Mitchel L. Zoler, PhD

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK — The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the meeting. Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of the disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million American children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference. Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK — The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the meeting. Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of the disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million American children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference. Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK — The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the meeting. Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of the disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million American children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference. Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

Major Finding: Among adolescents presenting for inpatient or partial hospital treatment of acute mental illness, those with vitamin D deficiency (blood levels below 20 ng/mL) had a fourfold higher prevalence of psychotic symptoms, compared with adolescents with normal vitamin D levels (greater than 30 ng/mL).

Data Source: Review of 77 adolescents seen at a U.S. referral hospital during October 2008–June 2009.

Disclosures: Dr. Gracious said he had no financial disclosures.

NEW YORK — Vitamin D deficiency was associated with an increased prevalence of psychotic symptoms in adolescents who were hospitalized for psychiatric reasons, in a single-center study of 77 patients.

“The association of vitamin D deficiency with psychotic features warrants further investigation as a risk factor for both physical and mental health outcomes” in adolescents with serious mental illness, Dr. Barbara L. Gracious and her associates reported in a poster at the meeting.

“The importance of vitamin D for brain development and function in both healthy and psychiatric populations is less well appreciated and understood, compared with its known role in bone health and emerging role in metabolic health,” said Dr. Gracious, a psychiatrist at Nationwide Children's Hospital in Columbus, Ohio, and her coinvestigators.

Prior study findings have documented links between vitamin D levels and seasonal affective disorder, depression, and schizophrenia, observations that highlighted the potential for vitamin D levels to modulate vulnerability to mental disorders.

To explore a possible link between vitamin D and psychosis, Dr. Gracious and her associates studied 77 adolescents who presented at the University of Rochester (N.Y.) for inpatient or partial hospital mental health treatment during October 2008–June 2009.

Average age of the patients was 15 years. The patients underwent a psychiatric assessment at the time of their hospitalization by an emergency-department psychiatrist and by the attending child psychiatrist.

Psychosis was defined as hallucinations, paranoia, or delusions. The researchers measured blood levels of 25-hydroxy vitamin D with an immunoassay.

The assays showed that 31 of the referred adolescents (40%) had vitamin D deficiency, defined as a blood level less than 20 ng/mL; 26 of the subjects (34%) had vitamin D insufficiency, defined as a blood level of 20-30 ng/mL; and 20 of the subjects (26%) had a normal vitamin D level, defined as greater than 30 ng/mL.

Overall, the researchers identified psychotic symptoms in 19 of the 77 patients (25%). The psychotic prevalence rate among vitamin D–deficient adolescents was 13 out of 31 (42%). Among 26 adolescents with vitamin D insufficiency, 3 (12%) had psychotic symptoms. In 20 adolescents with a normal vitamin D level, 3 patients (15%) showed psychotic symptoms.

In an unadjusted, odds ratio analysis, vitamin D–deficient adolescents had a significant, fourfold increased risk of psychosis, compared with patients with normal vitamin D levels.

On the basis of these findings, physicians should now consider clinical screening of vitamin D levels in severely mentally ill adolescents who are at high risk for chronic mental and metabolic illness, and supplementing those who are deficient or insufficient, Dr. Gracious and her associates concluded.

Further research should explore the levels of vitamin D intake and sun exposure needed by these patients, and also explore the role that vitamin D plays in the severity of mental illness in patients of other ages, they said.

Major Finding: Among adolescents presenting for inpatient or partial hospital treatment of acute mental illness, those with vitamin D deficiency (blood levels below 20 ng/mL) had a fourfold higher prevalence of psychotic symptoms, compared with adolescents with normal vitamin D levels (greater than 30 ng/mL).

Data Source: Review of 77 adolescents seen at a U.S. referral hospital during October 2008–June 2009.

Disclosures: Dr. Gracious said he had no financial disclosures.

NEW YORK — Vitamin D deficiency was associated with an increased prevalence of psychotic symptoms in adolescents who were hospitalized for psychiatric reasons, in a single-center study of 77 patients.

“The association of vitamin D deficiency with psychotic features warrants further investigation as a risk factor for both physical and mental health outcomes” in adolescents with serious mental illness, Dr. Barbara L. Gracious and her associates reported in a poster at the meeting.

“The importance of vitamin D for brain development and function in both healthy and psychiatric populations is less well appreciated and understood, compared with its known role in bone health and emerging role in metabolic health,” said Dr. Gracious, a psychiatrist at Nationwide Children's Hospital in Columbus, Ohio, and her coinvestigators.

Prior study findings have documented links between vitamin D levels and seasonal affective disorder, depression, and schizophrenia, observations that highlighted the potential for vitamin D levels to modulate vulnerability to mental disorders.

To explore a possible link between vitamin D and psychosis, Dr. Gracious and her associates studied 77 adolescents who presented at the University of Rochester (N.Y.) for inpatient or partial hospital mental health treatment during October 2008–June 2009.

Average age of the patients was 15 years. The patients underwent a psychiatric assessment at the time of their hospitalization by an emergency-department psychiatrist and by the attending child psychiatrist.

Psychosis was defined as hallucinations, paranoia, or delusions. The researchers measured blood levels of 25-hydroxy vitamin D with an immunoassay.

The assays showed that 31 of the referred adolescents (40%) had vitamin D deficiency, defined as a blood level less than 20 ng/mL; 26 of the subjects (34%) had vitamin D insufficiency, defined as a blood level of 20-30 ng/mL; and 20 of the subjects (26%) had a normal vitamin D level, defined as greater than 30 ng/mL.

Overall, the researchers identified psychotic symptoms in 19 of the 77 patients (25%). The psychotic prevalence rate among vitamin D–deficient adolescents was 13 out of 31 (42%). Among 26 adolescents with vitamin D insufficiency, 3 (12%) had psychotic symptoms. In 20 adolescents with a normal vitamin D level, 3 patients (15%) showed psychotic symptoms.

In an unadjusted, odds ratio analysis, vitamin D–deficient adolescents had a significant, fourfold increased risk of psychosis, compared with patients with normal vitamin D levels.

On the basis of these findings, physicians should now consider clinical screening of vitamin D levels in severely mentally ill adolescents who are at high risk for chronic mental and metabolic illness, and supplementing those who are deficient or insufficient, Dr. Gracious and her associates concluded.

Further research should explore the levels of vitamin D intake and sun exposure needed by these patients, and also explore the role that vitamin D plays in the severity of mental illness in patients of other ages, they said.

Major Finding: Among adolescents presenting for inpatient or partial hospital treatment of acute mental illness, those with vitamin D deficiency (blood levels below 20 ng/mL) had a fourfold higher prevalence of psychotic symptoms, compared with adolescents with normal vitamin D levels (greater than 30 ng/mL).

Data Source: Review of 77 adolescents seen at a U.S. referral hospital during October 2008–June 2009.

Disclosures: Dr. Gracious said he had no financial disclosures.

NEW YORK — Vitamin D deficiency was associated with an increased prevalence of psychotic symptoms in adolescents who were hospitalized for psychiatric reasons, in a single-center study of 77 patients.

“The association of vitamin D deficiency with psychotic features warrants further investigation as a risk factor for both physical and mental health outcomes” in adolescents with serious mental illness, Dr. Barbara L. Gracious and her associates reported in a poster at the meeting.

“The importance of vitamin D for brain development and function in both healthy and psychiatric populations is less well appreciated and understood, compared with its known role in bone health and emerging role in metabolic health,” said Dr. Gracious, a psychiatrist at Nationwide Children's Hospital in Columbus, Ohio, and her coinvestigators.

Prior study findings have documented links between vitamin D levels and seasonal affective disorder, depression, and schizophrenia, observations that highlighted the potential for vitamin D levels to modulate vulnerability to mental disorders.

To explore a possible link between vitamin D and psychosis, Dr. Gracious and her associates studied 77 adolescents who presented at the University of Rochester (N.Y.) for inpatient or partial hospital mental health treatment during October 2008–June 2009.

Average age of the patients was 15 years. The patients underwent a psychiatric assessment at the time of their hospitalization by an emergency-department psychiatrist and by the attending child psychiatrist.

Psychosis was defined as hallucinations, paranoia, or delusions. The researchers measured blood levels of 25-hydroxy vitamin D with an immunoassay.

The assays showed that 31 of the referred adolescents (40%) had vitamin D deficiency, defined as a blood level less than 20 ng/mL; 26 of the subjects (34%) had vitamin D insufficiency, defined as a blood level of 20-30 ng/mL; and 20 of the subjects (26%) had a normal vitamin D level, defined as greater than 30 ng/mL.

Overall, the researchers identified psychotic symptoms in 19 of the 77 patients (25%). The psychotic prevalence rate among vitamin D–deficient adolescents was 13 out of 31 (42%). Among 26 adolescents with vitamin D insufficiency, 3 (12%) had psychotic symptoms. In 20 adolescents with a normal vitamin D level, 3 patients (15%) showed psychotic symptoms.

In an unadjusted, odds ratio analysis, vitamin D–deficient adolescents had a significant, fourfold increased risk of psychosis, compared with patients with normal vitamin D levels.

On the basis of these findings, physicians should now consider clinical screening of vitamin D levels in severely mentally ill adolescents who are at high risk for chronic mental and metabolic illness, and supplementing those who are deficient or insufficient, Dr. Gracious and her associates concluded.

Further research should explore the levels of vitamin D intake and sun exposure needed by these patients, and also explore the role that vitamin D plays in the severity of mental illness in patients of other ages, they said.

Major Finding: In 1996-2007, hospitalizations for primary psychiatric diagnoses in children aged 5-13 years jumped from 15.6 per 10,000 population to 28.3. In the same period, hospitalization rates rose by 42% in adolescents aged 14-19 and 8% for adults aged 20-64.

Data Source: Representative, nationwide database maintained by the Centers for Disease Control and Prevention.

Disclosures: Dr. Blader had no disclosures.

NEW YORK — During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the meeting.

The reasons behind these changes and their implications remain unclear, said Dr. Blader of the State University of New York at Stony Brook, but the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis.

“It's not a good thing” that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts “represent a significant development in mental health treatment in the United States,” he said in the poster.

The data Dr. Blader analyzed came from the Centers for Disease Control and Prevention's National Hospital Discharge Survey and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from “problems in the level of services provided by community care,” and has “more cost shifting” of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

“Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies,” or perhaps the effect “indicates better outpatient care among the privately insured,” he said in his poster. “In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage.”

