Chart review is a low-cost but highly informative method

Transcription

1 research ARTICLE.. Clinicl Chrcteristics of Depressed Youths in Child Psychitry Jen-Jcques Breton MD, MSc 1,2,4 ; Rél Lbelle PhD 1,3,4 ; Christophe Huynh MSc, PhD(cnd.) 1,4 ; Clude Berthiume MSc 1 ; Mrie St-Georges MPs 1 ; Jen-Mrc Guilé MD, MSc 1,4 Abstrct Objective: To describe the clinicl chrcteristics of depressed children nd dolescents ccording to ge groups nd sex. Methods: A retrospective chrt review study ws conducted on 75 youths ged 6-17 yers referred for depressive disorders to child psychitry in Descriptive sttistics nd tests of ssocition were completed to compre boys ged 6-11 yers, boys ged nd girls ged. Results: One out of two youths hs repeted school yer. About 60% of depressed boys ged 6-11 yers re referred to child psychitry services for behviorl difficulties nd 71% of boys in this ge group hve depressive disorder comorbid with disruptive behvior disorder. Adolescent boys nd girls re more likely to present internlized symptoms thn children. However, suicidl idetion is s widespred in children (71%) s in dolescent popultion, both boys (72%) nd girls (85%). Prent-child reltionl problems re observed in the mjority of the smple with higher prevlence mong dolescent girls. Conclusion: It is s importnt to ssess depressive symptoms nd suicidl idetion mong young boys with behviorl difficulties s in dolescent boys nd girls. Fmily functioning is importnt to consider in evluting nd treting youth. Key words: depressive disorders, suicidl ides, child nd dolescent, chrt reviews Introduction Chrt review is low-cost but highly informtive method to gin informtion on the clinicl profile of children nd dolescents ttending child psychitry services. Such studies contribute to djustment of ssessment nd intervention modlities in view of the clinicl relities of youth nd their fmilies. Dt from clinicl files cn lso generte reserch hypotheses (Gering, Min, Brber, & Ickowicz, 2006). A review of recent studies on clinicl popultions indictes tht young people re referred to child psychitry services for hyperctivity (18%), distrctibility (17.5%), nd school filure (15.7%) (Ars, Vrol Ts, & Unlu, 2007). The most frequent dignoses re dpttion disorders (17.5%), disruptive behvior disorders (12.7%), nxiety disorders ( %), mood disorders ( %) nd ADHD (7.2%) (Ars et l., 2007; Den, McDermott, & Mrshll, 2006). Breton et l Suicidl idetion nd suicide ttempts re reported respectively by 12% nd 10% of young people (Den et l., 2006). One ptient out of four is medicted nd phrmcotherpy is ssocited with longer tretment durtion, medicted ptients being followed for 32.3±23.0 weeks compred to 11.4±16.9 weeks for non medicted ptients (Den et l., 2006). These descriptive studies, like severl others in recent decdes, include ll youths dmitted to given child psychitric service. Other studies trget suicidl behvior (Jy, Grhm, & Flowers, 1989; Milling, Gyure, Dvenport, & Bir, 1991), self-hrm (Jcobson, Muehlenkmp, Miller, & Turner, 2008), dropping-out from tretment (Ottino, 1995) or use of vrious ctegories of psychotropic drugs such s ntidepressnts (Wilens et l., 2003), mood stbilizers (DelBello et l., 2002) or ntipsychotics (Mrchnd, Wirth, & Simon, 2004). 1 Reserch Service, Rivière-des-Priries Hospitl & Fernnd-Seguin Reserch Centre, Montrel, Quebec 2 McGill Group for Suicide Studies, McGill University, Montrel, Quebec 3 Centre for Reserch nd Intervention on Suicide nd Euthnsi, Université du Québec à Montrél, Montrel, Quebec 4 Deprtment of Psychitry, Fculty of Medicine, Université de Montrél, Montrel, Quebec Corresponding emil: jj.breton.hrdp@ssss.gouv.qc.c Submitted: Februry 13, 2011; Accepted: My 27, 2011 J Cn Acd Child Adolesc Psychitry, 21:1, Februry

