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Background: To describe trends and clinical experiences in applying commercial pharmacogenetic testing among pediatric patients with neuropsychiatric disorders. Methods: Demographic and clinical data of patients receiving GeneSight® testing from January 2015 to November 2016 at an urban pediatric hospital were retrospectively extracted from medical charts. Outcome data included pharmacogenetic test results and medication prescriptions before and after the test. Results: A total of 450 patients (12.1 ± 4.3 years) diagnosed with anxiety disorder, attention deficit hyperactivity disorder, developmental disorders including autism, and/or a mood disorder received testing, and 435 of them were prescribed medications. Comparing data before and after testing, the total number of psychotropic prescriptions were reduced by 27.2% and the number of prescribed medications with severe gene-drug interactions decreased from 165 to 95 (11.4% to 8.9% of total medications prescribed). Approximately 40% of actionable genetic annotation were related to CYP2CD6 and CYP2C19. Patients of Asian descent had significantly higher likelihood than other races of being classified as poor to intermediate metabolizers of antidepressants, mood stabilizers, and antipsychotics (p = 0.008, 0.007, and 0.001, respectively). Diagnoses, including autism spectrum disorder, were not associated with increased risks of severe gene-drug interactions. Conclusions: Pharmacogenetic testing in child and adolescent psychiatry is currently based on few clinically actionable genes validated by CPIC and/or FDA. Although this approach can be moderately utilized to guide psychotropic medication prescribing for pediatric patients with psychiatric disorders, clinicians should cautiously interpret test results while still relying on clinical experience and judgment to direct the final selection of medication.

Although Music Therapy, an allied health discipline, is often included in standard care for the treatment of children with mental health disorders, there is a lack of empirical evidence to support its contribution for the care of children and adolescents in mental health services. The goal of this retrospective research is to examine whether group music therapy affects mood states of adolescent inpatients in a psychiatric hospital service based within a large children’s hospital. A secondary aim was to understand if specific patient demographic predictors influenced the mood outcome. Participants included 352 predominately white, non-Hispanic patients (12–21 years old, with a mean age of 15.13 ± 1.88 years) who completed 596 mood measures between August 2010 and March 2013. Participants completed the Fast Assessment of Children’s Emotions (FACE) before and after a group music therapy session. Based on a binary outcome model of change or no change, the probability of a change in total mood score was high (probability of change 0.82 [95%CI 0.79, 0.85]). There were no significant associations between age, gender, or other specific demographics that were tested, nor changes in individual or total mood scores within this sample. This preliminary research documents the immediate impact of group music therapy sessions on mood of adolescent patients in this setting diagnosed with a range of psychiatric disorders.

Epidemiologic, prospective, and retrospective research confirms that family relational variables are significant risk factors for the development of mental and physical health problems in children as well as adults. In addition, relationships also play a moderating role in the maintenance, exacerbation, or amelioration of chronic health problems. Although acknowledgment of the importance of these variables in the pathophysiology of a number of health conditions is reaching more prominence, the integration of assessments of family factors as part of standard health care has made little progress. With the arrival of the Affordable Care Act in the United States, there is a desire for earlier identification of these risk factors, and the ability to implement prevention programs that reduce risk, and enhance protective factors. On a global level, there is increased awareness of the health impact of relational problems, for example, many countries have attempted to implement programs to decrease domestic violence. More reliable and standardized assessments of key relational processes will enhance both of these missions, and allow comparison of a variety of prevention and intervention programs. This article discusses progress over the last decade in constructing more reliable definitions of relationship processes, how these have been integrated into the Diagnostic and Statistical Manual 5th edition (DSM-5), and progress toward implementation into the World Health Organization's International Classification of Diseases (ICD-11).

Caregiving relationships are significant factors in the development, mediation, or moderation of childhood mental health problems. However, epidemiological and clinical research has been limited by lack of reliable, succinct, and standardized methods of assessing parent-child relationship constructs. The Relational Processes Workgroup (ad hoc to the DSM-5 process) proposed more specific criteria to define a parent-child relational problem (PCRP). These criteria were field tested in one of the DSM-5 Field trial sites, utilizing a similar research design as DSM-5. Participants included 133 symptomatic children (5-17 years) in active treatment for a mental health problem and their primary caregiver (86% mothers). Two separate clinicians, each blinded to the assessment of the other clinician as well as the DSM-5 diagnoses, interviewed the dyads within a 2-week period, utilizing the proposed PCRP criteria. Prior to each interview, parents were asked to write about their relationship with their child, and children (over the age of 10 years) filled out the Parental Bonding Instrument, Brief Current, and the Perceived Criticism Measure. Clinicians were able to read the narratives and see results of the child report measures before assessing the dyad. The weighted prevalence of a PCRP in this sample was 34%. The interclass kappa for overall agreement between clinicians was 0.58 (0.40, 0.72), which indicates good interrater reliability. Further, clinicians found the PCRP diagnostic criteria clinically useful and an improvement over the brief description of PCRP that was presented in DSM-IV. Relationships between children and their primary caregiver can be assessed in a reliable manner, based on clinical interview with the child-caregiver dyad and several self-report measures. Language: en

