Prevalence represents the overall proportion of individuals in a population who have the disorder of interest. It is different from incidence, which represents only the new cases that have developed over a particular time period. Point prevalence is the proportion of individuals who have the disorder at a given point in time. Period prevalence is the proportion of individuals who have the disorder over specific time periods. Lifetime prevalence is the proportion of individuals who have ever had the disorder. Lifetime morbid risk also includes those who had the disorder but were deceased at the time of the survey.

What is the evidence for the prevalence of PTSD in children and adolescents?

Moderate to high quality evidence finds the prevalence PTSD in children after an injury is 20.52%. Rates were highest in girls, in older children, and in children injured during a hurricane. The prevalence of PTSD in children exposed to earthquake is around 23.6%. Being older, having higher education, being trapped, experiencing fear, injury, or bereavement, and witnessing injury/death during the earthquakes were related to greater risk of PTSD. The prevalence of PTSD in children and adolescents after tsunamis it is between 6.0% and 70.7%, after hurricanes it is between 9.0% and 36.7%, after cyclones and tornadoes it is between 1.0% and 90.0%, after fires it is between 9.0% and 36.7%, after floods it is between 2.05% and 37.0%, and after ship sinking it is between 50.0% and 89.5%.

The prevalence of PTSD in children exposed to the chronic Israeli-Palestinian conflict was between 21% and 44.6%. In children exposed to the Iranian war, prevalence was 19%. In children exposed to the World Trade Centre terrorist attack, prevalence was 17%. Prevalence was 14.9% in children exposed to the second Lebanese war, prevalence was 14.9%, and in children exposed to the first Gulf war, prevalence was 7.8%.

The prevalence of PTSD in adolescent males in juvenile detention or correctional centres is 8.6% and 18.2% in adolescent females in juvenile detention or correctional centres. Prevalence of PTSD in children and adolescents in the child welfare system is 4%.

In children and adolescents after road traffic accidents, the prevalence of PTSD was 19.95%, which was higher in females, and higher in studies located in the UK than in the US.

Prevalence of PTSD is 22.7% in child and adolescent refugees, with rates highest in those displaced less than two years and in those with an insecure visa status.

Prevalence of PTSD in adolescent cancer survivors is between 3% and 13.8%, with rates higher in females than in males.

August 2021

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The incidence of PTSD refers to how many new cases there are per population in a specified time-period after exposure to a traumatic event. It is different from prevalence, which represents how many overall cases exist. This topic presents the evidence on incidence rates in children and adolescents.

What is the evidence for the incidence of PTSD?

Moderate quality evidence finds the incidence of PTSD in children and adolescents is around 16% at least one month after exposure to trauma. The incidence rate is highest in females, and in children and adolescents exposed to interpersonal rather than non-interpersonal trauma.

August 2021

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Traumatic events are highly prevalent in childhood and adolescence. PTSD is often chronic and has immense personal and social costs, and the prognosis for recovery without adequate treatment is poor. Therefore, early and effective treatment is important.

What is the evidence for psychotherapy for PTSD in children and adolescents?

Moderate quality evidence found a large improvement in PTSD symptoms with psychological treatments by the end of treatment, and a medium-sized improvement by six months post-treatment when compared to untreated or waitlist controls. Compared to treatment as usual or active controls, there were small to medium-sized improvements in PTSD symptoms by the end of treatment and by six months post-treatment. Depression and anxiety symptoms also improved, although to a lesser extent. Studies with older patients, more females, and higher-quality studies reported the largest effect sizes. Individual treatments showed larger effect sizes than group treatments. Treatments that involved caretakers showed larger effect sizes than those involving children/adolescents alone. Studies with more treatment time reported larger effect sizes than shorter treatments. School-based therapies were also effective. There were no influencing effects of trauma type on PTSD symptom outcomes.

For individual psychological therapies compared to waitlist/no treatment, moderate to low quality evidence found the following therapies were effective (in descending order of effect); cognitive therapy for PTSD (individual trauma-focussed cognitive behavioural therapy [CBT]), combined somatic/cognitive therapies, child-parent psychotherapy, combined trauma-focussed CBT plus parent training, meditation, narrative exposure, exposure/prolonged exposure, play therapy, Cohen trauma-focussed CBT/cognitive processing therapy, and eye movement desensitisation reprocessing [EMDR]. At 1-4 months post-treatment, combined somatic/cognitive therapies, Cohen trauma-focussed CBT/cognitive processing therapy, combined trauma-focussed CBT plus parent training, and narrative exposure all continued to show large effects. There were no significant improvements in symptoms with parent training alone, supportive counselling, or family therapy. Cognitive therapy for PTSD was the most cost-effective intervention, followed by narrative exposure, EMDR, parent training, and group trauma-focussed CBT. Family therapy and supportive counselling were the least cost-effective options.