2 Breton et l In terms of depressive symptoms, study in n outptient clinic showed tht boys re more likely to experience difficulties concentrting nd other cognitive symptoms while girls tend to present more self-esteem problems (Fu & Wng, 2008). A five yer follow-up study of children nd dolescents hospitlized for mjor depressive disorder reveled tht complete remission of the initil episode within yer ws observed for 98% of the youth. However 61% hd nother depressive episode during the 5-yer follow-up period, 47% relpsing in the first yer (Emslie et l., 1997). In study on self hrm in dolescents, bsed on outptient records, the most common dignoses were mjor depressive disorder (52%) nd nxiety disorders (36%), regrdless of the presence of self-hrming behviors. One youth out of five hd borderline personlity disorder (Jcobson et l., 2008). Overll, there re few descriptive studies on clinicl popultions of youth with depressive disorders wheres it is the ctegory of mentl disorders most often ssocited with suicidl behvior in children nd dolescents. In ddition 15 to 20% of dolescents in the generl popultion present depressive disorder. The proposed study ims to describe the clinicl chrcteristics of depressed youth in child psychitry by ge groups nd sex nd to present the clinicl implictions of these results. Methods The retrospective chrt review hs been completed within the child psychitry progrm t Hôpitl Rivière-des-Priries, child psychitric centre ffilited with the Université de Montrél. In the yer , 450 children nd dolescents were registered nd 81 (18%) hd clinicl dignosis of depressive disorder given by child psychitrist bsed on ll vilble informtion included in the ptient s file (best estimte). Two preschool children were excluded from the study for totl of 79 selected files. Agreement from the hospitl s director of professionl services ws obtined llowing reserchers nd reserch ssistnts to get ccess to the content of the files. An nlysis grid, bsed on erlier studies in the reserch service of Hôpitl Rivière-des-Priries, ws developed by the first two uthors. They rted the grid items by reviewing the content of ten files in the medicl records deprtment nd then n dditionl dt collection ws completed seprtely by the two reserch ssistnts on ten other files to ensure similr understnding of items. At the end of severl meetings between the two reserch ssistnts nd the first two uthors, finl version of the grid ws produced. Items were grouped into seven ctegories: socio-demogrphic chrcteristics, request for services, life events, symptoms, dignoses ccording to the five DSM-IV xes, types of tretment, nd resons for closing the file. Dt collection ws conducted from July to November As first step, the dt were nlyzed by sex combining the two ge groups. Interprettion ws certinly informtive on the influence of the sex vrible (for exmple, showing tht the boys ged 6-17 yers hd more depressive disorders comorbid with disruptive behvior thn girls in the sme ge group) but it did not ssess the impct of ge on the clinicl chrcteristics (Breton et l., 2005). In second step, other nlyses were conducted on three groups of boys 6-11 nd of ge nd girls of ge. The group of girls ged 6-11 yers could not be retined becuse it included only four subjects. Dt were nlyzed using the SPSS softwre. Tests of ssocition were conducted to compre the groups. The