anxiety (Petruzzello SJ et al; 1991). A more recent study from Canadian researchers at the University of Manitoba in Winnipeg noted that regular exercise may help people who suffer from OCD, phobias and other psychiatric disorders. When the investigators examined studies of anxiety disorder and exercise dating back to 1981, they found that strength training, running, walking, and other forms of aerobic exercise help relieve mild to moderate depression and may also help treat anxiety and substance abuse.

I’m looking forward to seeing how my daughter’s dissertation study comes out. And if you have a child who has, or may have, Post-Traumatic Stress Disorder, you may want to consider enrolling them in a similar study on the benefits of exercise.

Office for Civil Rights Data Suggests Racial and Disability Status Disparities in Discipline, Restraint, and Seclusion

Leslie E. Packer PhD — Sun, 18 Mar 2012 01:16:53 +0000

The Office for Civil Rights Data Collection (CRDC) aggregates data nationally. They recently released a report, which I’ve uploaded here. The report contains some statistics that come as no surprise to advocates but are still very disturbing. I’ve pulled out a few of the figures in this post.

Let’s start with racial disparities in discipline. As the following figure illustrates, African-American students represent 18% of students in the CRDC sample, but 35% of students suspended once, 46% of those suspended more than once, and 39% of students expelled.

In contrast to African-American students, the rates of discipline in Hispanic students appears to be comparable to their rates in the general sample. Asian-Pacific students have lower rates of discipline compared to their rates in the general sample. White students make up 51% of the general sample, but only 39% of those being expelled.

So how do we explain these data? And what do we do with them?

The data on disability and discipline are also of concern. CRDC’s data show that students with disabilities who are classified under I.D.E.A. are more than twice as likely to receive one or more out-of-school suspensions than their non-disabled peers.

Why the significant discrepancy? If the students’ disabilities are related to behavioral problems, those problems should be addressed in behavior intervention plans with positive supports. Why are we throwing children out of school at higher rates if they have disabilities? Could it be that school personnel are looking to get a break from challenging students and so suspend them more readily? Or is it the case that school personnel generally lack adequate training and skills to manage the behavioral features of some disabilities and don’t know what else to do?

Students with disabilities are also significantly more likely to be physically restrained than their non-disabled peers. Nearly 70% of restrained students have disabilities even though they comprise only 12% of the general sample.

Not surprisingly, African-American students with disabilities are significantly more likely to be subjected to mechanical restraints than other disabled students or their non-disabled peers:

When we look at the seclusion data for students with disabilities, it appears that Hispanic students with disabilities are at disproportionate risk of being put into seclusion rooms:

Disappointingly, the data collection does not provide any analysis of seclusion data on the basis of disability vs. no disability. Since seclusion is only supposed to be use for emergency situations in which there is an imminent risk of injury to the student or others, such data might shed some light on how often these rooms are actually being used – or overused.

Keep in mind that these patterns may not accurately reflect the state of discipline your school district. The report provides a comparison chart for some major urban school districts but they also note that their methodology in data collection may limit interpretations:

The CRDC has generally been collected biennially from school districts in each of the 50 states plus the District of Columbia. The CRDC for SY 2009-10 was collected in two parts. Part 1 is beginning-of-year “snapshot” data and Part 2 is cumulative and end-of-year data. The 2009-10 CRDC contains information on about 7,000 school districts and over 72,000 schools in those districts. It is important to note that the CRDC does not include data from all school and districts in the nation, although it does include data from all districts with greater than 3,000 students and 85% of all students. The conclusions in this report therefore apply only to these districts and schools sampled.

In other words, we need to be caution in drawing any conclusions from the data. But it’s always the case that we need to be cautious in drawing conclusions and that should not stop us from pointing to data that suggests discriminatory handling and asking, “What do we need to do better?”

Here’s a media report from Associated Press on the report and reactions to it.

Carousel image credit: © Battrick | Dreamstime.com

The lesson of the mismatched earrings

Leslie E. Packer PhD — Fri, 16 Mar 2012 15:04:10 +0000

Today is my mother’s birthday and I miss her dearly. But this post is not about grief. It’s about a lesson she taught me a few months ago, shortly before her death.

Mom had excellent – and expensive – taste in clothes and jewelry, but I’ve never met anyone who lost as much jewelry as she did.

Anyway…. one day when my daughter and I went to pick her up to take her out for lunch, I noticed that her earrings didn’t match each other. Being a psychologist and knowing that she was over 90 years old, my first thought was “Uh oh… is this cognitive decline?” So during lunch, I casually asked her, “What’s up with the earrings, Mom?”