He noted that during the period studied, the psychiatric field made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

In 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader's poster did not report rates for patients aged 65 or older, but in his analysis, this number fell “dramatically” from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The shifts 'represent a significant development in mental health treatment in the United States.'

Source DR. BLADER

Major Finding: In 1996-2007, hospitalizations for primary psychiatric diagnoses in children aged 5-13 years jumped from 15.6 per 10,000 population to 28.3. In the same period, hospitalization rates rose by 42% in adolescents aged 14-19 and 8% for adults aged 20-64.

Data Source: Representative, nationwide database maintained by the Centers for Disease Control and Prevention.

Disclosures: Dr. Blader had no disclosures.

NEW YORK — During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the meeting.

The reasons behind these changes and their implications remain unclear, said Dr. Blader of the State University of New York at Stony Brook, but the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis.

“It's not a good thing” that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts “represent a significant development in mental health treatment in the United States,” he said in the poster.

The data Dr. Blader analyzed came from the Centers for Disease Control and Prevention's National Hospital Discharge Survey and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from “problems in the level of services provided by community care,” and has “more cost shifting” of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

“Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies,” or perhaps the effect “indicates better outpatient care among the privately insured,” he said in his poster. “In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage.”

He noted that during the period studied, the psychiatric field made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

In 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader's poster did not report rates for patients aged 65 or older, but in his analysis, this number fell “dramatically” from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The shifts 'represent a significant development in mental health treatment in the United States.'

Source DR. BLADER

Major Finding: In 1996-2007, hospitalizations for primary psychiatric diagnoses in children aged 5-13 years jumped from 15.6 per 10,000 population to 28.3. In the same period, hospitalization rates rose by 42% in adolescents aged 14-19 and 8% for adults aged 20-64.

Data Source: Representative, nationwide database maintained by the Centers for Disease Control and Prevention.

Disclosures: Dr. Blader had no disclosures.

NEW YORK — During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the meeting.

The reasons behind these changes and their implications remain unclear, said Dr. Blader of the State University of New York at Stony Brook, but the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis.

“It's not a good thing” that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts “represent a significant development in mental health treatment in the United States,” he said in the poster.

The data Dr. Blader analyzed came from the Centers for Disease Control and Prevention's National Hospital Discharge Survey and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from “problems in the level of services provided by community care,” and has “more cost shifting” of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

“Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies,” or perhaps the effect “indicates better outpatient care among the privately insured,” he said in his poster. “In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage.”

He noted that during the period studied, the psychiatric field made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

In 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader's poster did not report rates for patients aged 65 or older, but in his analysis, this number fell “dramatically” from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The shifts 'represent a significant development in mental health treatment in the United States.'

Source DR. BLADER

NEW YORK – A diagnosis of attention-deficit/hyperactivity disorder might not be forever.

In fact, it can be pretty fleeting. Analysis of serial assessments of more than 8,000 U.S. children and adolescents for attention-deficit/hyperactivity disorder (ADHD) showed that the diagnosis often did not persist after follow-up of 1 year or longer, J. Blake Turner, Ph.D., said at the meeting

ADHD diagnoses “are extremely transient over a 1-year period. Generally, loss of the diagnosis is more likely than persistence,” said Dr. Turner, a researcher in the division of child and adolescent psychiatry at Columbia University in New York.

The findings suggest that problems exist with current nosology for ADHD, and that current prevalence estimates from community studies may be inflated. “We need to examine the predictors of ADHD persistence over time,” he said. “We need to look at what's going on here and what predicts the persistence of disruptive disorders.

“If patients are diagnosed with ADHD and it is transient – if it is reactive distress that is likely to go away – do we want to identify them?” he asked in an interview. “If a diagnosis is made of ADHD, do you let it go because it will likely resolve on its own, or will treatment help it resolve more quickly?” We think of ADHD as something that lasts, not something that comes and goes. Perhaps we need [a diagnosis] that's more stable,” possibly by basing it on a larger number of symptoms. “That would mean changing the ADHD diagnosis,” he said.

Preliminary analysis of serial assessments for oppositional defiance disorder and conduct disorder in the same data set of 8,714 children and adolescents showed similar, transient patterns after an initial diagnosis, Dr. Turner added.

“It troubles me that the [ADHD] phenotype looks so unstable,” commented Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the National Institute of Mental Health. “A lot of people are struggling with the threshold for [diagnosing] ADHD. This is a very different conceptualization of ADHD; we don't usually think of it as something that's gone in 2 years. If this is [children having] a transient reaction to stress, I don't want to talk about it [in] the same way as clinical ADHD.

Dr. Pine suggested that Dr. Turner's new finding might help explain the high reported prevalence rates of ADHD, and that the results also raised issues about using stimulants to treat newly diagnosed ADHD.

“I look at some of the prevalences [reported], and it's absurd. I find it very hard to believe that 20% of American boys have ADHD,” but that is what some recent reports documented, Dr. Pine said. Other reports said that about 6% of all American children and about 12% of boys receive stimulant treatment for ADHD. “When I look at these data [in Dr. Turner's report], the question of stimulant use is right behind there.”

Dr. Turner used data collected by 4 of the 16 studies done by researchers in the DISC (Diagnostic Interview Schedule for Children) Nosology Group. All of the studies used the DISC to assess a group of children, adolescents, or both. The four studies used by Dr. Turner included serial assessments using the DISC for ADHD a year or more apart. Depending on the study and whether the diagnostic criteria included the age of onset, the range of ADHD prevalence at the initial examination was 5%–40%, with roughly 1,200 total cases identified.

At a follow-up visit at least 1 year after the initial examination, loss of the ADHD diagnosis occurred in roughly 55%–75% of the patients who had been diagnosed with inattention ADHD the first time. In patients who were initially diagnosed with hyperactive ADHD, the loss rate at follow-up ran 55%–65%. Those who were first diagnosed with combined ADHD had a more stable course, with about 18%–35% not maintaining the diagnosis at follow-up.

Additional analysis showed that lost ADHD diagnoses usually did not occur as a small change in an initially marginal diagnosis. Patients who changed from having ADHD to not having it lost five ADHD symptoms, on average. And the remitters and nonremitters all had a similar pattern of disease severity at their initial diagnosis. Patients' age had no association with whether or not an ADHD diagnosis disappeared. And patients who received treatment had a higher likelihood of retaining their ADHD diagnosis at follow-up than did those who did not receive treatment, possibly because the patients who were treated generally had more chronic ADHD.

Dr. Turner had no disclosures.

NEW YORK – A diagnosis of attention-deficit/hyperactivity disorder might not be forever.

In fact, it can be pretty fleeting. Analysis of serial assessments of more than 8,000 U.S. children and adolescents for attention-deficit/hyperactivity disorder (ADHD) showed that the diagnosis often did not persist after follow-up of 1 year or longer, J. Blake Turner, Ph.D., said at the meeting

ADHD diagnoses “are extremely transient over a 1-year period. Generally, loss of the diagnosis is more likely than persistence,” said Dr. Turner, a researcher in the division of child and adolescent psychiatry at Columbia University in New York.

The findings suggest that problems exist with current nosology for ADHD, and that current prevalence estimates from community studies may be inflated. “We need to examine the predictors of ADHD persistence over time,” he said. “We need to look at what's going on here and what predicts the persistence of disruptive disorders.

“If patients are diagnosed with ADHD and it is transient – if it is reactive distress that is likely to go away – do we want to identify them?” he asked in an interview. “If a diagnosis is made of ADHD, do you let it go because it will likely resolve on its own, or will treatment help it resolve more quickly?” We think of ADHD as something that lasts, not something that comes and goes. Perhaps we need [a diagnosis] that's more stable,” possibly by basing it on a larger number of symptoms. “That would mean changing the ADHD diagnosis,” he said.

Preliminary analysis of serial assessments for oppositional defiance disorder and conduct disorder in the same data set of 8,714 children and adolescents showed similar, transient patterns after an initial diagnosis, Dr. Turner added.

“It troubles me that the [ADHD] phenotype looks so unstable,” commented Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the National Institute of Mental Health. “A lot of people are struggling with the threshold for [diagnosing] ADHD. This is a very different conceptualization of ADHD; we don't usually think of it as something that's gone in 2 years. If this is [children having] a transient reaction to stress, I don't want to talk about it [in] the same way as clinical ADHD.

Dr. Pine suggested that Dr. Turner's new finding might help explain the high reported prevalence rates of ADHD, and that the results also raised issues about using stimulants to treat newly diagnosed ADHD.

“I look at some of the prevalences [reported], and it's absurd. I find it very hard to believe that 20% of American boys have ADHD,” but that is what some recent reports documented, Dr. Pine said. Other reports said that about 6% of all American children and about 12% of boys receive stimulant treatment for ADHD. “When I look at these data [in Dr. Turner's report], the question of stimulant use is right behind there.”

Dr. Turner used data collected by 4 of the 16 studies done by researchers in the DISC (Diagnostic Interview Schedule for Children) Nosology Group. All of the studies used the DISC to assess a group of children, adolescents, or both. The four studies used by Dr. Turner included serial assessments using the DISC for ADHD a year or more apart. Depending on the study and whether the diagnostic criteria included the age of onset, the range of ADHD prevalence at the initial examination was 5%–40%, with roughly 1,200 total cases identified.

At a follow-up visit at least 1 year after the initial examination, loss of the ADHD diagnosis occurred in roughly 55%–75% of the patients who had been diagnosed with inattention ADHD the first time. In patients who were initially diagnosed with hyperactive ADHD, the loss rate at follow-up ran 55%–65%. Those who were first diagnosed with combined ADHD had a more stable course, with about 18%–35% not maintaining the diagnosis at follow-up.

Additional analysis showed that lost ADHD diagnoses usually did not occur as a small change in an initially marginal diagnosis. Patients who changed from having ADHD to not having it lost five ADHD symptoms, on average. And the remitters and nonremitters all had a similar pattern of disease severity at their initial diagnosis. Patients' age had no association with whether or not an ADHD diagnosis disappeared. And patients who received treatment had a higher likelihood of retaining their ADHD diagnosis at follow-up than did those who did not receive treatment, possibly because the patients who were treated generally had more chronic ADHD.

Dr. Turner had no disclosures.

NEW YORK – A diagnosis of attention-deficit/hyperactivity disorder might not be forever.

In fact, it can be pretty fleeting. Analysis of serial assessments of more than 8,000 U.S. children and adolescents for attention-deficit/hyperactivity disorder (ADHD) showed that the diagnosis often did not persist after follow-up of 1 year or longer, J. Blake Turner, Ph.D., said at the meeting

ADHD diagnoses “are extremely transient over a 1-year period. Generally, loss of the diagnosis is more likely than persistence,” said Dr. Turner, a researcher in the division of child and adolescent psychiatry at Columbia University in New York.