Background: Art for Life is a community arts mentorship program, connecting 25 Kindergarten through high school student/patients within a large children's hospital to 25 volunteer artist-mentors for 5 months each year. The students attend a unique in-hospital academic program called the Medical Day Treatment (MDT) program, designed to help patients with many chronic medical conditions. The Art for Life program is structured and facilitated by creative arts therapists (art, music and dance/movement therapists) who recruit community artist-mentors, match them to the MDT students and then provide the therapeutic foundation for the one-on-one mentoring relationships. Methods: A qualitative program evaluation, using structured interviews with 21 individuals offering different perspectives, was designed to identify the impact of the Art for Life program on participating students and artist-mentors. Results: Common themes include the perceived importance of mentorship relationships, reported increase in students...

Although dance/movement therapy (DMT) is often used in conjunction with traditional therapies for treating children with psychiatric disorders, the evidence base for this therapy is currently small. The goal of this retrospective research is to examine whether DMT, embedded within larger psychiatric therapeutic programs, affects changes in mood states of adolescents suffering from a variety of psychiatric illnesses. Participants include 402 predominately white, non-Hispanic patients (14–21 years old, with a mean age of 14.56 ± 1.70 years) who completed 671 mood measures between August 2010 and December 2011. Participants completed the Fast Assessment of Children's Emotions before and after a group DMT session. When controlling for pre-mood scores, there was a significant change in all mood states and a significant odds of a change in total mood score, per unit increase in pre-total mood score, after one DMT session (odds ratio = 1.84; p ≤ .01). There was no significant association between patient characteristics and changes in individual or total mood scores, indicating that DMT may be useful for a wide range of patients. The results from this formative study will help researchers develop prospective studies focusing on therapeutic effects of DMT for a wide range of patients.

To investigate the prevalence of asthma and mental health problems among representative samples of youth in high-risk service settings and the community, and to examine the relationship between asthma and mental health in these groups.Data were drawn from the Alternative Service Use Patterns of Youth with Serious Emotional Disturbance Study (SED) (n = 1181), a combined representative, cross-sectional sample of youth in various clinical settings and the community. Multiple logistic regression analyses were used to examine the association between asthma and mental disorders. Demographic characteristics were investigated as potential confounders.Asthma was common among 15.2% of youth in service settings and 18.8% of youth in the community. The prevalence of mental disorders was extremely high among youth with and without asthma in all service settings, and asthma was associated with increased prevalence of mental disorders among youth in the community, but not among youth in service settings. The relationship between asthma and internalizing disorders among youth in the community does not appear entirely attributable to confounding by demographics.Findings are consistent with and extend previous data by showing that both asthma and mental disorders are disproportionately common among youth in high-risk service settings. Almost half of youth with asthma in service settings meet diagnostic criteria for a mental disorder. Clinicians and policy makers who are responsible for the health care of youth in these high-risk groups should be aware that asthma is common, and that the prevalence of internalizing disorders are especially common among those with asthma.

Art, music, yoga, and dance/movement therapies have been researched individually, mostly in adults, but few studies explain the impact of integrating these therapies into the treatment of children with psychiatric illnesses. Given the financial constraints of current healthcare, as well as limitations of verbal and medical therapies, it is important to document the added value of integrating complementary therapies, including creative arts therapies, into childhood mental health and treatment. The present study looked to evaluate views of clinical professionals ( n = 23) (i.e. psychiatrists, psychologists, and social workers), nurses (n = 17) and milieu staff (mental health counselors; n = 56) within the Psychiatry Department of a large children's hospital on the perceived benefits of integrating Complementary and Alternative Medicine (CAM) therapies within inpatient and day treatment programs. The majority of respondents (96% of clinicians, 100% of nurses, and 82% of milieu staff) reported that CAM positively impacted patient care. Staff indicated that sessions facilitated by masters level creative arts therapists or yoga therapists helped patients by increasing self esteem, increasing motor coordination and body control, providing relaxation, teaching coping skills, decreasing acting out behaviors, developing patient's awareness of emotions or underlying issues, and helping to broach difficult topics or issues for the first time. Milieu staff who participated in CAM groups alongside patients also received personal and professional benefits.

This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity. For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children. These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.

Background: Respiratory problems have been shown to be associated with the development of panic anxiety. Family members play an essential role for children to emotionally manage their symptoms. This study aimed to examine the relation between severity of respiratory symptoms in children with asthma and separation anxiety. Relying on direct observation of family interactions during a mealtime, a model is tested whereby family interactions mediate the relation between asthma severity and separation anxiety symptoms. Methods: Sixty-three children (ages 9–12 years) with persistent asthma were interviewed via the Diagnostic Interview Schedule for Children IV; family interactions were assessed via direct observation of a mealtime; primary caregivers completed the Childhood Asthma Severity Scale; youth pulmonary function was ascertained with pre- and post-bronchodilator spirometry; adherence to asthma medications was objectively tracked for six weeks. Results: Poorer pulmonary function and higher functional asthma severity were related to higher numbers of separation anxiety symptoms. Controlling for medication adherence, family interaction patterns mediated the relationship between poorer pulmonary function and child separation anxiety symptoms. Conclusions: Family mealtime interactions may be a mechanism by which respiratory disorders are associated with separation anxiety symptoms in children, potentially through increasing the child’s capacity to cognitively frame asthma symptoms as less threatening, or through increasing the child’s sense of security within their family relationships.