“Oh,” Mom said. “I lost the mates to these but I loved both pairs so much that I decided I’d just wear them together. I’m starting a new fashion trend!”

I chuckled over her attitude and confidence.

After Mom’s death, as we went through her belongings to sort things out, I came across those two mismatched earrings that she had worn that day.

They weren’t her most expensive earrings, but they now had sentimental value to me.

And so I took one of those earrings to my jeweler and had him make it into a ring that I wear on my hand. I look at it and remember the lesson she taught me that day – that we can grieve what we may have lost or we can enjoy what we have and start our own trend.

If you’re parenting a child with challenges, you have a choice. It’s understandable that you may grieve for a while over what you might have had or dreams for the future that seem lost. But if you continue to grieve over what might have been, you may miss out on enjoying the child you have.

Wouldn’t today be a good day to start your own trend?

Carousel image: Mom in 2003.

Attentional performance in children and adolescents with tic disorder and co-occurring ADHD

Leslie E. Packer PhD — Thu, 15 Mar 2012 21:18:35 +0000

Those of us who work with or parent children and adolescents with Tourette syndrome (TS) have often had to educate teachers how tics or any premonitory urges can distract a student from a lesson. But we all “know” that it’s really any co-morbid Attention Deficit Hyperactivity Disorder (ADHD) that is the real “killer” on attention. So… does TS really impact core attentional abilities or does a child with TS have the same attention ability as any “normal” child who might be distracted while having hiccups?

A study by researchers in Germany suggests that TS does not impair core attentional abilities and that, TS by itself (“pure TS) may actually confer some benefit:

The aim of the present study was to investigate the effect of both tic disorder (TD) and attention-deficit/hyperactivity disorder (ADHD) on attentional functions. N=96 children and adolescents participated in the study, including n=21 subjects with TD, n=23 subjects with ADHD, n=25 subjects with TD+ADHD, and n=27 controls. Attentional performance was tested based on four computerized attention tasks (sustained attention, divided attention, go/nogo and set shifting). The effect of TD as well as ADHD on attentional performance was tested using a 2 × 2 factorial approach. A diagnosis of TD had no negative impact on attentional functions but was associated with improved performance in the set shifting task. By contrast, regardless of a diagnosis of TD, subjects with ADHD were found to perform worse in the sustained attention, divided attention and go/nogo task. No interaction effect between the factors TD and ADHD was revealed for any of the attention measures. Our results add to findings from other areas of research, showing that in subjects with TD and ADHD, ADHD psychopathology is often the main source of impairment, whereas a diagnosis of TD has little or no impact on neuropsychological performance in most cases and even seems to be associated with adaptive mechanisms.

You can download the full article in .html or .pdf (free resource).

Reference

Greimel E, Wanderer S, Rothenberger A, Herpertz-Dahlmann B, Konrad K, Roessner V. Attentional performance in children and adolescents with tic disorder and co-occurring attention-deficit/hyperactivity disorder: new insights from a 2 × 2 factorial design study. J Abnorm Child Psychol.2011 Aug;39(6):819-28.

On the functional anatomy of the urge-for-action

Leslie E. Packer PhD — Thu, 15 Mar 2012 20:56:51 +0000

Some premonitory urges are experienced as an urge to action. Such urges have been described in a number of clinical conditions including Tourette syndrome and Obsessive-Compulsive Disorder (OCD). An interesting article in the September 2011 issue of Cognitive Neuroscience looks at their functional underpinnings. Here’s the abstract:

Several common neuropsychiatric disorders (e.g., obsessive-compulsive disorder, Tourette syndrome (TS), autistic spectrum disorder) are associated with unpleasant bodily sensations that are perceived as an urge for action. Similarly, many of our everyday behaviors are also characterized by bodily sensations that we experience as urges for action. Where do these urges originate? In this paper, we consider the nature and the functional anatomy of “urges-for-action,” both in the context of everyday behaviors such as yawning, swallowing, and micturition, and in relation to clinical disorders in which the urge-for-action is considered pathological and substantially interferes with activities of daily living (e.g., TS). We review previous frameworks for thinking about behavioral urges and demonstrate that there is considerable overlap between the functional anatomy of urges associated with everyday behaviors such as swallowing, yawning, and micturition, and those urges associated with the generation of tics in TS. Specifically, we show that the limbic sensory and motor regions-insula and mid-cingulate cortex-are common to all of these behaviors, and we argue that this “motivation-for-action” network should be considered distinct from an “intentional action” network, associated with regions of premotor and parietal cortex, which may be responsible for the perception of “willed intention” during the execution of goal-directed actions.