significnce level ws set t Due to the explortory nture of the study nd the limited number of subjects, no correction hs been pplied for the multiplicity of tests. Such corrections become quickly too conservtive when the number of tests is elevted nd the vrious mesures used for the sttisticl tests re highly correlted. Results Youths live in similr proportion in two-prent nd singleprent fmilies nd 24% re prt of reconstituted fmily. One youth out of four is from n ethnic bse other thn Quebec origin. About one out of two in dolescence hs repeted school yer nd the difference of proportion between the three groups of boys ged 6-11, boys ged nd girls ged is significnt (p=0.010; χ 2 =9.15; df=2). The three groups differ significntly for resons of consulttion (p=0.017; χ 2 =18.63; df=8). Indeed, behviorl problems re the reson for consulttion for greter proportion of boys 6-11 yers (59%) in comprison to the two groups of dolescents (32% for boys nd 9% for girls). In contrst, girls consult in higher proportion for mnifesttions of depression (p=0.002; χ 2 =16.44; df=4). Anlysis of life events revels significnt difference between the three groups for prentl disputes (p=0.036; χ 2 =6.65; df=2), found in higher proportion mong boys thn girls (boys 6-11 yers vs. girls: p=0.020; χ 2 =5.45; df=1; nd boys ge vs. girls: p=0.049; χ 2 =3.87; df=1), nd, the rrivl/deprture of spouse (p=0.043; χ 2 =6.31; df=2) found in higher proportion mong young boys thn dolescent girls (p=0.012; χ 2 =6.27; df=1). Regrding symptoms, prent-child reltionl problems re reported for 80% of young people, the difference being significnt mong the three groups (p=0.011; χ 2 =9.02; df=2), prent-child reltionl problem being reported in significntly higher proportion in dolescent girls thn mong boys 6-11 yers (p=0.002; χ 2 =9.37; df=1). The proportion of subjects with suicidl ides is s high mong young boys (71%) s in the two groups of dolescents (72% nd 85%). There is significnt difference between the three groups for ttention seeking (p=0.014; χ 2 =8.56; df=2), the proportion being higher mong young boys thn mong the older ones (p=0.047; χ 2 =3.95; df=1) nd dolescent girls (p=0.003; J Cn Acd Child Adolesc Psychitry, 21:1, Februry 2012

3 Clinicl Chrcteristics of Depressed Youths in Child Psychitry Tble 1. Sociodemogrphic chrcteristics 6-11 yers (n=17) Boys Girls Totl (n=25) (n=33) 6-17 yers (n=75) Fmily structure Two-prent 5 (29%) 11 (44%) 13 (39%) 29 (39%) Single-prent 8 (47%) 5 (20%) 15 (46%) 28 (37%) Reconstituted 4 (24%) 9 (36%) 5 (15%) 18 (24%) Ethnic origin Quebecer 13 (77%) 16 (64%) 28 (85%) 57 (76%) Others (Centrl nd south Americ, Europe, Asi) 4 (24%) 9 (36%) 5 (15%) 18 (24%) Schooling Repeted grde* Yes 2 (12%) 13 (59%) 13 (45%) 28 (41%) * These dt re not vilble for three boys ged 12 to 17 yers nd four girls ged 12 to 17. p 0,01. Tble 2. Request for services 6-11 yers (n=17) Boys Girls Totl (n=25) (n=33) 6-17 yers (n=75) Referrl source type of service Hospitl 4 (24%) 9 (36%) 20 (61%) 33 (44%) Medicl clinic 6 (35%) 5 (20%) 4 (12%) 15 (20%) Locl community helth center 3 (18%) 6 (24%) 4 (12%) 13 (17%) Youth center 1 (6%) 4 (16%) 3 (9%) 8 (11%) School 3 (18%) 1 (4%) 2 (6%) 6 (8%) Resons for consulttion Mnifesttions of depression with suicidl behvior 3 (18%) 7 (28%) 15 (46%) 25 (33%) Behvior problems 10 (59%) 8 (32%) 3 (9%) 21 (28%) Mnifesttions of depression 1 (6%) 5 (20%) 8 (24%) 14 (19%) Worries nd nervousness 2 (12%) 4 (16%) 2 (6%) 8 (11%) Mnifesttions of depression with behvior problems 1 (6%) 1 (4%) 5 (15%) 7 (9%) p 0,05 χ 2 =8.56; df=1). Significnt differences re observed for sdness between groups (p=0.043; χ 2 =6.27; df=2), the proportion being significntly higher mong dolescent girls thn in young boys (p=0.007; χ 2 =7.22; df=1). There is lso significnt difference between the groups for loss of interest (p<0.001; χ 2 =21.36; df=2), the proportion being significntly lower mong young boys thn mong dolescent boys (p=0.013; χ 2 =6.18; df=1) nd dolescent girls (p<0.001; χ 2 =21.51; df=1). Overll, 63% of youths reported sleep problem, the proportions being similr from one group to the other. Anlysis of dignoses t xis I revels significnt differences between the three groups (p=0.002; χ 2 =16.81; df=4). Young boys hve higher proportion of depressive disorder comorbid with disruptive disorder thn the dolescents, the difference being observed between young boys nd dolescent girls (p<0.001; χ 2 =16.78; df=2). Fmily problems reported by 68% of youth re the min source of psychosocil problems t xis IV. Anlysis of tretments shows significnt difference between the three groups with regrd to the type of drug, ntidepressnts not being used for young boys (p=0.006; χ 2 =17.91; df=6). Anlysis of the resons for closing the file shows significnt difference between the three groups (p=0.037; χ 2 =10.21; df=4), lck of motivtion being found in significntly lower proportion mong young boys thn J Cn Acd Child Adolesc Psychitry, 21:1, Februry

4 Breton et l Tble 3. Life events nd most frequent symptoms 6-11 yers (n=17) Boys Girls Totl (n=25) (n=33) 6-17 yers (n=75) Life events Prent seprtion/divorce 13 (77%) 14 (56%) 18 (55%) 45 (60%) Birth of nother child 11 (65%) 17 (68%) 17 (52%) 45 (60%) Disgreement nd/or conjugl violence 12 (71%) 14 (56%) 12 (36%) 38 (51%) Prentl disputes 11 (65%) 14 (56%) 10 (30%) 35 (47%) Arrivl of new spouse or spouse leving home 12 (71%) 11 (44%) 11 (33%) 34 (45%) Symptoms Prent-child reltionl problem 10 (59 %) 19 (76%) 31 (94%) 60 (80%) Sdness 10 (59%) 18 (72%) 30 (91%) 58 (77%) Suicidl idetion 12 (71%) 18 (72%) 28 (85%) 58 (77%) Anxiety 14 (82%) 16 (64%) 25 (76%) 55 (73%) Problems concentrting 14 (82%) 19 (76%) 17 (52%) 50 (67%) Problems chieving in school 14 (82%) 19 (76%) 15 (46%) 48 (64%) Sleep problems 10 (59%) 15 (60%) 22 (67%) 47 (63%) Low self-esteem 9 (53%) 18 (72%) 19 (58%) 46 (61%) Attention seeking 15 (88%) 15 (60%) 15 (46%) 45 (60%) Loss of interest b 3 (18%) 14 (56%) 28 (85%) 45 (60%) Does not fulfil his/her potentil t school 12 (71%) 15 (60%) 17 (52%) 44 (59%) Oppositionl, srcstic, hostile 12 (71%) 15 (60%) 15 (46%) 42 (56%) Fit of rge 10 (59%) 17 (68%) 14 (42%) 41 (55%) Feeling devlued 5 (29%) 14 (56%) 20 (61%) 39 (52%) Difficult to control 11 (65%) 17 (68%) 11 (33%) 39 (52%) p 0,05 b p 0,01 in dolescent boys (p=0.039; χ 2 =6.51; df=2) nd dolescent girls (p=0.008; χ 2 =9.75; df=2). Discussion This study hs limittions s do other chrt review studies. The informtion collected t ech step of the file development my be incomplete nd errors my occur in the coding of dt by reserch ssistnts. In ddition, the study is completed in specific context of cre. Finlly, the bsence of group of girls ged 6-11 yers does not llow the study of this ge group. School filure is observed in one out of two dolescents, which cn contribute to depressive symptoms nd suggests tht tking ccount of the cognitive functioning of these youngsters would be relevnt for the definition of the intervention pln. Prent-child reltionl problems re found with high proportion in the three groups but prticulrly mong teengers. The mother-dughter conflicts