The findings suggest that problems exist with current nosology for ADHD, and that current prevalence estimates from community studies may be inflated. “We need to examine the predictors of ADHD persistence over time,” he said. “We need to look at what's going on here and what predicts the persistence of disruptive disorders.

“If patients are diagnosed with ADHD and it is transient – if it is reactive distress that is likely to go away – do we want to identify them?” he asked in an interview. “If a diagnosis is made of ADHD, do you let it go because it will likely resolve on its own, or will treatment help it resolve more quickly?” We think of ADHD as something that lasts, not something that comes and goes. Perhaps we need [a diagnosis] that's more stable,” possibly by basing it on a larger number of symptoms. “That would mean changing the ADHD diagnosis,” he said.

Preliminary analysis of serial assessments for oppositional defiance disorder and conduct disorder in the same data set of 8,714 children and adolescents showed similar, transient patterns after an initial diagnosis, Dr. Turner added.

“It troubles me that the [ADHD] phenotype looks so unstable,” commented Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the National Institute of Mental Health. “A lot of people are struggling with the threshold for [diagnosing] ADHD. This is a very different conceptualization of ADHD; we don't usually think of it as something that's gone in 2 years. If this is [children having] a transient reaction to stress, I don't want to talk about it [in] the same way as clinical ADHD.

Dr. Pine suggested that Dr. Turner's new finding might help explain the high reported prevalence rates of ADHD, and that the results also raised issues about using stimulants to treat newly diagnosed ADHD.

“I look at some of the prevalences [reported], and it's absurd. I find it very hard to believe that 20% of American boys have ADHD,” but that is what some recent reports documented, Dr. Pine said. Other reports said that about 6% of all American children and about 12% of boys receive stimulant treatment for ADHD. “When I look at these data [in Dr. Turner's report], the question of stimulant use is right behind there.”

Dr. Turner used data collected by 4 of the 16 studies done by researchers in the DISC (Diagnostic Interview Schedule for Children) Nosology Group. All of the studies used the DISC to assess a group of children, adolescents, or both. The four studies used by Dr. Turner included serial assessments using the DISC for ADHD a year or more apart. Depending on the study and whether the diagnostic criteria included the age of onset, the range of ADHD prevalence at the initial examination was 5%–40%, with roughly 1,200 total cases identified.

At a follow-up visit at least 1 year after the initial examination, loss of the ADHD diagnosis occurred in roughly 55%–75% of the patients who had been diagnosed with inattention ADHD the first time. In patients who were initially diagnosed with hyperactive ADHD, the loss rate at follow-up ran 55%–65%. Those who were first diagnosed with combined ADHD had a more stable course, with about 18%–35% not maintaining the diagnosis at follow-up.

Additional analysis showed that lost ADHD diagnoses usually did not occur as a small change in an initially marginal diagnosis. Patients who changed from having ADHD to not having it lost five ADHD symptoms, on average. And the remitters and nonremitters all had a similar pattern of disease severity at their initial diagnosis. Patients' age had no association with whether or not an ADHD diagnosis disappeared. And patients who received treatment had a higher likelihood of retaining their ADHD diagnosis at follow-up than did those who did not receive treatment, possibly because the patients who were treated generally had more chronic ADHD.

Dr. Turner had no disclosures.

NEW YORK – Adoption is founded on loss, and a child's reaction to being adopted often can be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the meeting.

In other cases, adopted children might act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

“I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety, and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It's not always present, but we need to look for it, and when it's present, it needs to be dealt with,” Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are “well within the normal range and do quite well,” he said. “Adopted individuals are highly variable in the way they experience adoption-related loss.”

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5–7 years. Children can begin to have a feeling of separation from someone about whom they don't know much, which can lead to anxiety, sadness, and anger. In some children, “the experience of loss may be quite subtle and not easily observed by others.”

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. “As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss,” Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. “Too often, the focus in adoption is on what the child gained” without an acknowledgment of what was lost, he said. “Too often adoptees and birth parents have not had their sense of loss validated by people around them.”

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child's reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are “life books” and bibliotherapy. Therapeutic rituals can help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child's past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child's age, willingness to deal with various adoption issues, and the information available.

When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. “Bibliotherapy is effective because you don't talk directly about adoption but metaphorically,” he said. “It is a basis to probe feelings and trigger communication.” It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child's tie to her adoptive family.

Dr. Brodzinsky said that he had no disclosures.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life.

Source DR. BRODZINSKY

NEW YORK – Adoption is founded on loss, and a child's reaction to being adopted often can be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the meeting.

In other cases, adopted children might act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

“I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety, and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It's not always present, but we need to look for it, and when it's present, it needs to be dealt with,” Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are “well within the normal range and do quite well,” he said. “Adopted individuals are highly variable in the way they experience adoption-related loss.”

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5–7 years. Children can begin to have a feeling of separation from someone about whom they don't know much, which can lead to anxiety, sadness, and anger. In some children, “the experience of loss may be quite subtle and not easily observed by others.”

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. “As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss,” Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. “Too often, the focus in adoption is on what the child gained” without an acknowledgment of what was lost, he said. “Too often adoptees and birth parents have not had their sense of loss validated by people around them.”

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child's reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are “life books” and bibliotherapy. Therapeutic rituals can help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child's past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child's age, willingness to deal with various adoption issues, and the information available.

When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. “Bibliotherapy is effective because you don't talk directly about adoption but metaphorically,” he said. “It is a basis to probe feelings and trigger communication.” It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child's tie to her adoptive family.

Dr. Brodzinsky said that he had no disclosures.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life.

Source DR. BRODZINSKY

NEW YORK – Adoption is founded on loss, and a child's reaction to being adopted often can be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the meeting.

In other cases, adopted children might act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

“I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety, and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It's not always present, but we need to look for it, and when it's present, it needs to be dealt with,” Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are “well within the normal range and do quite well,” he said. “Adopted individuals are highly variable in the way they experience adoption-related loss.”

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5–7 years. Children can begin to have a feeling of separation from someone about whom they don't know much, which can lead to anxiety, sadness, and anger. In some children, “the experience of loss may be quite subtle and not easily observed by others.”

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. “As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss,” Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. “Too often, the focus in adoption is on what the child gained” without an acknowledgment of what was lost, he said. “Too often adoptees and birth parents have not had their sense of loss validated by people around them.”

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child's reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are “life books” and bibliotherapy. Therapeutic rituals can help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child's past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child's age, willingness to deal with various adoption issues, and the information available.

When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. “Bibliotherapy is effective because you don't talk directly about adoption but metaphorically,” he said. “It is a basis to probe feelings and trigger communication.” It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child's tie to her adoptive family.

Dr. Brodzinsky said that he had no disclosures.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family's life.

Source DR. BRODZINSKY

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK – The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever-diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference.

Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK – The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever-diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference.

Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

Major Finding: During 2007–2008, U.S. children and adolescents aged 4–17 years had a 9.5% prevalence rate of ever having attention-deficit/hyperactivity disorder, a significant increase from the 7.8% rate in 2003–2004.

Data Source: The National Survey of Children's Health, a random-sample telephone survey of parents with data on more than 70,000 U.S. children and adolescents aged 4–17 years run by the Centers for Disease Control and Prevention.

Disclosures: Ms. Danielson said that she had no disclosures.

NEW YORK – The U.S. prevalence of attention-deficit/hyperactivity disorder among children and adolescents rose to its highest level in 2007–2008, with 9.5% of children and adolescents ever diagnosed, according to a federally sponsored national telephone survey covering more than 70,000 American children and adolescents.

Although the reasons behind the increased prevalence of attention-deficit/hyperactivity disorder (ADHD) remain unclear, the increase over the 7.8% rate of ever-diagnosed ADHD in 2003–2004 reached statistical significance and appears real.

“We think something is going on,” Melissa L. Danielson said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Explanations might include increased awareness of the diagnosis, and more children and adolescents undergoing formal evaluation, she said. Backing up the national finding are data on ADHD prevalence in each individual state. Prevalence rates rose in almost every state, and in 13 states recent increases reached statistical significance, she said in an interview.

The National Survey of Childrens Health, run by the Centers for Disease Control and Prevention, receives its primary funding from the Department of Health and Human Services. In 2007 and 2008, a randomly selected sample of U.S. parents answered a telephone survey about their children's health. Parents answered four questions about ADHD: Did they have a child aged 4–17 years who ever received a diagnosis of disorder? Did their child have a current diagnosis? Is the ADHD mild, moderate, or severe? Does the child receive medication?

Extrapolated survey results showed that in 2007–2008, 4.1 million children and adolescents had a current diagnosis, 7.2% of the 4- to 17-year-old population (less than the 9.5% ever diagnosed with ADHD). Of these, two-thirds – 2.7 million – received medical treatment for their ADHD, and parents said that 570,000 (14%) of their kids had severe ADHD. About half had mild ADHD, with the remaining patients having what their parents described as moderate disorder. Subgroups with significantly less-severe ADHD included girls and adolescents aged 15–17.

Boys, adolescents aged 15–17 years, and multiracial and non-Hispanic children all had significantly higher prevalence rates of current ADHD relative to their respective comparator subgroups. Gender, race, and ethnicity had no linkage with medication use, but medication treatment occurred less often in the 15- to 17-year-olds, said Ms. Danielson, a statistician on the Child Development Studies team of the CDC in Atlanta. Children aged 11–14 years had the widest medication use, 73%, while adolescents aged 15–17 had the lowest rate of medication, 56%, a statistically significant difference.

Children aged 11–14 years with severe disease had a roughly 90% rate of medical treatment; teens aged 15–17 years with mild ADHD had the lowest medication rate, about 50%.

Children and teens with a concurrent diagnosis of disruptive behavior disorder had a statistically significant, 50% adjusted, relative increased rate of receiving medical treatment for their ADHD and also had a significantly higher prevalence of current, severe ADHD. More than 30% of children with the combination of current ADHD and disruptive behavior disorder had severe ADHD.

NEW YORK – The still-in-development DSM-5 contains two new child psychiatric diagnoses.

The Childhood and Adolescent Disorders Work Group designed one of the new diagnoses, temper dysregulation disorder with dysphoria (TDD), to include many children who were previously diagnosed with severe mood dysregulation or pediatric bipolar disorder. The second new diagnosis, from the ADHD and Disruptive Behavior Disorders Work Group, uses nonsuicidal self-injury (NSSI) to distinguish a pattern of self-inflicted damage to the body surface (usually by cutting) vs. suicide attempts. The goal of both new diagnoses is to refine patient identification and better assess appropriate treatments, said work group members in a session on pending changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at the meeting.

Temper Dysregulation Disorder With Dysphoria

Creation of TDD grew from a need to “do something about the severe mood dysregulation and very irritable child, which has had no good home in DSM-IV,” said Dr. Ellen Leibenluft, chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health (NIMH). Lack of a good diagnostic home for this disorder “may be why it is often diagnosed as bipolar disorder,” she said.

But “categorization as a disruptive behavior disorder does not do justice to the mood and anxiety disorders” these patients have.

“Physicians diagnose these patients as [having] bipolar disorder and therefore conclude that stimulants and SSRIs [selective serotonin reuptake inhibitors] are 'contraindicated,'” which leads to the prescription of atypical antipsychotics or – less often – mood stabilizers, Dr. Leibenluft said. But no treatment trial has focused on the patients proposed to have TDD, making its optimal treatment unclear.

The new TDD diagnosis also creates a niche for patients who are “numerous, much more common than [patients with] typical bipolar disorder. They are a very important group that needs psychotherapy, medications, and services.

A diagnosis of oppositional defiant disorder and attention-deficit/hyperactivity disorder does not justify the amount of services they need and does not do justice to their mood and anxiety disorder,” she said.

The new diagnosis “will sensitize people to a syndrome that had previously not been recognized or had been very difficult to code. My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar disorder who may not be at risk for bipolar disorder,” said Dr. David Shaffer, professor of child psychiatry and chief of the division of child psychiatry at Columbia University in New York.

“It will also free up the treatment options in an important way. At the moment, [these patients] are often denied antidepressants and stimulants with the assumption that it will make them flip into a manic episode, although the evidence for that is very scanty.

“I think [a diagnosis of TDD] will have an impact on the way these kids are managed, and I suspect they'll be managed much more effectively and the period of their illness will be greatly shortened.

“Most of us who see these kids for second opinions usually diagnose anxiety or dysthymia, and we usually see a good response quite quickly to an antidepressant,” Dr. Shaffer said in an interview.

In addition, “what is regrettable about the diagnosis 'bipolar disorder NOS [not otherwise specified]' is borrowing a term from another disorder with no evidence of linkage,” he said during the session. “Using the term bipolar disorder, you assign a lifelong diagnosis with many implications for the family and for the future social adaptation of the child. Evidence from retrospective analyses of adult bipolar patients does not support a link.”

“The feeling by members of DSM-5 is that the diagnosis of pediatric bipolar disorder is misapplied and made too loosely,” said Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the NIMH. “The fundamental problem is that this is a large group of kids who are not getting services.

“Until there are systematic treatment studies, we won't know” how to best manage these patients, and the new diagnosis definition is an important step toward undertaking systematic treatment studies, Dr. Pine said.

Some psychiatrists in the DSM-5 work group who came up with the TDD diagnosis argued for defining these patients as having oppositional defiant disorder with a specifier for their number of outbursts per week, their inter-outburst mood, and their impairment. But this solution has drawbacks, Dr. Leibenluft said: Clinicians don't use specifiers, the disorder is better categorized in the DSM-5 mood section rather than in the disruptive behavior disorders section, and the relatively high prevalence of the condition justifies a new diagnosis.

The new diagnosis should also facilitate exploration of the disorder's etiology, she added.

Although consensus favors creating the new diagnosis, the name “temper dysregulation disorder with dysphoria” remains tentative. “We're still in the name market,” Dr. Leibenluft said.

The following nine criteria have been proposed for the new diagnosis:

1. TDD is characterized by severe, recurrent temper outbursts in response to common stressors. Outbursts manifest verbally, in behavior, or both, and include verbal rages and physical aggression.

Reactions are grossly disproportionate in intensity or duration to the provocation and are inconsistent with developmental level.

2. Temper outbursts occur three or more times a week, on average.

3. Mood between temper outbursts is persistently negative: irritable, angry, sad, or any combination of these. The negative mood is observable by parents, teachers, peers, or others.

4. Criteria 1–3 have been present for at least 12 months; during that time, the person was not without criteria 1–3 for more than 3 months at a time.

5. Temper outbursts and negative mood occur in at least two settings, such as home, school, or with peers, and must be severe in at least one setting.

6. Chronological age is at least 6 years old, or an equivalent developmental level.

7. Onset occurs before age 10 years.

8. TDD should be excluded if in the past year there never was a distinct period, lasting more than 1 day, during which an abnormally elevated or expansive mood was present most of the day, and the abnormally elevated or excessive mood was accompanied by onset or worsening of three of the “B” criteria of mania, such as grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with high potential for painful consequences. (Abnormally elevated mood is distinct from developmentally appropriate mood elevation, such as in the context of a highly positive life event or its anticipation.)

9. The behaviors do not occur exclusively during a psychotic or mood disorder (such as major depressive disorder, dysthymic disorder, or bipolar disorder), and are not better explained by another mental disorder (such as pervasive developmental disorder, posttraumatic stress disorder, or separation anxiety). The diagnosis of TDD can coexist with oppositional defiant disorder, ADHD, conduct disorder, and substance use disorders. Symptoms do not directly result from the physiological effects of a drug of abuse, or are secondary to a medical or neurologic condition.

Nonsuicidal Self-Injury

NSSI involves much less controversy. Currently, the DSM-IV connects self-mutilation to borderline personality disorder and links it with recurrent suicidal behavior, Dr. Shaffer said.

A new diagnostic entity makes sense because about half of these self-mutilation cases do not meet criteria for borderline personality disorder; the self-inflicted damage differs from suicide attempts; misperception of NSSI events as suicide attempts leads to inappropriate treatment; and correct categorization of these patients should aid research.

NSSI episodes and suicide attempts differ by the methods used, a higher repetition rate with NSSI, broader comorbidity with NSSI, a stronger link between NSSI and peer experience, and a difference in lethality (that is, death from NSSI cutting is very rare).

The following four criteria have been proposed for NSSI, according to Dr. Shaffer:

1. On 5 or more days in the past year, the person has engaged in intentional, self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain, using methods such as cutting, burning, stabbing, hitting, or excessive rubbing.

Unlike body piercing or tattooing, the damage is done for purposes that are not socially sanctioned, and with an expectation that the injury will involve only mild or moderate physical harm. Either the patient reports no suicidal intent, or the lack of intent can be inferred by the patient's frequent use of a method known through experience to have no lethal potential. The behavior is not of a common or trivial nature, such as picking at a wound or nail biting.

2. The intentional injury associates with at least two of the following four characteristics:

▸ Negative feelings or thoughts – such as depression, anxiety, tension, anger, generalized distress, or self criticism – are present immediately prior to the self-injurious act.

▸ A period of preoccupation with the intended behavior is present prior to engagement in the act.

▸ There is a frequent urge to perform self-injury, even if the urge is not acted upon.

▸ The self-injury occurs with a purpose, such as relief from a negative feeling, cognitive state, or interpersonal difficulty or the induction of a positive feeling. The patient anticipates that the relief or positive feeling will occur either during or immediately after the self-injury.

3. The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of function. (This criterion is tentative.)

4. Self-injury does not exclusively occur during states of psychosis, delirium, or intoxication. In people with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies.

The behavior cannot be attributed to another mental or medical disorder, such as psychotic disorder, pervasive developmental disorder, mental retardation, or Lesch-Nyhan syndrome.

The proposed criteria also establish a subthreshold diagnosis, if all other criteria are met but self-injury occurred fewer than five times during the past 12 months, in people who frequently think about performing self-injury but infrequently do it.

Patients who meet the NSSI criteria and express an intent of achieving relief or positive feeling, but who also intend to commit suicide, meet criteria as an “intent uncertain” form of NSSI.

“The issue is failure to recognize NSSI as benign,” Dr. Shaffer said in an interview. “I think [the new diagnosis] will safely avert hospital admissions. Although some of these youngsters will, at certain times, make suicide attempts, an episode of cutting doesn't mean that they need hospitalization, which can be a traumatizing and damaging process.”

In addition, keeping patients with NSSI out of hospitals will prevent the contagion that often results. (Introduction of a child or adolescent who has self-mutilated in a hospital ward often leads to an outbreak of similar behavior among others in the ward.)

Dr. Leibenluft, Dr. Pine, and Dr. Shaffer had no relevant financial disclosures.

Dr. Ellen Leibenluft says the new temper dysregulation disorder diagnosis would create a niche for an important group of patients.

Source COURTESY NIMH

'Until there are systematic treatment studies, we won't know' how to best manage these patients.

Source DR. PINE

'My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar.'

Source DR. SHAFFER

Sweeping Changes to DSM-5 Proposed

Members from various work groups of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders presented the following tentative changes that involve pediatric psychiatric diagnoses:

▸ Children and Adolescents in DSM-5. Most fundamentally, the DSM-5 might drop the “disorders usually first diagnosed in children and adolescents” category. Those disorders now are generally split between the neurodevelopmental disorders group and the disruptive behavior disorders group. Other likely, sweeping changes include eliminating definitions based on etiology and increasing focus on development, said Dr. Pine, who also chairs the DSM-5 Childhood and Adolescent Disorders Work Group.

▸ Feeding and Eating Disorders. The DSM-5 might eliminate the previous category of feeding and eating disorders of infancy or early childhood. All of the specific disorders previously listed in the category would shift into a newly named category: feeding and eating disorders. The category includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, and “conditions not elsewhere classified,” which will include atypical anorexia nervosa, purging disorder, and night eating syndrome.

Avoidant/restrictive food intake disorder is a new name for what the DSM previously called feeding disorder of infancy or early childhood. The purpose of the change “is to reduce the not-otherwise-specified diagnoses, and to give a landing place for a lot of kids who have eating problems but no place to land in DSM-IV,” said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia University in New York. “What we're proposing [for this diagnosis] will be a heterogeneous collection” of patients. A key factor in making the avoidant/restrictive diagnosis is that “it has to have significant consequences, because a lot of these behaviors occur normally in kids growing up,” he said.

▸ Reactive Attachment Disorders. This diagnosis now lists two forms: inhibited and disinhibited. Current proposals will change this to two separate diagnoses. “Reactive attachment disorder” will apply exclusively to the inhibited form, for withdrawn patients with emotional unresponsiveness. The disinhibited, indiscriminately social form would receive the new name “disinhibited social engagement disorder.” One reason for such a change is that the disinhibited form “is not related to level of social attachment,” said Dr. Charles H. Zeanah, professor and director of child and adolescent psychiatry at Tulane University in New Orleans.

