A Comparison of Depressive Symptom Self-Reported Measures in the Texas Youth Depression and Suicide Research Network (TX-YDSRN)

Objective: To evaluate psychometrically and provide crosswalks between 3 self-report measures of depressive symptomatology in youth in psychiatric care settings. Ratings included the Patient Health Questionnaire for Adolescents (PHQ-A), a widely used 9-item self-report; the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16); and the 5-item Very Quick Inventory of Depressive Symptomatology-Self-Report (VQIDS-SR5), a recent effort to create a bridge from the QIDS-SR16 to clinical practice.

Methods: Data from the Texas Youth Depression and Suicide Research Network Registry (August 26, 2020-May 11, 2022) were included in this work. At first visit, 795 depressed or suicidal adolescent (12-20 years of age) psychiatric outpatients completed the PHQ-A, QIDS-SR16, and VQIDS-SR5. Classical test theory and item-response theory (IRT) analyses were conducted. Crosswalks among total scales were created. Sensitivity to change over 1-month follow-up was assessed for all 3 scales (n = 682).

Results: Cronbach alphas were 0.86 (PHQ-A), 0.80 (QIDS-SR16), and 0.76 (VQIDS-SR5). Item total correlations were 0.49-0.72, 0.29-0.64, and 0.43-0.61, respectively. All 3 scales were unidimensional and sensitive to change over a 1-month period. IRT analyses revealed satisfactory item performance. Modest but significant associations were found between baseline to 1-month changes in PHQ-A and VQIDS-SR5 total scores (r = 0.50, P < .0001) and between PHQ-A and QIDS-SR16 total scores (r = 0.56; P < .0001). Categorical thresholds of severity (ie, mild, moderate, severe, and very severe) were comparable between PHQ-A and QIDS-SR16.

Conclusions: The PHQ-A, QIDS-SR16, and VQIDS-SR5 are unidimensional, psychometrically acceptable self-reports of depressive prevalence or severity in adolescents and young adults in this sample. Total scale scores on any measure can be converted reliably to those on any other.

Texas Youth Depression and Suicide Research Network (TX-YDSRN) research registry and learning healthcare network: Rationale, design, and baseline characteristics

BACKGROUND

American youth are seriously impacted by depression and suicide. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) Participant Registry Study was initiated in 2020 to develop predictive models for treatment outcomes in youth with depression and/or suicidality. This report presents the study rationale, design and baseline characteristics of the first 1000 participants.

METHODS

TX-YDSRN consists of the Network Hub (coordinating center), 12 medical school "Nodes" (manage/implement study), each with 1-5 primary care, inpatient, and/or outpatient Sub-Sites (recruitment, data collection). Participants are 8-20-year-olds who receive treatment or screen positive for depression and/or suicidality. Baseline data include mood and suicidality symptoms, associated comorbidities, treatment history, services used, and social determinants of health. Subsequent assessments occur every two months for 24 months.

RESULTS

Among 1000 participants, 68.7 % were 12-17 years, 24.6 % were ≥ 18 years, and 6.7 % were < 12. Overall, 36.8 % were non-Hispanic Caucasian, 73.4 % were female, and 79.9 % had a primary depressive disorder. Nearly half of the sample reported ≥1 suicide attempt, with rates similar in youth 12-17 years old (49.9 %) and those 18 years and older (45.5 %); 29.9 % of children <12 reported at least one suicide attempt. Depression and anxiety scores were in the moderate-severe range for all age groups (Patient Health Questionnaire for Adolescents [PHQ-A]: 12.9 ± 6.4; Generalized Anxiety Disorder [GAD-7]: 11.3 ± 5.9).

LIMITATIONS

The sample includes youth who are receiving depression care at enrollment and may not be representative of non-diagnosed, non-treatment seeking youth.

CONCLUSIONS

The TX-YDSRN is one of the largest prospective longitudinal cohort registries designed to develop predictive models for outcome trajectories based on disorder heterogeneity, social determinants of health, and treatment availability.