Because family oriented patient care improves patient outcome and reduces family burden, clinical family skills of communication, assessment, alliance, and support are part of core competencies required of all residents. Teaching residents to "think family" as part of core competencies and to reach out to families requires change in the teaching environment.This article advocates teaching residents family skills throughout the training years as an integrated part of routine patient care rather than in isolated family clinics or a course in "family therapy." It reviews family skills required of residents in all treatment settings and family skills that are specific to inpatient, emergency room, outpatient, and consultation-liaison services.Families can be seen in multiple treatment settings throughout resident training using recent research to support appropriate interventions for patients and caregivers.The process of establishing change in the training environment requires a commitment on the part of the training faculty to include families, but is possible within the current training framework.

RATIONALE: This study assesses the relationships between ADHD symptoms, specific family asthma management domains, and pediatric asthma morbidity. METHODS: Participants were 110 children with asthma and a respective parent (ages 7-17, X = 11.6 years, 25% ethnic/racial minority). Parents completed measures of asthma morbidity and report of child ADHD symptoms. Children completed measures of attention, concentration, and impulsivity. Families participated in the Family Asthma Management System Scale (FAMSS) interview to assess the effectiveness of eight features of asthma management. RESULTS: Parent report of ADHD symptoms and poor child performance on a computerized task of sustained visual attention were associated with asthma morbidity. Paper and pencil tasks of visual attention, and an index of auditory attention, were not related to asthma morbidity. Modest associations were found between parent report of ADHD symptoms, child performance-based indicators of attention and concentration, and features of family asthma management, although not across all measures. The family response to asthma partially mediated the relationship between ADHD symptoms and morbidity. CONCLUSIONS: ADHD symptoms are modestly associated with difficulties in family asthma management.

The purpose of this study was to examine the association between asthma symptom perception measured during a 5–6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7–17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each “subjective” guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV1. An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV1) and a lower proportion of SM blows (using FEV1) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV1 more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception. Pediatr Pulmonol. 2007; 42:339–347. © 2007 Wiley-Liss, Inc.

Objective A new condition, "child affected by parental relationship distress" (CAPRD), was introduced in the DSM-5 . A relational problem, CAPRD is defined in the chapter of the DSM-5 under "Other Conditions That May Be a Focus of Clinical Attention." The purpose of this article is to explain the usefulness of this new terminology. Method A brief review of the literature establishing that children are affected by parental relationship distress is presented. To elaborate on the clinical presentations of CAPRD, four common scenarios are described in more detail: children may react to parental intimate partner distress; to parental intimate partner violence; to acrimonious divorce; and to unfair disparagement of one parent by another. Reactions of the child may include the onset or exacerbation of psychological symptoms, somatic complaints, an internal loyalty conflict, and, in the extreme, parental alienation, leading to loss of a parent–child relationship. Results Since the definition of CAPRD in the DSM-5 consists of only one sentence, the authors propose an expanded explanation, clarifying that children may develop behavioral, cognitive, affective, and physical symptoms when they experience varying degrees of parental relationship distress, that is, intimate partner distress and intimate partner violence, which are defined with more specificity and reliability in the DSM-5 . Conclusion CAPRD, like other relational problems, provides a way to define key relationship patterns that appear to lead to or exacerbate adverse mental health outcomes. It deserves the attention of clinicians who work with youth, as well as researchers assessing environmental inputs to common mental health problems.

The purpose of this study was to evaluate the safety and efficacy of asenapine in adolescents with schizophrenia.In an 8 week, randomized, double-blind placebo-controlled trial, subjects (12-17 years of age) meeting Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria for schizophrenia were randomized 1:1:1 to placebo, asenapine 2.5 mg b.i.d., or asenapine 5 mg b.i.d. Subjects who completed the 8 week acute study could participate in a 26 week flexible-dose asenapine-only open-label extension (OLE).A similar percentage of subjects completed treatment on day 56 (2.5 mg b.i.d. (n=98): 83%; 5 mg b.i.d. [n=106]: 79%; placebo [n=102]: 79%). In the mixed model for repeated measures analysis of the primary end-point (with Hochberg correction for multiplicity), least squares (LS) mean differences between asenapine and placebo on the Positive and Negative Syndrome Scale (PANSS) total score at day 56 were not significant (-4.8 for 2.5 mg b.i.d., p=0.070; -5.6 for 5 mg b.i.d., p=0.064). Significant improvement in the Clinical Global Impressions-Severity score was observed in the 5 mg b.i.d. group versus placebo on day 56 (LS mean -0.3, p=0.024). In the acute phase, ≥7% weight gain and the composite event of somnolence, sedation, and hypersomnia were more common in both asenapine groups than in the placebo group. Akathisia, fasting glucose elevation, and extrapyramidal syndrome were more common in the 5 mg b.i.d. group than in the placebo group. There were no unexpected adverse events in the OLE, and PANSS total scores decreased by -16.1 points in the group previously treated with placebo (n=62) and by -11.2 points in the continuous asenapine group (n=131) from OLE baseline to week 26.Although improvements in PANSS total score at day 56 of the acute phase were numerically greater for both asenapine 2.5 and 5 mg b.i.d. than for placebo and were maintained in the OLE, the primary end-point did not achieve statistical significance in the acute phase. No new or unexpected safety concerns were detected during the acute phase or after an additional 26 weeks of asenapine treatment in the adolescent population with schizophrenia.NCT01190254 and NCT1190267 at ClinicalTrials.gov.

Efforts to expand and update the description of relational processes in theDiagnostic and Statistical Manual of Mental Disorders(DSM) to enhance its clinical utility began with DSM-IV, but met with limited success. The current effort to revise the description of relational problems has focused on both the DSM-V and theInternational Classification of Diseases(ICD)-11, with an emphasis on (1) documenting a solid empirical foundation for inclusion of relational processes in these diagnostic systems and (2) creating categories and symptom sets that reflect that empirical foundation. In this chapter we describe the process that led to the current revisions, along with steps that were taken to ensure broad consensus and relevance for a range of countries and cultures. We also briefly recap several arguments for continued attention to relational processes as well as additional changes that might be considered in future revisions. Finally, we also briefly discuss the issue of whether some relational processes are better thought of as categories in addition to being dimensions. Scientific aspects of the project have been very productive. However, revision of relational problem descriptions in DSM-V was limited and final revisions to the ICD-11 are still underway.

The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) has made many strides but can be improved with the addition of relationship descriptions. Relational patterns may result from individual genetic risk factors and thus help to define disorders more clearly. Relationships may also mediate genetic risk factors and be useful in identifying the genetic vulnerability, or they may moderate underlying vulnerable genes so that they are less expressed. Key prototypic relationship patterns have inherent interest to humans, moderate numerous illnesses, and deserve attention in and of themselves. Similar to the use of genetic strategies in clarifying taxons of individual disorders, genetic strategies can help delineate patterns within these key relationships, their common origins, their common outcomes, and their distinctions from near-neighbor patterns.

Objective: To assess posttraumatic stress (PTS) symptoms in adolescents with and without asthma and their parents and the relationship between PTS symptoms and asthma morbidity. Method: Three groups of adolescents (12-18 years) participated: adolescents who had experienced a life-threatening asthma episode (n = 49), asthma controls (n = 71), and healthy controls (n = 80). Adolescents completed the UCLA PTSD Reaction Index, Multidimensional Anxiety Scale for Children, and Reynolds Depression Inventory. Parents completed the Impact of Events Scale-Revised, Brief Symptom Inventory, and Asthma Functional Morbidity Scale. Results: Twenty percent of adolescents with life-threatening asthma met criteria for PTSD compared with 11% of the asthma controls and 8% of the normal controls. Twenty-nine percent of parents of adolescents with life-threatening asthma met criteria for PTSD compared with 14% of parents of asthma controls and 2% of normal controls. Adolescent PTS symptoms accounted for 5% of the variance in functional asthma morbidity even after controlling for disease severity and other anxiety and depressive symptoms (β = .26). Conclusions: Adolescents with asthma and their parents, particularly those who have experienced a life-threatening event, have high levels of PTS symptoms that are linked to asthma morbidity. Interventions to improve asthma outcomes should include assessment and treatment of trauma and PTS symptoms.

The authors provide a description of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and its limitations, as well as empirical connections between relational processes and mental health. Four types of relational processes are identified, with each type clearly distinguished in terms of its pattern of association with psychopathology. For illustrative purposes, examples are provided along with suggestions of how each might be accommodated in the DSM-V. In view of the importance and complexity of the connections between relational processes and mental health, the authors argue that reliable and standardized assessments of relational processes are needed and suggest 6 possible approaches for providing better coverage of relational processes and relational disorders in the DSM-V. The article concludes with a discussion of potential concerns about expansion of attention to relational processes in the DSM-V.

Non-adherence with prescribed asthma treatment causes compromised treatment effectiveness, including greater morbidity, mortality, and health care utilization costs. As a result, there is an increasing interest in measuring patient adherence behaviors. Electronic monitoring devices offer a promising method for assessing patient adherence behavior patterns. The reliability of the Doser Clinical Trials (CT) (Meditrack Products, Hudson, MA), an inexpensive, pressure-actuated device that monitors metered-dose inhaler (MDI) usage, was evaluated in a field study of outpatient pediatric asthmatics. Canister weight and various Doser CT measures of patient medication use were compared to determine the reliability and usefulness of the device. Doser CTs were dispensed to 16 research subjects for use on corticosteroid MDIs over a period of several months. One Doser CT per month was dispensed to each subject. Doser CTs were collected at 30-60 day intervals, with a total of 61 months of Doser CT data obtained across the subjects. MDI canister weights were monitored for a subset of 6 subjects. Usable Doser CT data were summarized and average adherence estimates were computed. Adherence estimates differed from one another and the adherence estimate, as measured by canister weight, was significantly higher than each Doser CT estimate. However, overall, the Doser CT showed adequate reliability as evidenced by high correlations among the Doser CT estimates of adherence and the existing gold standard of canister weight. The Doser CT is likely to be useful for monitoring MDI use in clinical care and research, potentially providing greater accuracy than the standard of canister weight.

Objective: To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population. Methods: Data were drawn from the National Comorbidity Survey ( n =5877), a representative sample of adults age 15–54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression. Results: Childhood abuse was associated with significantly increased odds of panic attacks (OR=2.2 (1.5, 3.1)) and depression (OR=1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR=1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR=10.7 (2.2, 51.5)). Conclusion: These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association.

Background: Asthma knowledge is frequently assumed to be a prerequisite for optimal asthma treatment. However, the validity of existing asthma knowledge questionnaires has not been rigorously examined, and no contemporary measure of asthma knowledge has received widespread acceptance. Objective: To construct and examine the psychometric properties of an asthma knowledge instrument, and its association with demographic and psychosocial variables, asthma medication adherence, and treatment outcome. Methods: A 25-item Asthma Knowledge Questionnaire was developed with input from national pediatric asthma experts. Parents of 155 children with asthma completed the Asthma Knowledge Questionnaire as well as demographic, family functioning, and home environment measures. Asthma outcomes and adherence with inhaled medication was measured across 12 months. Results: Despite the many steps taken to develop a strong measure of asthma knowledge, reliability was relatively poor. There was also no association between asthma knowledge and treatment adherence or outcomes. Furthermore, asthma knowledge was not a unidimensional construct and was not a simple function of education. Conclusions: Findings from this study, in combination with previous studies of asthma knowledge questionnaires, suggest that the construction of a simple self-report asthma knowledge instrument for use as a primary outcome measure demonstrating mastery of asthma self-management skills may not be achievable. (J Allergy Clin Immunol 2003;111:498-502.)

This article examines the usefulness of the Family Assessment Device(FAD) in assessing family functioning with school-aged children (under 12 years of age) compared to children 12 and older and mothers. FAD reports from 194 children with asthma (132 under 12 years; 62 12 years and older) were evaluated in comparison to mothers' FAD reports as well as mothers' reports on two other family functioning measures: the Family Inventory of Life Events (FILE) and the Impact on Family (IOF) scale, both relevant to functioning in families with children with asthma. Although FAD scale reliabilities were lowest in younger children (alpha = 48-.79), good concurrent validity was found with mothers' reports on the three different measures of family functioning. Older childrens' FAD scales showed good reliability (> .70) but poorer agreement with the various maternal measures. With modifications to make items more structured and simplified, the FAD could be tried with younger children, although documentation of improved reliability is needed before more widespread use with school-aged children is advocated. The measure already shows good agreement with maternal report in this younger age group, which likely would be strengthened with improved reliability. FAD reports in older children correlated less well with maternal measures, but may represent nonredundant information on family health from an independent perspective and are worth considering in addition to mothers' perspectives.

Objective: To explore the influences of adolescent self-reported and interviewer-rated perceptions of family functioning, parent perceptions of the family, and adolescent personality on internalizing symptoms. Method: Two hundred one adolescent twins (mean age = 16.2 ± 2.0 years; 90% white) completed the Family Assessment Device (FAD), Eysenck Personality Inventory, Children's Depression Inventory, and Multidimensional Anxiety Scale for Children and participated in an interview about their relationships with parents. Parents completed the FAD. Twins were divided into two samples for analysis. Results: Multiple regression analyses in sample A showed that adolescent perceptions of family function accounted for 35% of the variance in depressive symptoms, but did not significantly predict anxiety. Self-reported perceptions were more strongly associated with symptoms than were interviewer-rated perceptions. Parent FAD and adolescent neuroticism accounted for 24% of the variance in adolescent self-reported perceptions. Results were similar in sample B. Conclusions: Adolescent perceptions of the family are linked to their depressive symptoms and associated with neuroticism. Adolescents who are high in neuroticism may perceive their families more negatively. Clinicians need to carefully discern components of family function that lead to teen depression versus biased cognitions that lead teenagers to perceive family relationships as negative.

To evaluate the reliability and validity of a standardized asthma outcome coding system, we obtained medical records for 182 asthmatic children. Records were coded by trained staff using explicit and detailed criteria. Outcome variables coded included number of corticosteroid bursts, asthma-related physician contacts, emergency room visits, hospitalizations, and number of asthma episodes. Interrater reliability was excellent. Patterns of associations between the coded variables and other independently obtained outcome measures supported concurrent and construct validity. Given the intense scrutiny of health outcomes in the current managed-care marketplace, use of this system may foster further clinical research examining asthma outcomes.