▸ Posttraumatic Stress Disorder. The diagnosis criteria would change to deal with the large number of preschool children who cannot meet current criteria despite being highly symptomatic. In particular, the work group proposes changing the avoidance and numbing criteria, because until now, few children met those criteria. The revision lists avoidance and numbing separately, and proposes changing numbing to “negative alterations in mood or cognition.”

▸ Attention-Deficit/Hyperactivity Disorder. Age of onset would increase from 7 years to 12 years. Also, the revision proposes adding new exemplifications for ADHD symptoms that illustrate behaviors across the life span. Also added would be four new symptoms of impulsiveness: acting without thinking, impatience, being uncomfortable doing things slowly and systematically, and difficulty resisting temptations or opportunities. The revision sets the threshold for diagnosis as six symptoms of inattention, and six symptoms of hyperactivity and impulsivity in children and adolescents up to age 16 years; in those aged 17 years and older, the threshold for each diagnosis was set to four symptoms. And the work group removed the exclusion of diagnosing ADHD in patients with autism spectrum disorders.

“No question that 50%–70% of children and adolescents with autism spectrum disorders present with very significant inattention and hyperactivity symptoms,” said Dr. F. Xavier Castellanos, professor of child and adolescent psychiatry at New York University. “Is it the same as ADHD? It's been a very sore point that you can't diagnose ADHD in these patients. The vote was to remove the exclusion. It leaves open the question of blurring a boundary” between ADHD and autism spectrum disorders, he said.

▸ Conduct Disorder. The work group added a proposed specifier for conduct disorder on callous and unemotional traits. Results from more than 30 studies suggest that the presence of callous and unemotional traits predicts a more severe, stable, and difficult-to-treat conduct disorder, said Paul J. Frick, Ph.D., professor and chair of psychology at the University of New Orleans. It constitutes just a small fraction of all conduct disorder cases. The callous and unemotional specifier requires at least two of these traits: lack of remorse or guilt, lack of empathy, unconcern about performance, and shallow or deficient affect. The ability of clinicians to assess these traits will need testing in a field trial, Dr. Frick said.

▸ Oppositional Defiant Disorder. The changes remove an exclusionary criteria for conduct disorder, organize the symptom criteria to separate emotional (“often loses temper”) and behavioral (“often argues with adults”) symptoms, and sets a severity index based on symptom number and setting number, Dr. Frick said.

Dr. Walsh said he has received research support from AstraZeneca. Dr. Pine, Dr. Zeanah, Dr. Castellanos, and Dr. Frick had no disclosures.

NEW YORK – The still-in-development DSM-5 contains two new child psychiatric diagnoses.

The Childhood and Adolescent Disorders Work Group designed one of the new diagnoses, temper dysregulation disorder with dysphoria (TDD), to include many children who were previously diagnosed with severe mood dysregulation or pediatric bipolar disorder. The second new diagnosis, from the ADHD and Disruptive Behavior Disorders Work Group, uses nonsuicidal self-injury (NSSI) to distinguish a pattern of self-inflicted damage to the body surface (usually by cutting) vs. suicide attempts. The goal of both new diagnoses is to refine patient identification and better assess appropriate treatments, said work group members in a session on pending changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at the meeting.

Temper Dysregulation Disorder With Dysphoria

Creation of TDD grew from a need to “do something about the severe mood dysregulation and very irritable child, which has had no good home in DSM-IV,” said Dr. Ellen Leibenluft, chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health (NIMH). Lack of a good diagnostic home for this disorder “may be why it is often diagnosed as bipolar disorder,” she said.

But “categorization as a disruptive behavior disorder does not do justice to the mood and anxiety disorders” these patients have.

“Physicians diagnose these patients as [having] bipolar disorder and therefore conclude that stimulants and SSRIs [selective serotonin reuptake inhibitors] are 'contraindicated,'” which leads to the prescription of atypical antipsychotics or – less often – mood stabilizers, Dr. Leibenluft said. But no treatment trial has focused on the patients proposed to have TDD, making its optimal treatment unclear.

The new TDD diagnosis also creates a niche for patients who are “numerous, much more common than [patients with] typical bipolar disorder. They are a very important group that needs psychotherapy, medications, and services.

A diagnosis of oppositional defiant disorder and attention-deficit/hyperactivity disorder does not justify the amount of services they need and does not do justice to their mood and anxiety disorder,” she said.

The new diagnosis “will sensitize people to a syndrome that had previously not been recognized or had been very difficult to code. My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar disorder who may not be at risk for bipolar disorder,” said Dr. David Shaffer, professor of child psychiatry and chief of the division of child psychiatry at Columbia University in New York.

“It will also free up the treatment options in an important way. At the moment, [these patients] are often denied antidepressants and stimulants with the assumption that it will make them flip into a manic episode, although the evidence for that is very scanty.

“I think [a diagnosis of TDD] will have an impact on the way these kids are managed, and I suspect they'll be managed much more effectively and the period of their illness will be greatly shortened.

“Most of us who see these kids for second opinions usually diagnose anxiety or dysthymia, and we usually see a good response quite quickly to an antidepressant,” Dr. Shaffer said in an interview.

In addition, “what is regrettable about the diagnosis 'bipolar disorder NOS [not otherwise specified]' is borrowing a term from another disorder with no evidence of linkage,” he said during the session. “Using the term bipolar disorder, you assign a lifelong diagnosis with many implications for the family and for the future social adaptation of the child. Evidence from retrospective analyses of adult bipolar patients does not support a link.”

“The feeling by members of DSM-5 is that the diagnosis of pediatric bipolar disorder is misapplied and made too loosely,” said Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the NIMH. “The fundamental problem is that this is a large group of kids who are not getting services.

“Until there are systematic treatment studies, we won't know” how to best manage these patients, and the new diagnosis definition is an important step toward undertaking systematic treatment studies, Dr. Pine said.

Some psychiatrists in the DSM-5 work group who came up with the TDD diagnosis argued for defining these patients as having oppositional defiant disorder with a specifier for their number of outbursts per week, their inter-outburst mood, and their impairment. But this solution has drawbacks, Dr. Leibenluft said: Clinicians don't use specifiers, the disorder is better categorized in the DSM-5 mood section rather than in the disruptive behavior disorders section, and the relatively high prevalence of the condition justifies a new diagnosis.

The new diagnosis should also facilitate exploration of the disorder's etiology, she added.

Although consensus favors creating the new diagnosis, the name “temper dysregulation disorder with dysphoria” remains tentative. “We're still in the name market,” Dr. Leibenluft said.

The following nine criteria have been proposed for the new diagnosis:

1. TDD is characterized by severe, recurrent temper outbursts in response to common stressors. Outbursts manifest verbally, in behavior, or both, and include verbal rages and physical aggression.

Reactions are grossly disproportionate in intensity or duration to the provocation and are inconsistent with developmental level.

2. Temper outbursts occur three or more times a week, on average.

3. Mood between temper outbursts is persistently negative: irritable, angry, sad, or any combination of these. The negative mood is observable by parents, teachers, peers, or others.

4. Criteria 1–3 have been present for at least 12 months; during that time, the person was not without criteria 1–3 for more than 3 months at a time.

5. Temper outbursts and negative mood occur in at least two settings, such as home, school, or with peers, and must be severe in at least one setting.

6. Chronological age is at least 6 years old, or an equivalent developmental level.

7. Onset occurs before age 10 years.

8. TDD should be excluded if in the past year there never was a distinct period, lasting more than 1 day, during which an abnormally elevated or expansive mood was present most of the day, and the abnormally elevated or excessive mood was accompanied by onset or worsening of three of the “B” criteria of mania, such as grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with high potential for painful consequences. (Abnormally elevated mood is distinct from developmentally appropriate mood elevation, such as in the context of a highly positive life event or its anticipation.)

9. The behaviors do not occur exclusively during a psychotic or mood disorder (such as major depressive disorder, dysthymic disorder, or bipolar disorder), and are not better explained by another mental disorder (such as pervasive developmental disorder, posttraumatic stress disorder, or separation anxiety). The diagnosis of TDD can coexist with oppositional defiant disorder, ADHD, conduct disorder, and substance use disorders. Symptoms do not directly result from the physiological effects of a drug of abuse, or are secondary to a medical or neurologic condition.

Nonsuicidal Self-Injury

NSSI involves much less controversy. Currently, the DSM-IV connects self-mutilation to borderline personality disorder and links it with recurrent suicidal behavior, Dr. Shaffer said.

A new diagnostic entity makes sense because about half of these self-mutilation cases do not meet criteria for borderline personality disorder; the self-inflicted damage differs from suicide attempts; misperception of NSSI events as suicide attempts leads to inappropriate treatment; and correct categorization of these patients should aid research.

NSSI episodes and suicide attempts differ by the methods used, a higher repetition rate with NSSI, broader comorbidity with NSSI, a stronger link between NSSI and peer experience, and a difference in lethality (that is, death from NSSI cutting is very rare).

The following four criteria have been proposed for NSSI, according to Dr. Shaffer:

1. On 5 or more days in the past year, the person has engaged in intentional, self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain, using methods such as cutting, burning, stabbing, hitting, or excessive rubbing.

Unlike body piercing or tattooing, the damage is done for purposes that are not socially sanctioned, and with an expectation that the injury will involve only mild or moderate physical harm. Either the patient reports no suicidal intent, or the lack of intent can be inferred by the patient's frequent use of a method known through experience to have no lethal potential. The behavior is not of a common or trivial nature, such as picking at a wound or nail biting.

2. The intentional injury associates with at least two of the following four characteristics:

▸ Negative feelings or thoughts – such as depression, anxiety, tension, anger, generalized distress, or self criticism – are present immediately prior to the self-injurious act.

▸ A period of preoccupation with the intended behavior is present prior to engagement in the act.

▸ There is a frequent urge to perform self-injury, even if the urge is not acted upon.

▸ The self-injury occurs with a purpose, such as relief from a negative feeling, cognitive state, or interpersonal difficulty or the induction of a positive feeling. The patient anticipates that the relief or positive feeling will occur either during or immediately after the self-injury.

3. The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of function. (This criterion is tentative.)

4. Self-injury does not exclusively occur during states of psychosis, delirium, or intoxication. In people with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies.

The behavior cannot be attributed to another mental or medical disorder, such as psychotic disorder, pervasive developmental disorder, mental retardation, or Lesch-Nyhan syndrome.

The proposed criteria also establish a subthreshold diagnosis, if all other criteria are met but self-injury occurred fewer than five times during the past 12 months, in people who frequently think about performing self-injury but infrequently do it.

Patients who meet the NSSI criteria and express an intent of achieving relief or positive feeling, but who also intend to commit suicide, meet criteria as an “intent uncertain” form of NSSI.

“The issue is failure to recognize NSSI as benign,” Dr. Shaffer said in an interview. “I think [the new diagnosis] will safely avert hospital admissions. Although some of these youngsters will, at certain times, make suicide attempts, an episode of cutting doesn't mean that they need hospitalization, which can be a traumatizing and damaging process.”

In addition, keeping patients with NSSI out of hospitals will prevent the contagion that often results. (Introduction of a child or adolescent who has self-mutilated in a hospital ward often leads to an outbreak of similar behavior among others in the ward.)

Dr. Leibenluft, Dr. Pine, and Dr. Shaffer had no relevant financial disclosures.

Dr. Ellen Leibenluft says the new temper dysregulation disorder diagnosis would create a niche for an important group of patients.

Source COURTESY NIMH

'Until there are systematic treatment studies, we won't know' how to best manage these patients.

Source DR. PINE

'My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar.'

Source DR. SHAFFER

Sweeping Changes to DSM-5 Proposed

Members from various work groups of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders presented the following tentative changes that involve pediatric psychiatric diagnoses:

▸ Children and Adolescents in DSM-5. Most fundamentally, the DSM-5 might drop the “disorders usually first diagnosed in children and adolescents” category. Those disorders now are generally split between the neurodevelopmental disorders group and the disruptive behavior disorders group. Other likely, sweeping changes include eliminating definitions based on etiology and increasing focus on development, said Dr. Pine, who also chairs the DSM-5 Childhood and Adolescent Disorders Work Group.

▸ Feeding and Eating Disorders. The DSM-5 might eliminate the previous category of feeding and eating disorders of infancy or early childhood. All of the specific disorders previously listed in the category would shift into a newly named category: feeding and eating disorders. The category includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, and “conditions not elsewhere classified,” which will include atypical anorexia nervosa, purging disorder, and night eating syndrome.

Avoidant/restrictive food intake disorder is a new name for what the DSM previously called feeding disorder of infancy or early childhood. The purpose of the change “is to reduce the not-otherwise-specified diagnoses, and to give a landing place for a lot of kids who have eating problems but no place to land in DSM-IV,” said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia University in New York. “What we're proposing [for this diagnosis] will be a heterogeneous collection” of patients. A key factor in making the avoidant/restrictive diagnosis is that “it has to have significant consequences, because a lot of these behaviors occur normally in kids growing up,” he said.

▸ Reactive Attachment Disorders. This diagnosis now lists two forms: inhibited and disinhibited. Current proposals will change this to two separate diagnoses. “Reactive attachment disorder” will apply exclusively to the inhibited form, for withdrawn patients with emotional unresponsiveness. The disinhibited, indiscriminately social form would receive the new name “disinhibited social engagement disorder.” One reason for such a change is that the disinhibited form “is not related to level of social attachment,” said Dr. Charles H. Zeanah, professor and director of child and adolescent psychiatry at Tulane University in New Orleans.

▸ Posttraumatic Stress Disorder. The diagnosis criteria would change to deal with the large number of preschool children who cannot meet current criteria despite being highly symptomatic. In particular, the work group proposes changing the avoidance and numbing criteria, because until now, few children met those criteria. The revision lists avoidance and numbing separately, and proposes changing numbing to “negative alterations in mood or cognition.”

▸ Attention-Deficit/Hyperactivity Disorder. Age of onset would increase from 7 years to 12 years. Also, the revision proposes adding new exemplifications for ADHD symptoms that illustrate behaviors across the life span. Also added would be four new symptoms of impulsiveness: acting without thinking, impatience, being uncomfortable doing things slowly and systematically, and difficulty resisting temptations or opportunities. The revision sets the threshold for diagnosis as six symptoms of inattention, and six symptoms of hyperactivity and impulsivity in children and adolescents up to age 16 years; in those aged 17 years and older, the threshold for each diagnosis was set to four symptoms. And the work group removed the exclusion of diagnosing ADHD in patients with autism spectrum disorders.

“No question that 50%–70% of children and adolescents with autism spectrum disorders present with very significant inattention and hyperactivity symptoms,” said Dr. F. Xavier Castellanos, professor of child and adolescent psychiatry at New York University. “Is it the same as ADHD? It's been a very sore point that you can't diagnose ADHD in these patients. The vote was to remove the exclusion. It leaves open the question of blurring a boundary” between ADHD and autism spectrum disorders, he said.

▸ Conduct Disorder. The work group added a proposed specifier for conduct disorder on callous and unemotional traits. Results from more than 30 studies suggest that the presence of callous and unemotional traits predicts a more severe, stable, and difficult-to-treat conduct disorder, said Paul J. Frick, Ph.D., professor and chair of psychology at the University of New Orleans. It constitutes just a small fraction of all conduct disorder cases. The callous and unemotional specifier requires at least two of these traits: lack of remorse or guilt, lack of empathy, unconcern about performance, and shallow or deficient affect. The ability of clinicians to assess these traits will need testing in a field trial, Dr. Frick said.

▸ Oppositional Defiant Disorder. The changes remove an exclusionary criteria for conduct disorder, organize the symptom criteria to separate emotional (“often loses temper”) and behavioral (“often argues with adults”) symptoms, and sets a severity index based on symptom number and setting number, Dr. Frick said.

Dr. Walsh said he has received research support from AstraZeneca. Dr. Pine, Dr. Zeanah, Dr. Castellanos, and Dr. Frick had no disclosures.

NEW YORK – The still-in-development DSM-5 contains two new child psychiatric diagnoses.

The Childhood and Adolescent Disorders Work Group designed one of the new diagnoses, temper dysregulation disorder with dysphoria (TDD), to include many children who were previously diagnosed with severe mood dysregulation or pediatric bipolar disorder. The second new diagnosis, from the ADHD and Disruptive Behavior Disorders Work Group, uses nonsuicidal self-injury (NSSI) to distinguish a pattern of self-inflicted damage to the body surface (usually by cutting) vs. suicide attempts. The goal of both new diagnoses is to refine patient identification and better assess appropriate treatments, said work group members in a session on pending changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at the meeting.

Temper Dysregulation Disorder With Dysphoria

Creation of TDD grew from a need to “do something about the severe mood dysregulation and very irritable child, which has had no good home in DSM-IV,” said Dr. Ellen Leibenluft, chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health (NIMH). Lack of a good diagnostic home for this disorder “may be why it is often diagnosed as bipolar disorder,” she said.

But “categorization as a disruptive behavior disorder does not do justice to the mood and anxiety disorders” these patients have.

“Physicians diagnose these patients as [having] bipolar disorder and therefore conclude that stimulants and SSRIs [selective serotonin reuptake inhibitors] are 'contraindicated,'” which leads to the prescription of atypical antipsychotics or – less often – mood stabilizers, Dr. Leibenluft said. But no treatment trial has focused on the patients proposed to have TDD, making its optimal treatment unclear.

The new TDD diagnosis also creates a niche for patients who are “numerous, much more common than [patients with] typical bipolar disorder. They are a very important group that needs psychotherapy, medications, and services.

A diagnosis of oppositional defiant disorder and attention-deficit/hyperactivity disorder does not justify the amount of services they need and does not do justice to their mood and anxiety disorder,” she said.

The new diagnosis “will sensitize people to a syndrome that had previously not been recognized or had been very difficult to code. My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar disorder who may not be at risk for bipolar disorder,” said Dr. David Shaffer, professor of child psychiatry and chief of the division of child psychiatry at Columbia University in New York.

“It will also free up the treatment options in an important way. At the moment, [these patients] are often denied antidepressants and stimulants with the assumption that it will make them flip into a manic episode, although the evidence for that is very scanty.

“I think [a diagnosis of TDD] will have an impact on the way these kids are managed, and I suspect they'll be managed much more effectively and the period of their illness will be greatly shortened.

“Most of us who see these kids for second opinions usually diagnose anxiety or dysthymia, and we usually see a good response quite quickly to an antidepressant,” Dr. Shaffer said in an interview.

In addition, “what is regrettable about the diagnosis 'bipolar disorder NOS [not otherwise specified]' is borrowing a term from another disorder with no evidence of linkage,” he said during the session. “Using the term bipolar disorder, you assign a lifelong diagnosis with many implications for the family and for the future social adaptation of the child. Evidence from retrospective analyses of adult bipolar patients does not support a link.”

“The feeling by members of DSM-5 is that the diagnosis of pediatric bipolar disorder is misapplied and made too loosely,” said Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the NIMH. “The fundamental problem is that this is a large group of kids who are not getting services.

“Until there are systematic treatment studies, we won't know” how to best manage these patients, and the new diagnosis definition is an important step toward undertaking systematic treatment studies, Dr. Pine said.

Some psychiatrists in the DSM-5 work group who came up with the TDD diagnosis argued for defining these patients as having oppositional defiant disorder with a specifier for their number of outbursts per week, their inter-outburst mood, and their impairment. But this solution has drawbacks, Dr. Leibenluft said: Clinicians don't use specifiers, the disorder is better categorized in the DSM-5 mood section rather than in the disruptive behavior disorders section, and the relatively high prevalence of the condition justifies a new diagnosis.

The new diagnosis should also facilitate exploration of the disorder's etiology, she added.

Although consensus favors creating the new diagnosis, the name “temper dysregulation disorder with dysphoria” remains tentative. “We're still in the name market,” Dr. Leibenluft said.

The following nine criteria have been proposed for the new diagnosis:

1. TDD is characterized by severe, recurrent temper outbursts in response to common stressors. Outbursts manifest verbally, in behavior, or both, and include verbal rages and physical aggression.

Reactions are grossly disproportionate in intensity or duration to the provocation and are inconsistent with developmental level.

2. Temper outbursts occur three or more times a week, on average.

3. Mood between temper outbursts is persistently negative: irritable, angry, sad, or any combination of these. The negative mood is observable by parents, teachers, peers, or others.

4. Criteria 1–3 have been present for at least 12 months; during that time, the person was not without criteria 1–3 for more than 3 months at a time.

5. Temper outbursts and negative mood occur in at least two settings, such as home, school, or with peers, and must be severe in at least one setting.

6. Chronological age is at least 6 years old, or an equivalent developmental level.

7. Onset occurs before age 10 years.

8. TDD should be excluded if in the past year there never was a distinct period, lasting more than 1 day, during which an abnormally elevated or expansive mood was present most of the day, and the abnormally elevated or excessive mood was accompanied by onset or worsening of three of the “B” criteria of mania, such as grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with high potential for painful consequences. (Abnormally elevated mood is distinct from developmentally appropriate mood elevation, such as in the context of a highly positive life event or its anticipation.)

9. The behaviors do not occur exclusively during a psychotic or mood disorder (such as major depressive disorder, dysthymic disorder, or bipolar disorder), and are not better explained by another mental disorder (such as pervasive developmental disorder, posttraumatic stress disorder, or separation anxiety). The diagnosis of TDD can coexist with oppositional defiant disorder, ADHD, conduct disorder, and substance use disorders. Symptoms do not directly result from the physiological effects of a drug of abuse, or are secondary to a medical or neurologic condition.

Nonsuicidal Self-Injury

NSSI involves much less controversy. Currently, the DSM-IV connects self-mutilation to borderline personality disorder and links it with recurrent suicidal behavior, Dr. Shaffer said.

A new diagnostic entity makes sense because about half of these self-mutilation cases do not meet criteria for borderline personality disorder; the self-inflicted damage differs from suicide attempts; misperception of NSSI events as suicide attempts leads to inappropriate treatment; and correct categorization of these patients should aid research.

NSSI episodes and suicide attempts differ by the methods used, a higher repetition rate with NSSI, broader comorbidity with NSSI, a stronger link between NSSI and peer experience, and a difference in lethality (that is, death from NSSI cutting is very rare).

The following four criteria have been proposed for NSSI, according to Dr. Shaffer:

1. On 5 or more days in the past year, the person has engaged in intentional, self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain, using methods such as cutting, burning, stabbing, hitting, or excessive rubbing.

Unlike body piercing or tattooing, the damage is done for purposes that are not socially sanctioned, and with an expectation that the injury will involve only mild or moderate physical harm. Either the patient reports no suicidal intent, or the lack of intent can be inferred by the patient's frequent use of a method known through experience to have no lethal potential. The behavior is not of a common or trivial nature, such as picking at a wound or nail biting.

2. The intentional injury associates with at least two of the following four characteristics:

▸ Negative feelings or thoughts – such as depression, anxiety, tension, anger, generalized distress, or self criticism – are present immediately prior to the self-injurious act.

▸ A period of preoccupation with the intended behavior is present prior to engagement in the act.

▸ There is a frequent urge to perform self-injury, even if the urge is not acted upon.

▸ The self-injury occurs with a purpose, such as relief from a negative feeling, cognitive state, or interpersonal difficulty or the induction of a positive feeling. The patient anticipates that the relief or positive feeling will occur either during or immediately after the self-injury.

3. The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of function. (This criterion is tentative.)

4. Self-injury does not exclusively occur during states of psychosis, delirium, or intoxication. In people with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies.

The behavior cannot be attributed to another mental or medical disorder, such as psychotic disorder, pervasive developmental disorder, mental retardation, or Lesch-Nyhan syndrome.

The proposed criteria also establish a subthreshold diagnosis, if all other criteria are met but self-injury occurred fewer than five times during the past 12 months, in people who frequently think about performing self-injury but infrequently do it.

Patients who meet the NSSI criteria and express an intent of achieving relief or positive feeling, but who also intend to commit suicide, meet criteria as an “intent uncertain” form of NSSI.

“The issue is failure to recognize NSSI as benign,” Dr. Shaffer said in an interview. “I think [the new diagnosis] will safely avert hospital admissions. Although some of these youngsters will, at certain times, make suicide attempts, an episode of cutting doesn't mean that they need hospitalization, which can be a traumatizing and damaging process.”

In addition, keeping patients with NSSI out of hospitals will prevent the contagion that often results. (Introduction of a child or adolescent who has self-mutilated in a hospital ward often leads to an outbreak of similar behavior among others in the ward.)

Dr. Leibenluft, Dr. Pine, and Dr. Shaffer had no relevant financial disclosures.

Dr. Ellen Leibenluft says the new temper dysregulation disorder diagnosis would create a niche for an important group of patients.

Source COURTESY NIMH

'Until there are systematic treatment studies, we won't know' how to best manage these patients.

Source DR. PINE

'My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar.'

Source DR. SHAFFER

Sweeping Changes to DSM-5 Proposed

Members from various work groups of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders presented the following tentative changes that involve pediatric psychiatric diagnoses:

▸ Children and Adolescents in DSM-5. Most fundamentally, the DSM-5 might drop the “disorders usually first diagnosed in children and adolescents” category. Those disorders now are generally split between the neurodevelopmental disorders group and the disruptive behavior disorders group. Other likely, sweeping changes include eliminating definitions based on etiology and increasing focus on development, said Dr. Pine, who also chairs the DSM-5 Childhood and Adolescent Disorders Work Group.

▸ Feeding and Eating Disorders. The DSM-5 might eliminate the previous category of feeding and eating disorders of infancy or early childhood. All of the specific disorders previously listed in the category would shift into a newly named category: feeding and eating disorders. The category includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, and “conditions not elsewhere classified,” which will include atypical anorexia nervosa, purging disorder, and night eating syndrome.

Avoidant/restrictive food intake disorder is a new name for what the DSM previously called feeding disorder of infancy or early childhood. The purpose of the change “is to reduce the not-otherwise-specified diagnoses, and to give a landing place for a lot of kids who have eating problems but no place to land in DSM-IV,” said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia University in New York. “What we're proposing [for this diagnosis] will be a heterogeneous collection” of patients. A key factor in making the avoidant/restrictive diagnosis is that “it has to have significant consequences, because a lot of these behaviors occur normally in kids growing up,” he said.

▸ Reactive Attachment Disorders. This diagnosis now lists two forms: inhibited and disinhibited. Current proposals will change this to two separate diagnoses. “Reactive attachment disorder” will apply exclusively to the inhibited form, for withdrawn patients with emotional unresponsiveness. The disinhibited, indiscriminately social form would receive the new name “disinhibited social engagement disorder.” One reason for such a change is that the disinhibited form “is not related to level of social attachment,” said Dr. Charles H. Zeanah, professor and director of child and adolescent psychiatry at Tulane University in New Orleans.

▸ Posttraumatic Stress Disorder. The diagnosis criteria would change to deal with the large number of preschool children who cannot meet current criteria despite being highly symptomatic. In particular, the work group proposes changing the avoidance and numbing criteria, because until now, few children met those criteria. The revision lists avoidance and numbing separately, and proposes changing numbing to “negative alterations in mood or cognition.”

▸ Attention-Deficit/Hyperactivity Disorder. Age of onset would increase from 7 years to 12 years. Also, the revision proposes adding new exemplifications for ADHD symptoms that illustrate behaviors across the life span. Also added would be four new symptoms of impulsiveness: acting without thinking, impatience, being uncomfortable doing things slowly and systematically, and difficulty resisting temptations or opportunities. The revision sets the threshold for diagnosis as six symptoms of inattention, and six symptoms of hyperactivity and impulsivity in children and adolescents up to age 16 years; in those aged 17 years and older, the threshold for each diagnosis was set to four symptoms. And the work group removed the exclusion of diagnosing ADHD in patients with autism spectrum disorders.

“No question that 50%–70% of children and adolescents with autism spectrum disorders present with very significant inattention and hyperactivity symptoms,” said Dr. F. Xavier Castellanos, professor of child and adolescent psychiatry at New York University. “Is it the same as ADHD? It's been a very sore point that you can't diagnose ADHD in these patients. The vote was to remove the exclusion. It leaves open the question of blurring a boundary” between ADHD and autism spectrum disorders, he said.

▸ Conduct Disorder. The work group added a proposed specifier for conduct disorder on callous and unemotional traits. Results from more than 30 studies suggest that the presence of callous and unemotional traits predicts a more severe, stable, and difficult-to-treat conduct disorder, said Paul J. Frick, Ph.D., professor and chair of psychology at the University of New Orleans. It constitutes just a small fraction of all conduct disorder cases. The callous and unemotional specifier requires at least two of these traits: lack of remorse or guilt, lack of empathy, unconcern about performance, and shallow or deficient affect. The ability of clinicians to assess these traits will need testing in a field trial, Dr. Frick said.

▸ Oppositional Defiant Disorder. The changes remove an exclusionary criteria for conduct disorder, organize the symptom criteria to separate emotional (“often loses temper”) and behavioral (“often argues with adults”) symptoms, and sets a severity index based on symptom number and setting number, Dr. Frick said.

Dr. Walsh said he has received research support from AstraZeneca. Dr. Pine, Dr. Zeanah, Dr. Castellanos, and Dr. Frick had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – Adoption is founded on loss, and a child’s reaction to being adopted can often be best understood with a grief model.

The unresolved, uncommunicated, and unvalidated grief that some adopted children may feel often goes unrecognized as an overlay that accompanies more typical psychiatric disorders in adopted children, David Brodzinsky, Ph.D., said at the annual meeting of the American Academy of Child & Adolescent Psychiatry.

In other cases, adopted children may act up and present what looks like a serious psychiatric problem, but closer examination shows it is an adjustment reaction or other low-level problem that occurs as an adopted child struggles to understand the meaning and implications of adoption, said Dr. Brodzinsky, research and project director at the Evan B. Donaldson Adoption Institute in Oakland, Calif.

"I see two kinds of cases. In children with clinically relevant problems, such as depression, anxiety, or attention-deficit/hyperactivity disorder, the grief model is secondary to understanding and dealing with the psychopathology they have. But there is an overlay that often gets missed, a sense of loss that often is not treated because what you see is depression or anxiety and that has to be dealt with first. But we need to be sure not to miss the underlying sense of grief and loss. It’s not always present, but we need to look for it, and when it’s present, it needs to be dealt with," Dr. Brodzinsky said in an interview.

The second type of case involves children who have what might appear to be depression or anxiety but rather are symptoms that result exclusively from adoption-related grief that has not been appropriately validated.

However, the vast majority of adopted kids do not experience unvalidated grief and are "well within the normal range and do quite well," he said. "Adopted individuals are highly variable in the way they experience adoption-related loss."

If a sense of loss occurs among children who were adopted as infants, it usually appears before age 5-7 years. Children can begin to have a feeling of separation from someone about whom they don’t know much, which can lead to anxiety, sadness, and anger. In some children, "the experience of loss may be quite subtle and not easily observed by others."