Suicidal thoughts and behaviors in youth seeking mental health treatment in Texas: Youth Depression and Suicide Network research registry

INTRODUCTION

Suicidality in youth is a serious public health problem. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) was initiated in 2020 to create a research registry for youth with depression and/or suicidality in Texas. This report presents baseline clinical/demographic characteristics of the first 1000 participants, focusing on suicidal thoughts and behaviors.

METHODS

The registry includes 8-20-year-old youth receiving treatment for depression, or who screen positive for depression and/or suicidal ideation/behavior. Baseline data include diagnosis, depression/anxiety severity, suicidal ideation/behavior, trauma history, and measures of resilience.

RESULTS

We present baseline data on the first 1000 participants. Most (79.6%) of the sample had a primary depressive disorder. The sample had moderate to severe depression (Patient Health Questionnaire for Adolescents, PHQ-A; 12.9 ± 6.4) and anxiety (Generalized Anxiety Disorder, GAD-7; 11.3 ± 5.9). Nearly half reported ≥1 lifetime suicide attempts and 90% reported lifetime or current suicidal ideation. Participants with past/current suicidality (attempts and/or ideation) had greater illness severity (depression, anxiety, and suicidal thoughts/behaviors), lower resilience, and higher rates of trauma exposure than those without suicidality.

CONCLUSIONS

Baseline data indicate moderate levels of depression, anxiety, and suicidality and their correlates in this cohort. Future reports will determine trajectories of outcomes and predictors, moderators, and social determinants related to these outcomes.

Predicting suicidal events: A comparison of the Concise Health Risk Tracking Self-Report (CHRT-SR) and the Columbia Suicide Severity Rating Scale (C-SSRS)

This report examines the predictive capabilities of two scales of suicidality in high-risk adolescents. Charts of adolescents with severe suicidality participating in an intensive outpatient program were reviewed. Self-report data from the 9-item Concise Health Risk Tracking Self-Report (CHRT-SR9) and clinician-completed data from the Columbia Suicide Severity Risk Scale (C-SSRS) were obtained at entry. Scales' performances in predicting suicide attempts and suicidal events were evaluated using logistic regression models and ROC analyses. Of 539 adolescents, 53 had events of which 19 were attempts. The CHRT-SR9 total score predicted events (OR=1.05) and attempts (OR=1.09), as did the C-SSRS Suicide Ideation (SI) Intensity Composite for events (OR=1.10) and attempts (OR=1.16). The CHRT-SR9 AUC was 0.70 (84.2% sensitivity; 41.7% specificity; PPV=5.0%; NPV=98.6%) for attempts. The C-SSRS Intensity Composite AUC was 0.62 (89.5% sensitivity; 24.1% specificity; PPV=4.2%; NPV=98.4%) for attempts. Both the CHRT-SR9 and C-SSRS capture important parameters related to suicidal events or attempts that can help assess suicidal risk in adolescents.

Psychometric properties of Concise Associated Symptom Tracking (CAST) scale in youths and young adults: Findings from the Texas youth depression and suicide research network (TX-YDSRN)

Symptoms of irritability, anxiety, panic, and insomnia are common in patients with depression, and their worsening after antidepressant treatment initiation is associated with poorer long-term outcomes. The Concise Associated Symptom Tracking (CAST) scale was developed to measure these symptoms in adults with major depressive disorder (MDD). Here, we evaluate the psychometric properties of CAST in an ongoing community-based observational study involving children, adolescents, and young adults. Individuals from the ongoing Texas Youth Depression and Suicide Research Network (TX-YDSRN; N = 952) with CAST data available were included. Fit statistics [Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)] from confirmatory factor analyses were used to evaluate the five- and four-domain structure of CAST. Item response theory (IRT) analyses were also used. Individuals were grouped based on age (in years) as youths (8-17) and young adults (18-20). Correlations with other clinical measures were used to inform construct validity. Four-domain (irritability, anxiety, panic, and insomnia) 12-item structure of CAST (CAST-12) was optimal for youths (N = 709, GFI = 0.906, CFI = 0.919, RMSEA = 0.095) and young adults (N = 243, GFI = 0.921, CFI = 0.938, RMSEA = 0.0797) with Cronbach's alpha of 0.87 and 0.88, respectively. Slope of each item exceeded 1.0 on IRT analyses suggesting adequate discrimination for each item. Scores on irritability, anxiety, panic, and insomnia were significantly correlated with similar items on other scales. Together these findings suggest that CAST-12 is a valid self-report measure of irritability, anxiety, insomnia, and panic in youths and young adults.