If you’re interested, you can download the full article here in .html or here in .pdf (free resource).

Reference:

Jackson SR, Parkinson A, Kim SY, Schüermann M, Eickhoff SB. On the functional anatomy of the urge-for-action. Cogn Neurosci. 2011 Sep;2(3-4):227-243.

Sensory phenomena associated with repetitive behaviors in OCD

Leslie E. Packer PhD — Thu, 15 Mar 2012 20:43:58 +0000

Sensory phenomena in Tourette syndrome and Obsessive-Compulsive Disorder (OCD) fascinate me, and I was delighted to learn that a number of investigators were undertaking some systematic studies on them. Here’s the abstract of one of the studies:

A substantial number of patients with obsessive-compulsive disorder (OCD) report compulsions that are preceded not by obsessions but by subjective experiences known as sensory phenomena. This study aimed to investigate the frequency, severity, and age at onset of sensory phenomena in OCD, as well as to compare OCD patients with and without sensory phenomena in terms of clinical characteristics. We assessed 1,001 consecutive OCD patients, using instruments designed to evaluate the frequency/severity of OC symptoms, tics, anxiety, depression, level of insight and presence/severity of sensory phenomena. All together, 651 (65.0%) subjects reported at least one type of sensory phenomena preceding the repetitive behaviors. Considering the sensory phenomena subtypes, 371 (57.0%) patients had musculoskeletal sensations, 519 (79.7%) had externally triggered “just-right” perceptions, 176 (27.0%) presented internally triggered “just right,” 144 (22.1%) had an “energy release,” and 240 (36.9%) patients had an “urge only” phenomenon. Sensory phenomena were described as being as more severe than were obsessions by 102(15.7%) patients. Logistic regression analysis showed that the following characteristics were associated with the presence of sensory phenomena: higher frequency and greater severity of the symmetry/ordering/arranging and contamination/washing symptom dimensions; comorbid Tourette syndrome, and a family history of tic disorders. These data suggest that sensory phenomena constitute a poorly understood psychopathological aspect of OCD that merits further investigation.

Reference

Ferrão YA, Shavitt RG, Prado H, Fontenelle LF, Malavazzi DM, de Mathis MA, Hounie AG, Miguel EC, do Rosário MC. Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: An exploratory study of 1001 patients. Psychiatry Res. 2012 Feb 21.

Atypical Antipsychotic More Effective than Older Drugs in Treating Childhood Mania, but Side Effects Can Be Serious

Leslie E. Packer PhD — Thu, 15 Mar 2012 20:16:27 +0000

While stimulant medications may not pose a serious risk of cardiac complications, atypical neuroleptics such as risperidone (Risperdal) are associated with serious risks of other types of problems.

The antipsychotic medication risperidone is more effective for initial treatment of mania in children diagnosed with bipolar disorder compared to other mood stabilizing medications, but it carries the potential for serious metabolic side effects, according to an NIMH-funded study published online ahead of print January 2, 2012, in the Archives of General Psychiatry.

Background

Childhood bipolar disorder is a relatively rare but seriously impairing condition. It is also associated with an increased risk of substance use disorders and suicide. To treat symptoms of mania, a key symptom of the disorder, medications such as mood stabilizers or antipsychotics are often prescribed. However, no prior study has addressed the question of which medication to try first.

In the Treatment of Early Age Mania (TEAM) study, Barbara Geller, M.D., of Washington University in St. Louis, and colleagues randomized 290 children ages 6-15 years diagnosed with bipolar I disorder (having mixed or manic symptoms) to treatment with lithium, divalproex sodium or risperidone for an 8-week trial. None of the children had taken an anti-manic medication before. Lithium has been used to treat bipolar disorder for many years. Divalproex sodium is an anticonvulsant mood stabilizer commonly prescribed to treat bipolar disorder as well. Risperidone is an atypical antipsychotic that has been approved by the U.S. Food and Drug Administration for the treatment of mania in youth age 10 and older.

Results of the Study

After eight weeks, 68.5 percent of the children taking risperidone showed improvement in manic symptoms, compared to 35.6 percent of those taking lithium and 24 percent of those taking divalproex sodium. Overall, 24.7 percent discontinued the trial, but more children taking lithium—32.2 percent—discontinued the trial compared to those taking risperidone (15.7 percent discontinued) or divalproex sodium (26 percent discontinued.)