Children who were adopted at an older age are more likely to have a more traumatic reaction, but again their understanding of adoption and their reaction to it varies over time as they age. "As children begin to understand the implications of their adoptive status, they become increasingly sensitized to adoption-related loss," Dr. Brodzinsky said.

The sense of loss that some adopted children develop can stem from several different factors and realizations, including loss of birth parents and loss of their entire birth family; loss of their biological, ethnic, racial, and cultural origins; loss of prior nonbiological caregivers; loss of status among their peers; loss of their emotional stability; loss of their feeling of fitting in with their adoptive family; loss of privacy; and loss of their self-identify.

Perhaps the most important consequence of an emerging sense of loss occurs when it leads to disenfranchised grief: The loss goes unrecognized by others or is minimized or trivialized. "Too often, the focus in adoption is on what the child gained" without an acknowledgement of what was lost, he said. "Too often adoptees and birth parents have not had their sense of loss validated by people around them."

Adopted children face the risk that their blocked, disenfranchised grief could become clinical depression. Viewing the loss in a grief model normalizes the child’s reactions rather than casting them as pathological.

Four interventions have shown efficacy for resolving grief and a sense of loss in adopted children. Two approaches especially suited to younger children are "life books" and bibliotherapy. Therapeutic rituals can potentially help at any age. Written role play is a good intervention for older teens and adults.

Many therapists use life books for interventions. Dr. Brodzinsky prefers books created by the patient, often as loose-leaf pages in a binder, rather than commercially available versions. The book is like a photo album of the child’s past, but can also contain drawings and text. The child constructs the book, which helps bring order to what can feel like an otherwise chaotic life story, giving the child a sense of where she comes from and where she is going. What goes into the book depends on the child’s age, willingness to deal with various adoption issues, and the information available. When used in treatment, the child and therapist review the contents of the book repeatedly, as well as adding to it when appropriate. Use of a book opens communication, gives the child a more realistic understanding of his adoption, and gives the child a more positive view of self. Life books usually work best for those aged 4 years to about 11, Dr. Brodzinsky said.

Bibliotherapy involves a parent reading to or with a child an existing piece of literature that opens communication with the child about adoption issues. "Bibliotherapy is effective because you don’t talk directly about adoption but metaphorically," he said. "It is a basis to probe feelings and trigger communication." It is usually most appropriate for children at an age when they are still being read to, usually age 12 or younger.

Therapeutic rituals can be effective for a child of any age if rituals are part of a family’s life. A ritual could involve candle lighting, or planting and cultivating a memorial garden. A ritual can focus on grief or letting go of birth parents, or it can focus on the child’s tie to her adoptive family.

For older children as well as adults, written role play can help open communication. The therapist can encourage the child to write a letter to his birth mother, which can be followed by the child’s composing his reply to the letter by imagining how his birth mother might respond. This can develop into a series of letters back and forth that the patient composes. This approach could also help an adoptee prepare for meeting his birth mother. Writing letters to and from the birth mother before an actual meeting may help the patient externalize his hopes, fantasies, and fears, Dr. Brodzinsky said.

Dr. Brodzinsky said that he had no disclosures.

NEW YORK – During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The reasons behind these changes and their implications for the quality of care American psychiatric patients receive remain unclear, said Dr. Blader, a researcher in the division of child and adolescent psychiatry at the State University of New York at Stony Brook. However, the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis, he said.

"It’s not a good thing" that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts "represent a significant development in mental health treatment in the United States," he said in the poster.

The data Dr. Blader analyzed came from the National Hospital Discharge Survey, and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid. Again, the implications of this – and how it might play into the increased hospitalization rates – remain unclear.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from "problems in the level of services provided by community care," and has "more cost shifting" of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

"Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies," or perhaps the effect "indicates better outpatient care among the privately insured," he said in his poster. "In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage."

He noted that during the period studied, the psychiatric field has made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

"When a child is on many medications and a crisis occurs, the physician may not be sure what to do, which drug to stop," and thus may feel it’s safer to hospitalize and manage the child or adolescent there, Dr. Blader said in an interview.

However, he dismissed the notion that clinical criteria for hospitalization shifted during the period examined. "It’s unlikely that there was a lower threshold for hospitalization" in 2007 compared with 11 years earlier, he said.

The National Hospital Discharge Survey, run by the Centers for Disease Control and Prevention, collected data from 366,000 U.S. hospitalizations in 2007.

Survey data showed that in 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader’s poster did not report rates for patients aged 65 or older, but in his analysis, this number fell "dramatically" from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The impact of both increases in hospitalization rates as well as increased population levels also led to substantial boosts in total days hospitalized for primary psychiatric diagnoses among children and adolescents, but not in adults. For children, total hospitalized days soared from 644,461 in 1996 to 1,528,117 in 2007. Among adolescents, total days rose from 1,317,660 in 1996 to 2,115,905 in 2007.

Dr. Blader had no disclosures.

NEW YORK – During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The reasons behind these changes and their implications for the quality of care American psychiatric patients receive remain unclear, said Dr. Blader, a researcher in the division of child and adolescent psychiatry at the State University of New York at Stony Brook. However, the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis, he said.

"It’s not a good thing" that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts "represent a significant development in mental health treatment in the United States," he said in the poster.

The data Dr. Blader analyzed came from the National Hospital Discharge Survey, and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid. Again, the implications of this – and how it might play into the increased hospitalization rates – remain unclear.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from "problems in the level of services provided by community care," and has "more cost shifting" of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

"Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies," or perhaps the effect "indicates better outpatient care among the privately insured," he said in his poster. "In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage."

He noted that during the period studied, the psychiatric field has made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

"When a child is on many medications and a crisis occurs, the physician may not be sure what to do, which drug to stop," and thus may feel it’s safer to hospitalize and manage the child or adolescent there, Dr. Blader said in an interview.

However, he dismissed the notion that clinical criteria for hospitalization shifted during the period examined. "It’s unlikely that there was a lower threshold for hospitalization" in 2007 compared with 11 years earlier, he said.

The National Hospital Discharge Survey, run by the Centers for Disease Control and Prevention, collected data from 366,000 U.S. hospitalizations in 2007.

Survey data showed that in 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader’s poster did not report rates for patients aged 65 or older, but in his analysis, this number fell "dramatically" from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The impact of both increases in hospitalization rates as well as increased population levels also led to substantial boosts in total days hospitalized for primary psychiatric diagnoses among children and adolescents, but not in adults. For children, total hospitalized days soared from 644,461 in 1996 to 1,528,117 in 2007. Among adolescents, total days rose from 1,317,660 in 1996 to 2,115,905 in 2007.

Dr. Blader had no disclosures.

NEW YORK – During the period 1996-2007, hospitalization rates for psychiatric disorders among American children aged 5-13 years rose dramatically, nearly doubling during that period.

Concurrently, psychiatric hospitalizations for U.S. adolescents (aged 14-19 years) also rose substantially, by 42%. During the same period, psychiatric hospitalizations rose modestly (by 8%) for adults aged 20-64 years, whereas psychiatric hospitalizations for Americans aged 65 or older fell dramatically, Joseph C. Blader, Ph.D., said while presenting a poster at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The reasons behind these changes and their implications for the quality of care American psychiatric patients receive remain unclear, said Dr. Blader, a researcher in the division of child and adolescent psychiatry at the State University of New York at Stony Brook. However, the shifts in hospitalization rates – especially the larger such shifts among children and adolescents – raise concerns that demand further analysis, he said.

"It’s not a good thing" that substantially more children and adolescents require hospitalization for psychiatric diagnoses, Dr. Blader said in an interview. The shifts "represent a significant development in mental health treatment in the United States," he said in the poster.

The data Dr. Blader analyzed came from the National Hospital Discharge Survey, and also showed that in 1996-2007, payment for the psychiatric hospitalizations underwent a significant shift away from private insurance coverage and toward an increased share of the hospitalizations paid for by government agencies, most typically Medicaid. Again, the implications of this – and how it might play into the increased hospitalization rates – remain unclear.

According to Dr. Blader, the questions now are, Does the rise in hospitalizations result from "problems in the level of services provided by community care," and has "more cost shifting" of patients into Medicaid from private insurance led to or resulted from the rise in hospitalizations?

"Beneficiaries of publicly funded inpatient care may have become disproportionately vulnerable to psychiatric emergencies," or perhaps the effect "indicates better outpatient care among the privately insured," he said in his poster. "In many states, privately insured patients with extended psychiatric hospitalizations become eligible for Medicaid coverage."

He noted that during the period studied, the psychiatric field has made a diagnostic shift: More children who engage in injurious behavior are being labeled with bipolar disorder. He also speculated that the increasingly complex polypharmacy treatment of psychiatric patients, including children, might be a factor boosting hospitalizations.

"When a child is on many medications and a crisis occurs, the physician may not be sure what to do, which drug to stop," and thus may feel it’s safer to hospitalize and manage the child or adolescent there, Dr. Blader said in an interview.

However, he dismissed the notion that clinical criteria for hospitalization shifted during the period examined. "It’s unlikely that there was a lower threshold for hospitalization" in 2007 compared with 11 years earlier, he said.

The National Hospital Discharge Survey, run by the Centers for Disease Control and Prevention, collected data from 366,000 U.S. hospitalizations in 2007.

Survey data showed that in 1996-2007, the rate of hospitalization for a primary diagnosis of a psychiatric disorder in children aged 5-13 years rose from 15.6 per 10,000 U.S. residents to 28.3. In adolescents aged 14-19 years, the rate rose from 68.4 per 10,000 to 96.9, while in those aged 20-64 years, the rate increased from 92.1 per 10,000 to 99.1. All of the changes were statistically significant. Dr. Blader’s poster did not report rates for patients aged 65 or older, but in his analysis, this number fell "dramatically" from 1996 to 2007, he said.

During the period studied, private insurance coverage of these psychiatric hospitalizations among children fell from 36% of cases to 23%, while government-based sources of payment rose from 63% of cases to 71%. Among adolescents, private payment fell from 52% of cases to 22% while government coverage rose from 44% to 62%. Among adults, private coverage fell from 36% to 23%, while government coverage was flat, at 58% in 1996 and 59% in 2007.

The impact of both increases in hospitalization rates as well as increased population levels also led to substantial boosts in total days hospitalized for primary psychiatric diagnoses among children and adolescents, but not in adults. For children, total hospitalized days soared from 644,461 in 1996 to 1,528,117 in 2007. Among adolescents, total days rose from 1,317,660 in 1996 to 2,115,905 in 2007.

Dr. Blader had no disclosures.