relted to requests for referrls would be correlted with more intense depressive symptoms mong girls (Zhn-Wxler, Shirtcliff, & Mrceu, 2008). Fmily dynmics is thus n importnt 26 dimension to consider in the evlution process nd psychitric tretment (Villeneuve, 2006). Depression mong boys 6-11 yers implies more behviorl profile thn in the two other groups since more thn 50% of the boys with dignosis of depressive disorder re referred for disruptive behvior problems. Indeed behviorl difficulties cn hide depressive symptoms nd it seems tht depression without behviorl problems cn go unnoticed in this ge group. This hypothesis could explin tht only four depressed girls ged 6-11 yers re included in this study, girls from 6-11 yers showing lower prevlence of disruptive behvior disorders thn boys in the sme ge group in the generl popultion, yet showing prevlence of depressive disorders comprble to boys nd girls in this ge group (Birmher et l., 1996; Breton et l., 1999). The boys lso demnd more ttention (88% versus 46-60% for dolescent groups), which cn be understood s request for help nd not disruptive behvior only. Suicidl idetion is s common in children (71%) thn in dolescent boys (72%) nd dolescent girls (84%). Thus, the proportion of depressed children who re suicidl in J Cn Acd Child Adolesc Psychitry, 21:1, Februry 2012

5 Clinicl Chrcteristics of Depressed Youths in Child Psychitry Tble 4. DSM-IV Dignoses Boys Girls Totl 6-11 yers 6-17 yers Axis I (n=17) (n=25) (n=33) (n=75) Mjor depressive disorder/dysthymi 2 (12%) 10 (40%) 21 (64%) 33 (44%) Mjor depressive disorder with disruptive behvior 12 (71%) 10 (40%) 5 (15%) 27 (36%) disorders Mjor depressive disorder with nxiety disorders 3 (18 %) 5 (20%) 7 (21%) 15 (20%) Axe II (n=15) (n=23) (n=31) (n=69) Mentl retrdtion or limited intellectul functioning 2 (13%) 1 (4%) 2 (7%) 5 (7%) Personlity trits 1 (7%) 4 (17%) 1 (3%) 6 (9%) None 12 (80%) 18 (78%) 28 (90%) 58 (84%) Axe III (n=17) (n=23) (n=33) (n=73) Present 5 (29%) 6 (26%) 7 (21%) 18 (25%) Axe IV (n=17) (n=25) (n=33) (n=75) Fmily problems 12 (71%) 17 (68%) 22 (67%) 51(68%) School problems 4 (24%) 1 (4%) 3 (9%) 8 (11%) Other problems 0 (0%) 4 (16%) 1 (3%) 5 (7%) None 1 (6%) 3 (12%) 7 (21%) 11 (15%) Axe V (n=16) (n=23) (n=33) (n=72) Absent-mild (61-100) 5 (31%) 5 (22%) 10 (30%) 20 (28%) Moderte-serious (0-60) 11 (69%) 18 (78%) 23 (70%) 52 (72%) p 0,01 Tble 5. Types of tretment nd resons for closing the file Boys Girls Totl 6-11 yers 6-17 yers Types of tretment Psychotherpy (n=16) (n=23) (n=27) (n=66) 13 (81%) 13 (57%) 20 (74%) 46 (70%) Prentl or fmily intervention (n=16) (n=23) (n=29) (n=68) 9 (56%) 9 (39%) 9 (31%) 27 (40%) Mediction (n=16) (n=23) (n=30) (n=69) Present 10 (63%) 18 (78%) 22 (73%) 50 (73%) Type of mediction Antidepressnts or mood stbilizers 0 (0%) 5 (22%) 15 (50%) 20 (29%) Antidepressnts with other drugs 6 (38%) 6 (26%) 6 (20%) 18 (26%) Others 4 (25%) 7 (30%) 1 (3%) 12 (17%) Hospitlistion (n=16) (n=24) (n=30) (n=70) 2 (13%) 6 (25%) 8 (27%) 16 (23%) Resons for closing the file b (n=7) (n=10) (n=18) (n=35) Improvement 5 (71%) 3 (30%) 3 (17%) 11 (31%) Lck of motivtion 0 (0%) 6 (60%) 12 (67%) 18 (51%) Trnsfer/moving 2 (29%) 1 (10%) 3 (17%) 6 (17%) p 0,01 b p 0,05 J Cn Acd Child Adolesc Psychitry, 21:1, Februry