For children in low and middle-income countries, moderate to low quality evidence found improvements in PTSD symptoms post-treatment with any psychosocial therapy and at follow up (up to one year). Most improvements were found in the children aged 15-18 years, in non-displaced children, and in children living in smaller households (<6 members). Depression, functioning, hope, coping, and social support also improved. There was a strong relationship between improvements in functioning and improvements in PTSD symptoms. Interventions delivered by trained, non-specialist lay health workers in schools improved PTSD symptoms, depression, and functioning.

August 2021

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Prevalence quantifies the proportion of individuals in a population who have a disorder during a specific time period, while incidence refers to the number of new cases that develop in a population during a specific time period. In disorders of short duration, incidence and prevalence rates may be similar, however with disorders of long duration, such as bipolar disorder, there can be variation between the two. Current, or ‘point’ prevalence is the proportion of individuals who have the disorder at a given point in time, ‘period’ prevalence measures the proportion of individuals who have the disorder during a specified period (e.g. one year), a ‘lifetime’ prevalence is the proportion of individuals in the population who have ever had the disorder.

What is the evidence on prevalence of bipolar disorder in children?

Moderate quality evidence finds the current prevalence of bipolar spectrum disorders in children is around 4%. Rates were higher in studies using broad diagnostic measures (8.6%), in older samples (8.3%), and in studies using lifetime rates (6.4%).

October 2021

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Roughly 2% of youth under the age of 18 experience bipolar disorder. For 55 to 60% of adults with bipolar disorder, the pathology begins in childhood and adolescence with displays of subthreshold forms or prodromal signs of the disorder during this time. An earlier age at the first episode of bipolar disorder is associated with a more severe clinical course.

What is the evidence for childhood bipolar disorder?

Moderate quality evidence shows the most common mania symptoms reported in youth with bipolar disorder are (in decreasing order) increased energy, irritability, mood lability, distractibility, goal-directed activity, euphoric/elated mood, pressured speech, hyperactivity, racing thoughts, poor judgment, grandiosity, inappropriate laughter, decreased need for sleep, and flight of ideas.

Compared to children and adolescents with no mental illness, there was a medium-sized increased risk of suicide ideation in children and adolescents with bipolar disorder. There was also greater severity of functional impairment, mania and depression symptoms, disruptive behaviour, suicidal ideation and attempts, and more mood and substance use disorders in children with subthreshold bipolar disorder symptoms compared to children with no mental illness. Conversely, compared to children with a diagnosis of bipolar disorder, children with subthreshold symptoms showed less severe functional impairment, mania and psychosis symptoms, suicidal ideation and attempts, and less service use.

Compared to children or youth with unipolar depression, the clinical features found more often in children or youth with bipolar depression include more psychiatric comorbidities and behavioural problems (oppositional disorder, conduct disorder, anxiety disorders, irritability, suicidal/self-harm, social impairment, and substance use), earlier onset of mood symptoms, more severe depression, and having a family history of psychiatric illness.

Compared to adults with bipolar disorder, there was more irritability, aggression, and low insight common in youths with bipolar disorder. Odd appearance, grandiosity, flight of ideas, decreased sleep, and increased sexual interest are more common in adults with bipolar disorder than in youth with bipolar disorder.

Moderate to high quality evidence suggests having a family history of any mood disorder, subthreshold symptoms of mania, emotional dysregulation, and behaviour problems are associated with greater likelihood of switching to mania in children with major depression.

Moderate quality evidence finds the prevalence of mixed states (having hypo/manic symptoms within a depressive episode, or depressive symptoms within a manic or hypomanic episode) in children with bipolar disorder is around 55%. There were high rates of comorbidities in these children, particularly ADHD, oppositional defiant disorder, and anxiety disorders.

Moderate quality evidence finds diagnostic stability over 10 years was between 73% and 100% in children with bipolar disorder. Recovery rates from the index episode were between 81.5% and 100%, and recurrence rates were between 35% and 67%. Suicide attempts were between 18% and 20%.

September 2021

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Bipolar disorder is a chronic psychiatric illness that can have devastating effects on afflicted individuals and their families. It is the sixth leading cause of disability worldwide, and prevalence is estimated to be around 1% in the general adult population. The age of onset of bipolar disorder typically occurs during late adolescence or early adulthood, although onset can occur in childhood. Early-onset bipolar disorder is commonly associated with impairment in multiple domains, including increased risk of psychiatric hospitalisation, antisocial behaviour, addictions and suicidal behaviour. The need to optimise treatments for for these patients for whom medication could be long-term and associated with adverse side effects, has increased the interest in the role of psychological treatments.

What is the evidence for psychosocial treatments for childhood bipolar disorder?

Moderate to low quality evidence suggests cognitive behavioural therapy, education, and family therapies may improve mood symptoms and increase knowledge about the disorder in children or youth with bipolar disorder. More research is needed to assess Interpersonal Social Rhythms Therapy and Dialectical Behavioural Therapy.

November 2021

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Bipolar disorder is a chronic psychiatric illness that can have devastating effects on individuals and their families. It is the sixth leading cause of disability worldwide, with prevalence estimated to be around 1% in the general adult population. The age of onset of bipolar disorder typically occurs during early adulthood, although onset can occur in childhood or adolescence. