PSYCHIATRY ALERTS CHILD& ADOLESCENT. Cyber Bullying and Depression

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1 ADHD Resources...17 CHILD& ADOLESCENT PSYCHIATRY ALERTS Benefits of Treating Maternal Depression...14 DBS Complications...16 Depression and Cyber Bullying...13 Depression: Recovery and Recurrence...15 Eating Disorder Prevalence...17 Self Injury and the Internet...14 Volume XIII / March 2011 / Number 3 Cyber Bullying and Depression Research has shown a link between bullying and depression, both in victims and in the adolescents who bully. Little research has examined the effects of cyber bullying. Methods: A nationally representative sample of adolescents in grades 6 through 10 (mean age, 14 years) was evaluated as part of the Health Behavior in School-aged Children study. A sample of 7313 adolescents completed anonymous surveys that collected information on depression and bullying behaviors. Depression was not assessed with a standardized measure. Rather, participants rated the frequency of 6 feelings and behaviors (i.e., sadness; irritability; hopelessness about the future; changes in eating habits; changes in sleeping habits; difficulty concentrating) in the previous 30 days. In addition, the frequency of victimization and engagement in physical, verbal, relational, and cyber bullying behaviors were evaluated. Results: In this sample, 54% of adolescents reported either being a victim of or engaging in verbal bullying; 52% reported relational bullying; 21% reported physical bullying; and 14% reported cyber bullying. Adolescents with any involvement in bullying, regardless of the nature, reported higher levels of depression. Levels of depression were significantly higher among adolescents frequently involved with traditional forms of bullying (i.e., physical, verbal, relational) than in those with occasional involvement. The association was present whether the adolescent was the victim or perpetrator of the bullying behavior. In contrast, with cyber bullying, the incidence of depression was significantly higher among frequent victims than among those doing the bullying. Discussion: With cyber bullying, the attacker may be anonymous and the negative information about the victim may be spread much more broadly. As a result, the victim of cyber bullying, as opposed to other forms, may experience more social isolation and stronger feelings of dehumanization and helplessness. This may explain the differences in the patterns of depression in these adolescents. Wang J, Nansel T, Iannotti R: Cyber and traditional bullying: differential association with depression. Journal of Adolescent Health 2011;48: From the NIH, Bethesda, Md. Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; and the Maternal and Child Health Bureau of the Health Resources and Services Administration. The authors did not include disclosure of potential conflicts of interest. CHILD & ADOLESCENT PSYCHIATRY ALERTS (ISSN ) is published monthly by M.J. Powers & Co. Publishers, 65 Madison Ave., Morristown, NJ Telephone child@alertpubs.com. Periodical-class postage paid at Morristown, NJ, and at additional mailing offices. POSTMASTER: Send address changes to Child & Adolescent Psychiatry Alerts, 65 Madison Ave., Morristown, NJ by M.J. Powers & Co. Publishers. Written permission from M.J. Powers & Co. is required to reproduce material from this publication. Subscription $89 a year in the U.S.; $97.50 Canada; $ elsewhere; $141 institutional. Back issues and single copies are available for $10.00 each, prepaid. Subscribers may enroll in the 12-month CME program for $77.00 per year. 13

2 Self-Injury and the Internet Research in adolescents and young adults has shown rates of nonsuicidal self-injury range from about 14% to 21%. Because online social interaction is popular among young people, the scope of self-injury videos accessed on YouTube was examined. Background: Online or other communication about self-injury can influence adolescents atrisk for or already engaging in these activities. Exposure to others engaging in the activities can reinforce the behaviors by normalizing the practice or could act as a trigger for continued self-injury. Adolescents may also learn new methods of self-injury, as well as ways to conceal the practice. Methods: A key word search of YouTube identified videos on self-injury and self-harm. At the time of data collection, these types of videos had a total of nearly 2.4 million views. The investigators selected the 50 most viewed character (with live individual) and 50 most viewed noncharacter videos for review. Results: Over 40% of self-injury themed videos were found to be neutral in purpose, in that they neither promoted nor discouraged the behaviors. Of the remaining videos, 26% discouraged self-injury and 23% gave a mixed message, while 7% encouraged the behaviors. The tone of each video was categorized as factual or educational (53%); melancholic (51%); encouraging the viewer to seek help (23%); hopeful (16%); angry (13%); humorous (4%); and other (25%). Trigger warnings, which indicate to viewers that the content may trigger self-harming thoughts or actions, are available on YouTube. However, less than half of the identified videos included such warnings. Nearly two-thirds of videos had visual depictions of self-injury (e.g., photographs), most commonly cutting, followed by burning, and the newer phenomenon of self-embedding, in which individuals embed objects (e.g., paper clips, small screws) under their skin. Depicted injuries were coded based on severity; most of those coded were considered moderately severe. Discussion: Although a small minority of self-injury YouTube videos encouraged self-injurious behavior, many included graphic imagery and/or live self-harm acts, and few carried warnings about the content. Because these videos, which overall appear to normalize or glamorize self-injurious behaviors, are easily accessible to a vulnerable population, it may be prudent to inquire about internet use when treating patients for self-harm. It should be noted that the investigators examined only the videos themselves, and not how the viewers were affected. Future research should address this issue. Lewis S, Heath N, St Denis J, Noble R: The scope of nonsuicidal self-injury on YouTube. Pediatrics 2011; doi /peds From the University of Guelph, Ont., Canada; and McGill University, Montreal, Que., Canada. Source of funding not stated. The authors disclosed no financial relationships relevant to the article. Long-Term Benefits of Maternal Depression Treatment Children of mothers with depression continued to experience decreases in symptoms and problem behaviors for up to a year after the mother's depression remitted. These benefits occurred even in children whose mothers achieved remission after 3 months of treatment. 1 Background: The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial investigated a 5-step treatment algorithm in adults with nonpsychotic major depression. The STAR*D Child Study is an extension that examines the effect of maternal treatment on the children of mothers with depression. This analysis builds on previous reports from the NIMH-funded STAR*D Child Study showing that maternal treatment benefitted children. 2,3 14 C&A PSYCHIATRY ALERTS / March 2011

3 Methods: The STAR*D Child Study enrolled 151 women who had children aged 7 17 years. Of the 151 women, 36 were early remitters ( 3 months), 28 were late remitters (between 3 and 12 months), and 16 women did not remit during the first year of the study. The analysis excluded 20 women who relapsed, 1 who remitted in year 2, and others who did not experience remission and for whom follow-up data were not available. Child symptoms were assessed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL), administered to both the mother and child. The Child Behavior Checklist (CBCL) assessed problem behaviors, and the Children's Global Assessment Scale (C-GAS) assessed function. Results: During the year after maternal remission, children of early remitters experienced improvement in all outcomes: symptoms, problem behaviors (internalizing, externalizing, and total), and function. Children of late remitters showed significant improvement in symptoms and internalizing behavior. Changes in other outcomes were modest and not statistically significant. Children of mothers who did not remit showed little or no improvement and had a significant increase in externalizing behavior problems. Discussion: Mothers who remitted early were more likely to be married and to have a higher household income. They also tended to have less severe depression. The lesser severity of their depression may be important for child outcomes. The less consistent improvements in children of mothers who remitted after 3 12 months may be explained by the heterogeneity of this group. The generally positive outcomes in these children suggest it is worthwhile to continue the mother's treatment until remission is achieved. 1 Wickramaratne P, Gameroff M, Pilowsky D, Hughes C, et al: Children of depressed mothers 1 year after remission of maternal depression: findings from the STAR*D-Child Study. American Journal of Psychiatry 2011; doi /appi.ajp From Columbia University, New York, N.Y.; and other institutions. Funded by the NIMH. Several study authors disclosed financial relationships with commercial sources. 2 Weissman M, et al: Remissions in maternal depression and child psychopathology: a STAR*D-Child report. JAMA 2006;295: See Child & Adolescent Psychiatry Alerts 2006;8 (May):27. 3 Pilowsky D, et al: Children of depressed mothers 1 year after the initiation of maternal treatment: findings from the STAR*D-Child study. American Journal of Psychiatry 2008; doi /appi.ajp See Child & Adolescent Psychiatry Alerts 2008;10 (July):40. Depression Recovery and Recurrence A naturalistic, longitudinal follow-up study of Treatment for Adolescents with Depression Study (TADS) participants indicates that while most adolescents recover from their index depressive episode, nearly half experience a recurrence. Neither short-term response, nor combined treatment with fluoxetine (Prozac) and CBT, the most effective TADS regimen, reduced the risk of recurrence. Methods: The randomized, controlled TADS examined fluoxetine, CBT, the combination of both, and placebo in 439 adolescents with major depression. Short-term acute treatment (12 weeks), continuation (6 weeks), and maintenance (18 weeks) were all evaluated. Patients were then followed for an additional year. The present study extends open-label follow-up by an additional 3.5 years in 196 TADS participants who agreed to continued monitoring in the Survey of Outcomes Following Treatment for Adolescent Depression (SOFTAD) study. Patient ages ranged from 14 to 22 years at SOFTAD entry, and 56% were female. Results: In the 196 SOFTAD patients, treatment assignment during TADS had been combin- ation therapy in 50, fluoxetine in 48, CBT in 53, and placebo in 45. Nearly all of these patients (n=189; 96%) recovered from their index depressive episode, most did so within 1 year of TADS entry. Acute treatment response was predictive of recovery, but receiving combination therapy was not. Of the 189 recovered patients, 88 (47%) experienced at least C&A PSYCHIATRY ALERTS / March

4 1 depressive recurrence; 14 patients had >1 recurrent episode. Time from recovery to recurrence ranged from 2 to 55 months and averaged 22 months. Patients with full or partial response to randomized TADS treatment were significantly less likely to experience a recurrence than those who had not responded to initial treatment (43% vs 68%; p=0.03). Again, combination therapy was not protective, but male gender was associated with lower rates of recurrence. Discussion: The high rate of depression recurrence after recovery in these adolescents highlights the need for recurrence prevention. The authors suggest symptom or medication monitoring or CBT booster sessions may be valuable beyond 36 weeks of treatment. Curry J, Silva S, Rohde P, Ginsburg G, et al: Recovery and recurrence following treatment for adolescent major depression. Archives of General Psychiatry 2011;68 (March): From Duke University Medical Center, Durham, N.C.; and other institutions. Funded by the NIMH. Several study authors disclosed financial relationships with commercial interests. Deep Brain Stimulation Complications In adults, DBS has been shown to improve treatment-resistant depression, 1 severe OCD, 2 and movement disorders. 3 In most studies, surgical or infectious complications have been reported. Little research has examined the treatment in children and adolescents. According to a case series, pallidal DBS is an effective treatment for primary generalized dystonia in children and adolescents. However, infection following hardware implantation was common. 4 Methods: Patients in the series were offered DBS surgery between 2000 and 2007 if they had significant functional disability from primary dystonia, normal brain MRIs, and little response to accepted medical therapies. A total of 51 DBS microelectrodes were implanted in 22 patients, aged 9 17 years. All but 1 patient had bilateral treatment. Results: At the time of the review, all patients had been followed for at least 1 year. One year after surgery, patients experienced a median 84% reduction in motor symptoms and an 80% reduction in disability score. Seventeen patients were able to reduce their dystonia medication by more than 50% after 1 year, and 8 were able to discontinue all dystonia medications. Adverse events were limited to complications related to the implanted devices, and nearly one-third of the devices were removed. In 3 patients (4 devices), the devices became infected and were removed and reimplanted after antibiotic therapy. An additional 4 patients had the devices removed and replaced for other reasons, including malfunction and incorrect initial placement. The high rate of device-related complications may be attributable to the size of the implanted pulse generators, which are designed for use in adults. The large generators could cause tension in the skin of the chest wall, which may increase risk of infection or slow healing. It is hoped that smaller pulse generators, possibly with antibiotic coating, will be developed. 1 Lozano A, et al: Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression. Biological Psychiatry 2008; doi /j.biopsych Mallet L, et al: Subthalamic nucleus stimulation in severe obsessive-compulsive disorder. NEJM 2008;359 (November 13): Servello D, et al: Tourette syndrome (TS) bears a higher rate of inflammatory complications at the implanted hardware in deep brain stimulation (DBS). Acta Neurochirurgica 2010; doi /s y. 4 Haridas A, Tagliati M, Osborn I, Isaias I, et al: Pallidal deep brain stimulation for primary dystonia in children. Neurosurgery 2011; doi /NEU.0b013e From Mount Sinai School of Medicine; and Beth Israel Medical Center, New York, N.Y. Two of the study authors disclosed speaking honoraria from Medtronic, manufacturer of the DBS devices. 16 C&A PSYCHIATRY ALERTS / March 2011

5 National Adolescent Prevalence of Eating Disorders Eating disorders and subthreshold eating problems have a high prevalence in adolescents and are associated with considerable comorbidity and role impairment, according to a nationwide population-based survey. Methods: The adolescent arm of the National Comorbidity Survey investigated the mental health status of a representative sample of >10,000 U.S. adolescents, aged years. DSM-IV disorders and subthreshold eating problems were assessed using the World Health Organization Composite International Diagnostic Interview, administered to the adolescents in face-toface interviews. Parents were also interviewed about some behavioral disorders. A diagnostic hierarchy was applied, with anorexia nervosa taking precedence, followed by bulimia nervosa, and then binge-eating disorder. The survey also assessed functional impairment, suicidal ideation and behavior, and treatment for emotional or behavioral problems. Results: The survey identified lifetime prevalence rates for anorexia nervosa (0.3%); bulimia (0.9%); binge-eating disorder (1.6%); subthreshold anorexia nervosa (0.8%); and subthreshold binge-eating disorder (2.5%). The survey did not obtain sufficient information to identify subthreshold bulimia nervosa. All disorders had an average age at onset of years. Bulimia, binge eating, and subthreshold anorexia were more prevalent in girls than in boys, but there were no gender differences in rates of anorexia and subthreshold binge eating. Most adolescents with an eating disorder had at least 1 comorbid psychiatric disorder. Bulimia and binge-eating disorder were associated with most other emotional disorders and were strongly associated with mood and anxiety disorders and with the presence of multiple disorders. Anorexia was associated only with oppositional-defiant disorder. The subthreshold conditions showed modest comorbidity. The proportion of adolescents reporting role impairment ranged from 35% (subthreshold binge eating) to 97% (anorexia nervosa). All disorders were associated with increased suicidal ideation. Bulimia showed a particularly strong association with suicidality, with lifetime rates of suicidal ideation of 53% and suicide attempts of 35%. Between 64% and 88% of adolescents in each diagnostic group received some treatment for an emotional or behavioral problem. However, much smaller proportions (3 28%) were treated specifically for their eating or weight problems. Discussion: The findings of this study confirm previous prevalence estimates of eating disorders in adolescents, underscore the high morbidity associated with these disorders, and support the need to improve treatment. The results support the nosological distinction among the major disorder subtypes and the importance of including the subthreshold problems when estimating the public health impact of eating disorders. Swanson S, Crow S, Le Grange D, Swendsen J, et al: Prevalence and correlates of eating disorders in adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry 2011; doi /archgenpsychiatry From the NIMH, Bethesda, Md.; and other institutions. Funded by NIMH. One study author disclosed a financial relationship with a pharmaceutical-industry source. ADHD Resources for Clinicians and Families The Institute for Clinical Systems Improvement (ICSI) recently published a guideline on the diagnosis and management of ADHD in school-aged children. Highlighted in the document are recommendations regarding screening and treatment. The guidance does not vary substantially from the AACAP Practice Parameter recommendations; however, a list of additional resources available to physicians and families was included and is summarized on the next page. C&A PSYCHIATRY ALERTS / March

6 ADHD Med Tracking Internet-based service for clinicians to assess and monitor ongoing treatment of patients with ADHD. National Committee for Quality Assurance Offers suggestions on resources to improve care and overcome barriers to ADHD treatment. American Academy of Pediatrics Provides information on clinical trials, research findings, and consensus statements on the diagnosis and management of ADHD. The Council for Exceptional Children International professional organization dedicated to improving educational outcomes for students with disabilities and other exceptional populations. The council advocates for appropriate governmental policies, sets professional standards, and provides continual professional development. American Academy of Child and Adolescent Psychiatry Disseminates information on clinical trials and conferences regarding ADHD and offers family resources and fact sheets on ADHD. ADD Warehouse Online catalog of resources, books, videos, training, and assessment products. Children and Adults with Attention Deficit Disorders (CHADD) Provides grassroots-level support, education and encouragement to parents, educators and professionals through local chapters. National Institute of Mental Health General resource for ADHD and comorbid psychological condition, including clinical trial information, fact sheets, brochures and books. Attention Deficit Disorder Association Offers comprehensive information on ADHD, including several essays that may be particularly helpful to parents and educators. PACER Center (Parent Advocacy for Children s Educational Rights) National organization designed to expand opportunities for and improve quality of life of young people with disabilities and their families. Individual assistance is available, as are workshops and materials for parents and clinicians, and guidance on securing an appropriate and free public education. Health Care Guideline: Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care for School-Age Children and Adolescents. Institute for Clinical Systems Improvement. Available at Contributing Editors: Bennett Silver, MD Kate Casano, MSHyg Theresa Waldron Consulting Editor: Theodore A. Petti, MD, UMDNJ Robert Wood Johnson Medical School Executive Editor: Trish Elliott Associate Editor: Tara Hausmann Assistant Editors: Mandie Stahl, Krista Strobel Founding Editor: Michael J. Powers Statement of Editorial Policy: All of the information and opinions presented in each Child & Adolescent Psychiatry Alerts article are strictly those contained in the cited article unless otherwise noted. Reader comments are welcome by mail, by telephone ( ) 8:30 4:00 Eastern time Monday Friday, or by (child@alertpubs.com). Off-Label Drug Use Statement: Some drugs discussed for specific indications in Child & Adolescent Psychiatry Alerts articles may not be approved for labeling and advertising for those indications by the United States Food and Drug Administration. 18 C&A PSYCHIATRY ALERTS /March 2011