6 Breton et l clinicl settings is fr from mrginl, suggesting the relevnce of screening for suicidl ides mong young children referred in child psychitry. Internlized symptoms such s sdness (72%), nxiety (64%), nd suicidl ides (72%) re s common mong dolescent boys s dolescent girls (91%, 76%, nd 85% respectively). Adolescent boys however present more school problems thn girls. Young nd older boys hve higher proportion of problem concentrting, s in the study of Fu & Wng (2008), wheres girls tend to hve lower self-esteem, which ws not observed in this study. Difficulties sleeping, observed in 10% of the dolescents in the generl popultion, re reported by mjority of youths in the present study, which confirms the importnce of ssessing this symptom in mjor depressive disorder (Roberts, Roberts, & Xing, 2011). Fifty-one percent of dolescents for whom the file ws closed dropped out from tretment due to lck of motivtion. This elevted proportion ws observed in other studies (Ottino, 1995). Adherence to tretment is low mong suicidl dolescents with rtes of dropping-out between 41.3% nd 57.7% (Burns, Cortell, & Wgner, 2008). Severl studies hve ttempted to identify different vribles predicting dropping-out from tretment for suicidl dolescents with vrious results (Grnbouln, Roudot-Thorvl, Lemerle, & Alvin, 2001; King, Hovey, Brnd, Wilson, & Ghziuddin, 1997; Ottino, 1995; Picentini et l., 1995; Rotherm-Borus et l., 1999), which could be explined, in prt, by difficulties defining the concept of drop-out. On the other hnd, the lck of motivtion ws not the reson to end tretment for 6-11 yer-old boys in our smple whose files were closed becuse of improvement. Conclusion The clinicl profile of depressed youth referred in child psychitry, s it ppers in our study, confirms tht depression in the prepubescent child is closely tied to externlized disorders. Resons for consulttion s well s observed symptoms nd dignoses confirm this observtion. Moreover the study shows tht suicidl idetion is s present in boys ged 6-11 yers thn mong dolescent boys nd girls. With regrd to the risk of suicide, this observtion clls for greter vigilnce on the prt of clinicins. Any ssessment of disruptive behvior disorders mong boys ged 6-11 yers should include the screening of depressive symptoms. The importnce of the reltionl nd fmilil dimensions contributing to the development of depression in the three ge groups confirms the relevnce of systemic pproch in the ssessment nd tretment of depressed youth. 28 Acknowledgements / Conflicts of Interest The uthors thnk Sophie Huneu, B.Sc. nd Andre Mrtin, Ph.D. who cted s reserch ssistnts for dt collection. References Ars, S., Vrol Ts, F., & Unlu, G. (2007). Mediction prescribing prctices in child nd dolescent psychitry outptient clinic. Child: Cre, Helth nd Development, 33(4), Birmher, B., Ryn, N. D., Willimson, D. E., Brent, D. A., Kufmn, J., Dhl, R. E., Nelson, B. (1996). Childhood nd dolescent depression: A review of the pst 10 yers. Prt I. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 35(11), Breton, J. J., Bergeron, L., Vll, J. P., Berthiume, C., Gudet, N., Lmbert, J., Lépine, S. (1999). Quebec child mentl helth survey: Prevlence of DSM-III-R mentl helth disorders. Journl of Child Psychology nd Psychitry, 40(3), Breton, J. J., Lbelle, R., Berthiume, C., Guile, J. M., St-Georges, M., Huneu, S., Mrtin A. (2005). Crctéristiques cliniques de jeunes déprimés pris en chrge en pédopsychitrie. 39ième congrès de l Assocition des médecins psychitres du Québec, Pris. Burns, C. D., Cortell, R., & Wgner, B. M. (2008). Tretment complince in dolescents fter ttempted suicide: A 2-yer follow-up study. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 47(8), Den, A. J., McDermott, B. M., & Mrshll, R. T. (2006). Psychotropic mediction utiliztion in child nd dolescent mentl helth service. Journl of Child nd Adolescent Psychophrmcology, 16(3), DelBello, M. P., Kowtch, R. A., Wrner, J., Schwiers, M. L., Rppport, K. B., Dniels, J. P., Strkowski, S. M. (2002). Adjunctive topirmte tretment for peditric bipolr disorder: A retrospective chrt review. Journl of Child nd Adolescent Psychophrmcology, 12(4), Emslie, G. J., Rush, A. J., Weinberg, W. A., Gullion, C. M., Rintelmnn, J., & Hughes, C. W. (1997). Recurrence of mjor depressive disorder in hospitlized children nd dolescents. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 36(6), Fu, I. L., & Wng, Y. P. (2008). Comprison of demogrphic nd clinicl chrcteristics between children nd dolescents with mjor depressive disorder. Revist Brsileir de Psiquitri, 30(2), Gering, R. E., Min, I. A., Brber, J., & Ickowicz, A. (2006). A methodology for conducting retrospective chrt review reserch in child nd dolescent psychitry. Journl of the Cndin Acdemy of Child nd Adolescent Psychitry, 15(3), Grnbouln, V., Roudot-Thorvl, F., Lemerle, S., & Alvin, P. (2001). Predictive fctors of post-dischrge follow-up cre mong dolescent suicide ttempters. Act Psychitric Scndinvic, 104(1), Jcobson, C. M., Muehlenkmp, J. J., Miller, A. L., & Turner, J. B. (2008). Psychitric impirment mong dolescents engging in different types of deliberte self-hrm. Journl of Clinicl Child nd Adolescent Psychology, 37(2), Jy, M. S., Grhm, C. J., & Flowers, C. (1989). Adolescent suicide ttempters presenting to peditric fcility. Adolescence, 24(94), King, C. A., Hovey, J. D., Brnd, E., Wilson, R., & Ghziuddin, N. (1997). Suicidl dolescents fter hospitliztion: Prent nd fmily impcts on tretment follow-through. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 36(1), Mrchnd, W. R., Wirth, L., & Simon, C. (2004). Quetipine djunctive nd monotherpy for peditric bipolr disorder: A retrospective chrt review. Journl of Child nd Adolescent Psychophrmcology, 14(3), J Cn Acd Child Adolesc Psychitry, 21:1, Februry 2012

7 Clinicl Chrcteristics of Depressed Youths in Child Psychitry Milling, L., Gyure, K., Dvenport, C. W., & Bir, P. (1991). Suicidl behvior mong psychitric outptient children: An estimte of prevlence. Child Psychitry nd Humn Development, 21(4), Ottino, J. (1995). Suicidl dolescents: Psychotherpy nd tretment interruption. Results of controlled study. Psychitrie de l enfnt, 38(2), Picentini, J., Rotherm-Borus, M. J., Gillis, J. R., Gre, F., Trutmn, P., Cntwell, C., Shffer, D. (1995). Demogrphic predictors of tretment ttendnce mong dolescent suicide ttempters. Journl of Consulting nd Clinicl Psychology, 63(3), Roberts R. E., Roberts C. R., & Xing Y. (2011). Restricted sleep mong dolescents: Prevlence, incidence, persistence, nd ssocited fctors. Behviorl Sleep Medicine, 9(1), Rotherm-Borus, M. J., Picentini, J., Vn Rossem, R., Gre, F., Cntwell, C., Cstro-Blnco, D., & Feldmn, J. (1999). Tretment dherence mong Ltin femle dolescent suicide ttempters. Suicide nd Life Thretening Behvior, 29(4), Villeneuve, C. (2006). L intervention en snté mentle: le pouvoir thérpeutique de l fmille, Les Presses de l Université de Montrél. Wilens, T. E., Biedermn, J., Forkner, P., Ditterline, J., Morris, M., Moore, H., Woznik, J. (2003). Ptterns of comorbidity nd dysfunction in cliniclly referred preschool nd school-ge children with bipolr disorder. Journl of Child nd Adolescent Psychophrmcology, 13(4), Zhn-Wxler, C., Shirtcliff, E. A., & Mrceu, K. (2008). Disorders of childhood nd dolescence: Gender nd psychopthology. Annul Review of Clinicl Psychology, 4, J Cn Acd Child Adolesc Psychitry, 21:1, Februry