However, those taking risperidone also gained more weight than those on the other medications—an average of more than 7 lbs compared to around 3 lbs for those taking lithium and 3.7 lbs for those taking divalproex sodium. Those taking risperidone were also more likely to experience other metabolic side effects, such as an increase in cholesterol levels, compared to those on the other medications.

Significance

The researchers concluded that risperidone was significantly more effective than lithium or divalproex sodium for initial treatment of childhood mania. In addition, the children were less likely to discontinue the drug compared to those taking lithium or divalproex sodium, indicating a higher tolerance for it. This finding is consistent with other studies that have compared second-generation antipsychotics like risperidone to placebo in treating childhood mania.

However, the researchers caution that risperidone is associated with adverse metabolic effects that can increase the risk for diabetes and cardiovascular problems. They note that many children responded to low doses of the medication, suggesting that clinicians should be conservative when determining how to dose the medication. A lower dose may minimize the potential for serious side effects. The researchers also caution that because diagnostic measures for childhood bipolar disorder are not always consistent across studies, and because the validity of such a diagnosis in younger children is under debate, TEAM findings may not generalize to patients diagnosed using other measures.

What’s Next

More research is needed to develop safer, more effective interventions for children with early onset bipolar disorder for both initial and longer term treatment.

Reference

Geller B, Luby J, Josh P, Wagner KD, Emslie G, Walkup JT, Axelson DA, Bolhofner K, Robb A, Wolf DV, Riddle MA, Birmaher B, Ryan ND, Severe J, Vitiello B, Tillman R, Lavori P. A randomized controlled trial of risperidone, lithium and divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Archives of General Psychiatry. Online ahead of print January 2, 2012.

Source: National Institute of Mental Health Science Update

Stimulant Treatment for ADHD Not Associated With Increased Risk of Cardiac Events in Youth

Leslie E. Packer PhD — Thu, 15 Mar 2012 20:11:07 +0000

Every so often, I read alarming case reports that raise the possibility that the use of stimulant medications might cause heart problems (or sudden death) in children and teens with ADHD. More controlled studies generally find that such is not the case and that there were other factors that caused the deaths, but such reports do alarm parents. Here’s a press release issued last month by the Journal of the American Academy of Child and Adolescent Psychiatry on this topic:

Attention-deficit/hyperactivity disorder (ADHD) affects 5- 9% of youth and is frequently treated with stimulant medications, such as methylphenidate and amphetamine products. A recent safety communication from the US Food and Drug Administration advised that all patients undergoing ADHD treatment be monitored for changes in heart rate or blood pressure.

Amidst growing concern over the risks of stimulant use in youth, a study by Dr. Mark Olfson of the New York State Psychiatric Institute and Columbia University, and his colleagues, published in the February 2012 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, assessed the risk of adverse cardiovascular events in children and adolescents without known heart conditions treated with stimulants for ADHD. It is one of the largest studies to date focusing primarily on youth while controlling for pre-existing cardiovascular risk factors.

As reported in the study, Olfson and colleagues examined claims records from a large privately insured population for associations between cardiovascular events in youth with ADHD and stimulant treatment. In total 171,126 privately insured youth aged 6-21 years without known pre-existing heart- related risk factors were followed throughout the study.

The study included patients who have previously received stimulant treatment, patients currently receiving stimulant treatment, and patients who began or ceased stimulant treatments during the study period. Olfson and colleagues assessed the various groups for incidents of severe cardiovascular events such as acute myocardial infarction, less severe cardiovascular events such as cardiac dysrhythmias, and cardiovascular symptoms such as tachycardia and palpitations. Analysis showed that cardiovascular events and symptoms were rare in this cohort and not associated with stimulant use.

This finding helps to allay concerns of adverse events in otherwise healthy young people receiving treatment for ADHD. Olfson and colleagues said of the results, “It is reassuring that in these young people, short-term stimulant treatment did not substantially increase the risk of cardiovascular events or symptoms.”

The article, “Stimulants and Cardiovascular Events in Youth With Attention-Deficit/Hyperactivity Disorder” by Mark Olfson, Cecilia Huang, Tobias Gerhard, Almut G. Winterstein, Stephen Crystal, Paul D. Allison, Steven C. Marcus (doi:10.1016/j.jaac.2011.11.008) appears in Journal of the American Academy of Child and Adolescent Psychiatry, Volume 51, Issue 2 (February 2012), published by Elsevier.

This study was supported by National Institute of Mental Health grant R21 MH079905, Agency for Healthcare Research and Quality award U18 HS016097, and the Center for Education and Research on Mental Health Therapeutics.