Two Trajectories of Depressive Symptom Reduction Throughout Behavioral Activation Teletherapy Among Underserved, Ethnically Diverse, Primary Care Patients: A VitalSign6 Report

While prior research has investigated trajectories of depressive symptom change throughout psychotherapy, such work has not been conducted exclusively among underserved patients receiving brief Behavioral Activation (BA) teletherapy, intervention modifications that should reduce barriers to therapy initiation and engagement. The current project used cluster analysis to determine discrete groups of symptom change among patients receiving an 8-session BA teletherapy intervention, and analyzed whether demographic and clinical characteristics were associated with group membership. Data from 105 patients referred from charity primary care clinics and receiving at least two therapy sessions were analyzed. Patients were predominantly female and Latina. The 9-item Patient Health Questionnaire (PHQ-9) was the outcome. Two categories were determined: a larger group (N = 61) demonstrating initially less severe symptoms and experiencing a gradual recovery, and a smaller group beginning with more severe symptoms, and experiencing a steeper recovery. In both groups, a majority of participants experienced at least a 5-point drop in depressive symptoms, while in the latter group, a majority of patients achieved depressive symptom remission (PHQ-9 < 5). Monolingual Spanish speakers were more likely to be in the former group, but no other demographic or clinical characteristics were associated with group membership. In both groups, a majority of the symptom reduction occurred by sessions 4-6. Therefore, two categories of depressive symptom change, slow responders and rapid responders, occur among patients receiving a brief BA teletherapy intervention. No demographic differences aside from primary language, nor any clinical characteristics, distinguish group membership, suggesting similar patterns of symptom reduction among a primarily underserved sample.

Hopelessness as a Predictor of Suicide Ideation in Depressed Male and Female Adolescent Youth

We examined hopelessness as a predictor of suicide ideation in depressed youth after acute medication treatment. A total of 158 depressed adolescents were administered the Children's Depression Rating Scale-Revised (CDRS-R) and Columbia Suicide Severity Rating Scale (C-SSRS) as part of a larger battery at baseline and at weekly visits across 6 weeks of acute fluoxetine treatment. The Beck Hopelessness Scale (BHS) was administered at baseline and week 6. A negative binomial regression model via a generalized estimating equation analysis of repeated measures was used to estimate suicide ideation over the 6 weeks of acute treatment from baseline measure of hopelessness. Depression severity and gender were included as covariates in the model. The negative binomial analysis was also conducted separately for the sample of males and females (in a gender-stratified analysis). Mean CDRS-R total scores were 60.30 ± 8.93 at baseline and 34.65 ± 10.41 at week 6. Mean baseline and week 6 BHS scores were 9.57 ± 5.51 and 5.59 ± 5.38, respectively. Per the C-SSRS, 43.04% and 83.54% reported having no suicide ideation at baseline and at week 6, respectively. The analyses revealed that baseline hopelessness was positively related to suicide ideation over treatment (p = .0027), independent of changes in depression severity. This significant finding persisted only for females (p = .0024). These results indicate the importance of early identification of hopelessness.

Predictors and Moderators of Relapse in Children and Adolescents With Major Depressive Disorder

OBJECTIVE

To identify predictors and moderators of relapse during continuation treatment among depressed youth randomly assigned to fluoxetine or placebo.

METHODS

Potential predictors and moderators of relapse that were identified by a literature review were examined in 102 youth (aged 7-18 years), diagnosed with major depressive disorder as defined by DSM-IV criteria, who were considered responders after 12 weeks of fluoxetine treatment (acute phase). This randomized controlled trial was conducted from June 2000 through October 2005. Each candidate predictor and moderator was evaluated with a multiple logistic regression model to examine the main and interaction effects of 12 weeks of continuation treatment on relapse status (at week 24) while controlling for age, sex, and depression severity. Relapse was defined as a Children's Depression Rating Scale-Revised total score ≥ 40 with worsening of depressive symptoms for at least 2 weeks.