Mood states of youth have a strong influence on their cooperation, comfort, and engagement in many health care and educational settings. Children who are fearful, angry, or sad are more likely to have difficulty learning new skills or connecting with others. Many interventions are used in hospital and school settings to help youth, but it is difficult to assess their effectiveness without appropriate assessment tools that are easy to administer, age appropriate, and psychometrically sound. We examined the validity and reliability of the Fast Assessment of Children's Emotions (FACE). After obtaining parental consent and youth assent, 61 patients ages 12 to 17 years were recruited from the psychiatry services at a large children's hospital. Participants completed the FACE, the Brunel Mood Scale (BRUMS), and a measure of satiety at three time points-before and after a 60-minute psychotherapeutic intervention and after lunch. The FACE measure was significantly correlated with the BRUMS (r(2) = 0.85; p < .001) and not correlated with the satiety measure (r(2) = -0.17; not significant). Cronbach's α for the FACE was 0.7734. The FACE showed significant changes in mood from before to after the therapeutic intervention for all patients. For general psychiatry patients, the FACE did not change significantly after lunch, although for patients with eating disorders, the FACE did indicate an increase in distressed emotions after lunch. This finding indicates sensitivity to change in a clinically meaningful manner. The FACE is easy to use and may be used quickly to assess mood changes in adolescents.

To examine a measure of children's perception of their relationships with parents.The Child and Adolescent Psychiatric Assessment (CAPA) was administered to 114 inpatients (aged 9-18 years) at a tertiary asthma center from 1991 to 1994. Ten items from the CAPA were developed as a separate scale, the Parent-Child Relationship Scale (PCRS). Some subjects (82) were given family and child assessments.The PCRS had good internal reliability (Cronbach alpha = .72). Construct validity was demonstrated by correlations with child and parent report on the Family Assessment Device (r= 0.46 and 0.35; p.001) and high expressed emotion of the parent (t= 2.89; p.01). Divergent validity may be evidenced by the fact that the PCRS was not significantly related to high emotional over-involvement. Predictive validity was shown by significant correlations with the total problem scores of parents' (r = 0.28; p.01) and children's (r = 0.41; p.001) Achenbach reports, and prediction of CAPA psychiatric diagnosis (OR = 5.83; 95% CI 1.80-22.63).The PCRS can potentially be used to assess the child's perspective of the parent-child relationship for research or clinical purposes and deserves further study.

Abstract This paper reports the differences between two methodologies for threshold detection of added resistive loads in children and adolescents. The first-generation apparatus utilized a series of laminar flow screens to present various total resistances, while in the second generation the apparatus utilized a servo-controlled cone that occluded an aperture to varying degrees. Protocol modifications in the second generation methodology included forced choice, attentional enhancements, and larger increments of added resistance. Two studies conducted 2 years apart provided data on the first and second generations of methodology. All participants in Study 1 (N = 33) and Study 2 (N = 33) were children with asthma. Subjects were matched for both age and asthma severity. Results showed the methodologic improvements in the second generation to be significant. Tracking and random thresholds were achieved by 85% and 82% of the subjects in Study 2 compared to 76% and 42% in Study 1, respectively. The correlation between the mean tracking and random thresholds was .40 in Study 2 compared to a statistically insignificant result in Study 1, indicating improved reliability. Raw thresholds were correlated with intrinsic resistance in both studies (r = .29-.88), supporting the use of Weber's Law in resistive loading studies of children. Results using the second generation methodologic improvements demonstrate that children as young as age 7 can complete resistance loading protocols. Standard methodology will enhance the comparability between studies.

Clinical studies have shown a relationship between allergic disorders and depression, panic disorder, attention deficit/hyperactivity disorder, and social anxiety for a significant subset of patients with these disorders. The nature of the relationship, whether due to shared environmental or biologic vulnerabilities or as a result of the stress of chronic illness, has been less clear. By examining the covariance of atopic disorders and depressive symptoms in a community sample of monozygotic (MZ) and dizygotic (DZ) twins, the contribution of genetic and/or shared environmental etiological factors can be established. A Finnish sample of 1337 MZ and 2506 DZ twin pairs, ages 33–60 years, was sent questionnaires inquiring about history of asthma, eczema, and atopic rhinitis, as well as the Beck Depression Inventory (BDI). The nature of the covariation between twins of these symptoms was investigated by fitting competing genetic and environmental models. Within-person correlation between atopic symptoms and BDI was 0.103 (P < 0.001) for the total sample. Using the Mx statistical modeling program to fit the data to competing quantitative genetic models, the best fitting model estimated that 64% of the association between atopy and BDI was due to shared familial vulnerability, primarily additive genetic influences. Although the measures for allergic disorders and depression are crude, this study supports the hypothesis that there is a small shared genetic risk for atopic and depressive symptoms, and if replicated, may open research for common mechanisms between allergic and depressive disorders. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:146–153, 2000. © 2000 Wiley-Liss, Inc.

Objective: To examine the concept of treatment alliance in the care of adolescents with asthma. Methods: Measures of treatment alliance were obtained from 60 adolescents with severe, chronic asthma admitted to a tertiary care facility, their parents, and their asthma specialists at the referral center. Associations were examined between the alliance measures and multimeasure, multiagent data concerning family functioning and asthma treatment adherence and outcome. Results: Physicians’ reports of treatment alliance were associated with concurrent family functioning and asthma medication adherence, as well as with asthma treatment adherence and outcome in the year after the stay at the asthma center. Conclusions: As emphasized in the recently revised Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997), the ability of children with asthma, their parents, and their physician to create a positive partnership, or treatment alliance, appears to have an important role in optimal asthma management.

The relationship of atopic and behavioral symptoms in a community sample of 66 monozygotic and 141 dizygotic twin pairs, ages 4–11 years, was investigated via mother report questionnaires. Within-person correlation between atopic symptoms and Child Behavior Checklist internalizing symptoms (CBCL-INT) was .21 ( p

Objective To determine whether physiological severity of asthma is associated with increased psychological symptoms in children. Method Participants were 337 children, aged 7 to 19 years (mean 11.9, SE 0.13), and a parent of each child. Children's asthma severity was rated by experienced pediatric asthma specialists using current guidelines from the National Heart, Lung, and Blood Institute. Children filled out the Children's Manifest Anxiety Scale and the Weinberger Adjustment Inventory. Parents reported on their child's medical history, completed the Child Behavior Checklist (CBCL) about their child, and completed the Pennebaker Inventory of Linguid Languidness as a measure of their own physical symptoms. Result Child-rated anxiety symptoms were unrelated to asthma severity or to markers of asthma functional morbidity. Parental ratings of internalizing symptoms in their children were related to severity. Parent physical symptoms explained 10.2 % of the variance in CBCL Internalizing symptoms, and asthma severity added an additional 6.7% to the variance. Conclusion Asthma severity may be a more salient stressor to parents, who in turn report higher levels of child internalizing symptoms for children with severe asthma, than to children themselves. Contrary to prior hypotheses, children with severe asthma did not rate themselves as having higher levels of anxiety than those with mild or moderate asthma or than standardized norms.

This study evaluated which factors most influenced the impact of childhood asthma on the child's family. Seventy children/families seen at a tertiary-care hospital for asthma were evaluated. Stepwise multiple regression examined the effects of illness severity; family socioeconomic status (SES); family structure; social support; child's emotional characteristics; parent's health; family functioning; and maternal psychological distress on the Family Impact of Illness Scale. Analysis indicated that only the parent's Psychiatric Symptom Index significantly predicted impact scores. The most important predictors of how much impact a child's asthma has on the family are parental emotional distress and amount of social support.

Children with asthma frequently have significant anxiety and depression that interfere with treatment outcome. Although the use of antidepressants may be helpful, in the one published study of antidepressant use in pediatric asthma, significant side effects necessitated discontinuance; these side effects were increased motor activity, impulsive behavior, insomnia, postural hypotension, premature auricular contractions, diastolic hypertension, and generalized seizure. The objective of this retrospective chart review was to examine whether antidepressants could be tolerated and administered safely to children on asthma medications. Forty pediatric inpatients (mean age 13.3 years, range 7-19) with varying levels of asthma severity (5 mild, 11 moderate, 24 severe) and an average duration of asthma treatment of 10.0 years were administered antidepressants while also taking an average of 5 medications for asthma (range 2-7). Ten of the patients had an additional comorbid medical diagnosis. There were 17 children diagnosed with a primary affective disorder; 7 with a primary anxiety disorder; and 16 with both an affective and anxiety disorder. Thirty-six children ultimately were continued on an antidepressant: 13 on desipramine, 9 on nortriptyline, 6 on imipramine, 4 on fluoxetine, 3 on bupropion, and 1 on sertraline. Significant cardiovascular side effects (tachycardia, hypertension, and postural hypotension) occurred in 4 subjects on tricyclic antidepressants (TCAs) and 1 subject on a non-TCA (fluoxetine); 3 of these subjects were able to continue treatment with an antidepressant. Two subjects were taken off antidepressants because of hypomanic symptoms (increased motor activity, mood lability, impulsive behavior, and insomnia). No medications were discontinued because of electrocardiogram changes, arrhythmias, or seizures. Doses of TCAs were comparable to those in previous studies, but the asthma medications differed. Discussion of current anti-asthmatic medications and potential for interactions with antidepressants is included.

There are currently no manualized, intensive outpatient programs (IOP), for diagnostically heterogeneous pediatric samples that simultaneously intervene with youth and parents. Such a program was developed and has been operating at Children’s Hospital Colorado since January 2006. The current study was conducted to characterize the patient sample and evaluate clinical outcomes for this novel program. The study used a method of retrospective chart review to examine demographic and diagnostic information of youth and their families, who participated in IOP. Clinical outcomes were similarly assessed, using paired-samples t test comparisons of the baseline and endpoint parent-report versions of the Ohio Youth Outcome Scales. Results indicated that there were statistically significant differences in each of the Subscale scores on the Ohio Youth Scales from baseline to endpoint of IOP. Preliminary findings suggest that participation in the IOP program was associated with improved clinical outcomes, at the end of treatment.