RESULTS

Youth with comorbid dysthymia (adjusted odds ratio [OR] = 2.88, P = .03) and low levels of family leadership (adjusted OR = 1.39, P = .006) at baseline are more likely to relapse than their counterparts. Higher levels of depression (OR = 1.21, P = .003) and higher levels of residual sleep disturbance (insomnia) (OR = 6.74, P = .006) and irritability (OR = 7.40, P = .01) at the end of acute treatment (12 weeks) increased the odds of relapse. Higher levels of depressive symptoms at baseline in youth who remained on fluoxetine for continuation treatment were associated with increased odds of relapse (adjusted OR = 1.14, P = .03). Females who remained on fluoxetine for the duration of continuation treatment were almost 9 times more likely to relapse than males (adjusted OR = 8.86, P = .007).

CONCLUSIONS

This is the first large continuation study for treatment of depression in youth to examine predictors and moderators of relapse. Youth with greater improvement by the end of 3 months of treatment were less likely to relapse than those with continued depressive symptoms. In addition, youth with comorbid dysthymia had 3 times greater risk of relapse that those without. Targeting residual symptoms, particularly sleep disturbance and irritability, earlier in treatment may reduce relapse rates.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00332787.

Developing a Peer Mentorship Program to Increase Competence in Clinical Supervision in Clinical Psychology Doctoral Training Programs

OBJECTIVES

Supervision has recently been recognized as a core competency for clinical psychologists. This recognition of supervision as a distinct competency has evolved in the context of an overall focus on competency-based education and training in health service psychology, and has recently gained momentum. Few clinical psychology doctoral programs offer formal training experiences in providing supervision.

METHODS

A pilot peer mentorship program (PMP) where graduate students were trained in the knowledge and practice of supervision was developed. The focus of the PMP was to develop basic supervision skills in advanced clinical psychology graduate students, as well as to train junior doctoral students in fundamental clinical and practical skills. Advanced doctoral students were matched to junior doctoral students to gain experience in and increase knowledge base in best practices of supervision skills. The 9-month program consisted of monthly mentorship meetings and three training sessions.

RESULTS

The results suggested that mentors reported a 30% or more shift from the category of not competent to needs improvement or competent, in the following supervision competencies: theories of supervision, improved skill in supervision modalities, acquired knowledge in supervision, and supervision experience. Furthermore, 50% of the mentors reported that they were not competent in supervision experience at baseline and only 10% reported that they were not competent at the end of the program. Satisfaction data suggested that satisfaction with the program was high, with 75% of participants indicating increased knowledge base in supervision, and 90% indicating that it was a positive addition to their training program.

CONCLUSIONS

This program was feasible and acceptable and appears to have had a positive impact on the graduate students who participated. Students reported both high satisfaction with the program as well as an increase in knowledge base and experience in supervision skills.

Efficacy of a Behavioral Activation Teletherapy Intervention to Treat Depression and Anxiety in Primary Care VitalSign6 Program

Objective

Research analyzing behavioral activation (BA) teletherapy outcomes is limited. Among low-income real-world primary care patients receiving a brief BA teletherapy program for depression and anxiety, we analyzed descriptive statistics and changes in depression and anxiety scores throughout treatment.

Methods

One hundred thirty patients completed an intake assessment from June 2015 to August 2016; outcomes included the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7). Data from 74 low-income, primary care patients completing at least one therapy session were analyzed to characterize the demographics of therapy patients, to describe their depression and anxiety symptoms throughout treatment, and to examine whether patients who completed 4 or more sessions had statistically lower exit scores than those completing fewer than 4.

Results

Patients were moderately depressed (PHQ-9 score: mean = 14.46) and anxious (GAD-7 score: mean = 11.91) at intake. Patients were predominantly Latino/Latina (68.9%), Spanish-speaking (54.0%), and female (79.7%). The majority of patients who received at least one therapy session achieved and sustained depression remission. Patients who completed ≥ 4 therapy sessions demonstrated lower final session depression (PHQ-9: mean = 5.13, SD = 4.75) and anxiety (GAD-7: mean = 4.77, SD = 4.21) scores compared to those completing < 4 sessions (PHQ-9: mean = 8.04, SD = 6.20, P = .029; GAD-7: mean = 8.00, SD = 6.02, P = .011).

Conclusions

Primary care patients demonstrated improvements in depressive and anxious symptoms throughout BA-based teletherapy. BA teletherapy is feasible and associated with improved outcomes as an adjunct or alternative intervention for primary care providers and in low-income, charity populations.​.

Developing a Brief Suicide Prevention Intervention and Mobile Phone Application: a Qualitative Report

Suicide is the second leading cause of death among youth and has become a serious public health problem. There has been limited research on strategies to decrease the likelihood of reattempt in adolescents. As phase one of a treatment development study, clinicians, parents and adolescents participated in qualitative interviews in order to gain new perspectives on developing a targeted intervention and a safety plan phone application for suicide prevention. Participants indicated that transition of care, specific treatment targets and safety planning were important parts of treatment. In addition, all participants endorsed the use of a smartphone application for these purposes.

Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth

Relapse rates for children and adolescents with major depressive disorder (MDD) range from 30% to 40% within 1 to 2 years after acute treatment. Although relapse rates are high, there have been relatively few studies on the prevention of relapse in youth. While acute phase pharmacotherapy has been shown to reduce symptoms rapidly in depressed youth, children and adolescents frequently report ongoing residual symptoms and often relapse following acute treatment. Recent adult trials have begun examining augmentation with psychosocial treatment after successful medication treatment to enhance medication response and prevent future relapse. This strategy has not yet been examined in youth with depression. Here we present initial efforts to develop a sequential, combination treatment strategy to promoting rapid remission and to prevent relapse in depressed youth. We describe efforts to adapt CBT to prevent relapse (RP-CBT) in youth who respond to pharmacotherapy. The goals of RP-CBT include: preventing relapse, increasing wellness, and developing skills to promote and sustain a healthy emotional lifestyle. We describe the rationale for, components of, and methods used to develop RP-CBT. The results from a small open series sample demonstrate feasibility and indicate that youth appear to tolerate RP-CBT well. A future test of the treatment in a randomized controlled trial is described.

The Quick Inventory of Depressive Symptomatology-Self-report: a psychometric evaluation in patients with asthma and major depressive disorder

BACKGROUND

Despite the high co-occurrence between depression and asthma, few studies have addressed methods assessing the severity of depressive symptoms among patients with asthma.

OBJECTIVE

To evaluate the psychometric properties of the Quick Inventory of Depressive Symptomatology-Self-report (QIDS-SR16), a 16-item measure of depressive symptom severity, in patients with asthma.

METHODS

The psychometric properties of the QIDS-SR16 were compared at treatment exit with those of the 30-item self-report Inventory of Depressive Symptomatology (IDS-SR30) and the 17-item clinician-rated Hamilton Rating Scale for Depression (HRSD17) in 73 outpatients with asthma who were treated with citalopram or placebo for nonpsychotic major depressive disorder. Correlations between the depression rating scales and the Mini Asthma Quality of Life Questionnaire were calculated.

RESULTS

Internal consistency at exit was strong for the QIDS-SR16 (Cronbach alpha values are .87 for the QIDS-SR16, .95 for the IDS-SR30, and .87 for the HRSD17). The QIDS-SR16 and HRSD17 total scores were highly correlated (r = 0.85), as were the QIDS-SR16 and IDS-SR30 total scores (r = 0.97). All QIDS-SR16 item total score correlations were significant (P < .001). The QIDS-SR16, IDS-SR30, and HRSD17 showed comparable sensitivity to symptom change, indicating high concurrent validity for all 3 scales. The total QIDS-SR16 baseline to exit change score demonstrated a significant negative correlation (r = -0.49, P < .001) with the Mini Asthma Quality of Life Questionnaire. Thus, greater depressive symptom severity was associated with lower asthma-related quality of life.

CONCLUSIONS

The QIDS-SR16 showed good reliability and impressive construct validity. Strong psychometric properties of this brief self-report format and its sensitivity to treatment change suggest that the QIDS-SR16 is a valuable clinical tool.

Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents

OBJECTIVE

The authors compared fluoxetine and placebo in continuation treatment to prevent relapse of major depressive disorder in children and adolescents.

METHOD

After a detailed evaluation, children and adolescents 7-18 years of age with major depressive disorder were treated openly with fluoxetine. Those who had an adequate response after 12 weeks, as indicated by a Clinical Global Impression improvement score of 1 or 2 and a decrease of at least 50% in Children's Depression Rating Scale-Revised score, were randomly assigned to receive fluoxetine or placebo for an additional 6 months. The primary outcome measures were relapse and time to relapse. Relapse was defined as either a score of 40 or higher on the Children's Depression Rating Scale with a history of 2 weeks of clinical deterioration, or clinical deterioration as judged by the clinician. Additional analyses were conducted with relapse defined only as a score of 40 or higher on the Children's Depression Rating Scale.

RESULTS

Of 168 participants enrolled in acute fluoxetine treatment, 102 were randomly assigned to continuation treatment with fluoxetine (N=50) or placebo (N=52). Of these, 21 participants (42.0%) in the fluoxetine group relapsed, compared with 36 (69.2%) in the placebo group, a significant difference. Similarly, under the stricter definition of relapse, fewer participants in the fluoxetine group relapsed (N=11; 22.0%) than in the placebo group (N=25; 48.1%). Time to relapse was significantly shorter in the placebo group.

CONCLUSIONS

Continuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.

Do children and adolescents have differential response rates in placebo-controlled trials of fluoxetine?

OBJECTIVE

Recent acute efficacy trials of antidepressants in youth have suggested that high placebo-response rates in children (< 12 years of age) indicate that children may be more responsive to non-specific treatment interventions. Yet, these studies generally have not presented age-specific outcome data. The objective of this study was to compare the efficacy outcomes for children (< 12 years of age) and adolescents (> or = 12 years of age) using the combined data from two previously published double-blind, placebo-controlled trials of fluoxetine.

METHODS

Children (< 12 years of age) and adolescents (> or = 12 years of age) with major depressive disorder were randomized to fluoxetine or placebo for 8-9 weeks of treatment. Outcome was assessed using the Children's Depression Rating Scale-Revised (CDRS-R) and Clinical Global Impressions scale.

RESULTS

Random regression of the CDRS-R showed a treatment group by age group interaction (F(1,338)=4.10, P=.044), indicating that the treatment effect was significantly more pronounced in children than adolescents. Within children, response at exit to fluoxetine was significantly better than placebo (56.9% vs 33.3%; P=.009). Adolescent response rates at exit were not significantly different between the groups (51.1% vs 38.6%; P=.128). Remission rates were low for both groups.

CONCLUSION

In the combined fluoxetine trials, drug-placebo difference was greater in children compared with adolescents. Contrary to expectations, the placebo-response rate was lower in the children than the adolescents.

Academic outcome in long-term survivors of pediatric liver transplantation

Fifty long-term (3-9 year) survivors of pediatric liver transplantation were assessed using IQ, achievement, and school history measures. Forty-seven of these children had been evaluated before transplantation on intellectual measures, with mean scores for the group found to be in the low average range. At follow-up evaluation, the scores remained in the low average range on all intellectual measures; performance on academic tests was also within the low average range. Thirteen children (26%) were classified as having learning problems based on discrepancies between intellectual and academic function, but only five of them (38%) had received special education services. Nine of the children (18%) had IQ scores less than 70. Academic outcome did not relate to diagnosis, time between diagnosis and transplantation, age at time of transplantation, or average levels of cyclosporin A. Careful assessment and appropriate special education services are indicated to optimize the educational outcome of children who survive liver transplantation.

Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study

OBJECTIVE

To compare compliance, psychiatric disorders, and family support in children with insulin-dependent diabetes mellitus (IDDM) hospitalized with diabetic ketoacidosis (DKA) and clinic controls.

METHOD

Twenty-five youths hospitalized with DKA and 25 matched outpatient subjects with IDDM with no history of DKA during the preceding year were assessed cross-sectionally, using the Diagnostic Interview Schedule for Children, measures of general and diabetes-specific family functioning, and measures of self-esteem and social competence. Levels of glycosylated hemoglobin and information about compliance with the treatment regimen were obtained.

RESULTS

A significantly higher number of psychiatric disorders was observed in the hospitalized children, with 88% meeting criteria for at least one disorder (versus 28% of controls). Self-esteem and social competence were lower in the hospitalized group, and their families scored lower on problem-solving and diabetes-specific "warmth-caring."

CONCLUSIONS

Children with recurrent DKA may be at greater risk of associated psychopathology than diabetic controls with no such history. DKA children's reports of noncompliance may be more sensitive than their parents' reports, and their families may lack warm, caring parent-child relationships.

A survey of psychosocial adaptation in long-term survivors of pediatric liver transplants

We assessed 41 children and adolescents who had received liver transplants at least 4 years ago, for social, behavioral, and emotional adaptation; physical function; and family stress. We compared their level of adaptive functioning to published data from chronically ill and medically well children. On many measures, transplant recipients had equivalent levels of function to the comparison groups. However, 6- to 11-year-old patients showed mild social and scholastic deficits. Patients' parents report less negative impact of the illness on the family than do parents of other chronically ill children. A listing of medication side effects and the degree to which they are problematic was obtained.

Cognitive function in children who receive organ transplantation

The number of children who undergo cardiac, renal, and liver transplantation continues to increase. This review of the literature describing their cognitive function indicates that deficits ranging from gross IQ delay to subtle neuropsychological dysfunction are present in some of these children both before and after transplantation. However, with the exception of certain definite contributors to vulnerability, such as cyanotic heart disease, early onset of disease, and growth deficits in infancy (particularly in head circumference and height), the correlates of cognitive deficits are not clear. Problems with determining contributing variables include significant heterogeneity within study populations, difficulties obtaining appropriate control groups, and the need for longitudinal, long-term studies. Additional research is required to address limitations of past studies.

Cognitive function in children who receive organ transplantation

The number of children who undergo cardiac, renal, and liver transplantation continues to increase. This review of the literature describing their cognitive function indicates that deficits ranging from gross IQ delay to subtle neuropsychological dysfunction are present in some of these children both before and after transplantation. However, with the exception of certain definite contributors to vulnerability, such as cyanotic heart disease, early onset of disease, and growth deficits in infancy (particularly in head circumference and height), the correlates of cognitive deficits are not clear. Problems with determining contributing variables include significant heterogeneity within study populations, difficulties obtaining appropriate control groups, and the need for longitudinal, long-term studies. Additional research is required to address limitations of past studies.

Mental and motor development, social competence, and growth one year after successful pediatric liver transplantation

We measured intellectual and motor function, social competence, and growth in 29 children (mean age 4 years 7 months) before liver transplantation and 1 year later. We used either the Bayley Scales, the Stanford-Binet Intelligence Scale, and the Minnesota Child Development Inventory (MCDI), Motor Age Quotient, or the Wechsler Scales, depending on the age of the child at testing. Social function was measured with the MCDI or the Child Behavior Checklist. All anthropometric measures were expressed relative to normal values for age and sex. Patients whose intellectual and motor scores were less than 80 before transplantation gained an average of 8 points, but these changes were not statistically significant, nor were the changes on these measures for the group as a whole. The development of children with onset of liver disease in the first year of life was more likely to remain delayed after transplantation. Older subjects improved significantly in social competence (p less than 0.008). There were significant increments after transplantation in weight, head circumference, and arm anthropometrics (p less than 0.0001 to 0.04), but there was no change in linear growth rate. Increments in length correlated negatively with steroid dosage, and change in head circumference was associated with age at time of transplantation (p less than 0.005 to 0.10).

Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebo-controlled trials

We enrolled 200 infants and older children with bacterial meningitis in two prospective double-blind, placebo-controlled trials to evaluate the efficacy of dexamethasone therapy in addition to either cefuroxime (Study 1) or ceftriaxone (Study 2). Altogether, 98 patients received placebo and 102 received dexamethasone (0.15 mg per kilogram of body weight every six hours for four days). At the beginning of therapy, the clinical and demographic characteristics of the patients in the treatment groups were comparable. The mean increase in the cerebrospinal fluid concentration of glucose and the decreases in lactate and protein levels after 24 hours of therapy were significantly greater in those who received dexamethasone than in those who received placebo (glucose, 2.0 vs. 0.4 mmol per liter [36.0 vs. 6.9 mg per deciliter], P less than 0.001; lactate, 4.0 vs. 2.1 mmol per liter [38.3 vs. 19.8 mg per deciliter], P less than 0.001; and protein, 0.64 vs. 0.25 g per liter [64.0 vs. 25.3 mg per deciliter], P less than 0.05). One patient in the placebo group in Study 1 died. As compared with those who received placebo, the patients who received dexamethasone became afebrile earlier (1.6 vs. 5.0 days; P less than 0.001) and were less likely to acquire moderate or more severe bilateral sensorineural hearing loss (15.5 vs. 3.3 percent; P less than 0.01). Twelve patients in the two placebo groups (14 percent) had severe or profound bilateral hearing loss requiring the use of a hearing aid, as compared with 1 (1 percent) in the two dexamethasone groups (P less than 0.001). We conclude that dexamethasone is beneficial in the treatment of infants and children with bacterial meningitis, particularly in preventing deafness.

Mental development and growth in children with chronic liver disease of early and late onset

Comparison was made of the mental function and physical growth of 21 children in whom liver disease occurred in the first year of life with 15 patients with late (17 months of age to 12 years of age) manifestation of liver disease. Ages (mean +/- SD) at testing for the two groups was 8 +/- 3 years for the early group and 11 +/- 5 years for the late group. Wechsler verbal, performance, and full-scale IQ scores were lower for the early group (range of mean scores: early, 85 to 86 v late, 96 to 103). Growth measures were significantly different in the two groups. Means +/- SD (percentage of standard) were: length for early group, 92 +/- 9; for late, 99 +/- 7; and head circumference for early, 98 +/- 4; for late, 101 +/- 2. The groups were similar in severity of liver disease and acute nutritional status, however. Patients with intellectual impairment had a longer duration of illness, poor nutritional status, and vitamin E deficiency; 82% of impaired patients were in the early group. The data suggest that liver disease during early life has pernicious effects on intellectual function and linear growth. Careful monitoring of nutritional status of children with early-onset liver disease and aggressive nutritional support beginning at the time of diagnosis may help reduce delays in growth and mental development.

Mental and motor development correlates in patients with end-stage biliary atresia awaiting liver transplantation

We measured mental and motor development in 27 infants and 14 children with end-stage biliary atresia who were awaiting liver transplantation, and we measured disease-related variables (physical growth, liver function, and severity and duration of disease) that may relate to development. We then determined the relationship between development and the disease-related variables. Infants were assessed with the Bayley scales, and children were assessed with the Stanford-Binet scales of intelligence and the Minnesota Child Development Inventory. The mean +/- SD mental and motor scores for infants were 79.5 +/- 19.6 and 69.7 +/- 17.6, respectively. The mean +/- SD IQ and motor development scores for children were 76.1 +/- 16.6 and 56.9 +/- 18.1, respectively. For infants, mental and motor development were related significantly to height and weight (r values ranged from .42 to .72). Mental development in infants was also related significantly to serum vitamin E levels (P = .03). Multiple regression analyses combining growth and disease-related indices predicted 70% of the variance in mental and motor development in infants (P = .001). For children, development was related to measures of liver function (ie, to serum bilirubin, r = -.51, P = -.08, and to serum albumin, r = .54, P = .06) but not to growth. Careful nutritional support during infancy and aggressive management of liver disease prior to transplantation may be important in optimizing the development of children with biliary atresia who subsequently undergo liver transplantation.