Background A small percentage of all cases of schizophrenia have a childhood onset. The impact on the individual and family can be devastating. We report the results of genetic analyses from a patient with onset of visual hallucinations at 5 years, and a subsequent diagnosis at 9 years of schizophrenia, attention deficit hyperactivity disorder (ADHD) with hyperactivity and impulsivity, and chronic motor tic disorder. Results Karyotypic analysis found 45,XX,i(13)(q10) in all cells examined. Alpha satellite FISH of isochromosome 13 revealed a large unsplit centromeric region, interpreted as two centromeres separated by minimal or undetectable short-arm material or as a single monocentric centromere, indicating that the isochromosome likely formed post-zygotically by a short arm U-type or centromeric exchange. Characterization of chromosome 13 simple tandem repeats and Affymetrix whole-genome 6.0 SNP array hybridization found homozygosity for all markers, and the presence of only a single paternal allele in informative markers, consistent with an isodisomic isochromosome of paternal origin. Analysis of two chromosome 13 schizophrenia candidate genes, D-amino acid oxidase activator (DAOA) and 5-hydroxytryptamine (serotonin) receptor 2A (5-HTR2A), failed to identify non-synonymous coding mutations but did identify homozygous risk polymorphisms. Conclusions We report a female patient with childhood-onset schizophrenia, ADHD, and motor tic disorder associated with an isodisomic isochromosome 13 of paternal origin and a 45,XX,i(13)(q10q10) karyotype. We examined two potential mechanisms to explain chromosome 13 involvement in the patient's pathology, including reduction to homozygosity of a paternal mutation and reduction to homozygosity of a paternal copy number variation, but were unable to identify any overtly pathogenic abnormality. Future studies may consider whether epigenetic mechanisms resulting from uniparental disomy (UPD) and the lack of chromosome 13 maternal alleles lead to the patient's features.

Objective The purpose of this double-blind, placebo-controlled exploratory pilot study was to evaluate the safety and efficacy of risperidone for the treatment of anorexia nervosa. Method Forty female subjects 12 to 21 years of age (mean, 16 years) with primary anorexia nervosa in an eating disorders program were randomized to receive risperidone (n = 18) or placebo (n = 22). Subjects completed the Eating Disorder Inventory 2, Color-A-Person Test, Body Image Software, and Multidimensional Anxiety Scale for Children at baseline and regular intervals. Weight, laboratory values, and electrocardiograms were monitored. Study medication was started at 0.5 mg daily and titrated upward weekly in 0.5-mg increments to a maximum dose of 4 mg until the subject reached a study endpoint. Results The mean dose for the risperidone group was 2.5 mg and for the placebo group was 3 mg for a mean duration of 9 weeks. Subjects taking risperidone had a significant decrease on the Eating Disorder Inventory 2 Drive for Thinness subscale over the first 7 weeks (effect size, 0.88; p = .002), but this difference was not sustained to the end of the study ( p = .13). The Eating Disorder Inventory 2 Interpersonal Distrust subscale decreased significantly more in subjects taking risperidone (effect size, 0.60; p = .03). Subjects taking risperidone had increased prolactin levels (week 7; p = .001). There were no significant differences between groups at baseline or the end of the study for the other rating scales, change in weight, or laboratory measurements. Conclusions This study does not demonstrate a benefit for the addition of risperidone in adolescents with anorexia nervosa during the weight-restoration phase of care. Clinical trial registration information—A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Anorexia Nervosa, http://www.clinicaltrials.gov, NCT00140426.

α7 Nicotinic acetylcholine receptors (α7nAchRs) modulate immune activation by suppressing production of pro-inflammatory cytokines in peripheral immune cells. α7nAchRs also modulate inhibitory output in the hippocampus, which provides input to key circuits of the HPA axis. Therefore, the α7 nicotinic acetylcholine receptor gene (CHRNA7) may be associated with cortisol stress response. Polymorphisms in the CHRNA7 promoter decrease its expression and may dampen the cholinergic response, leading to an increase in inflammation. Increased inflammation may change the intrauterine environment, altering neuroendocrine development in the offspring. Maternal CHRNA7 genotype could affect an offspring's HPA regulation via reprogramming in utero. Patients with allergic disorders have a differential cortisol response to stress. This study utilized samples collected from a cohort of 198 adolescents in a previous study of atopic disorders, who demonstrated a disturbance in HPA response associated with atopy. Salivary cortisol samples collected from the adolescents after a series of laboratory procedures and DNA samples collected from the adolescents and their parents were used for further analysis. DNA samples were genotyped for allelic variation in the CHRNA7 promoter. Genetic association analyses with the cortisol levels were performed in the adolescents. Maternal genotype influences were investigated for the CHRNA7 gene. We also included maternal and child atopy diagnosis as covariates in determining cortisol levels and tested for association of CHRNA7 to atopy. Polymorphisms in the CHRNA7 promoter were associated with lower cortisol levels after a small laboratory stress. Our findings also show that although the child's CHRNA7 genotype affects stress response, the maternal genotype has a stronger influence on cortisol release after stress in male offspring. These effects were independent of atopy status.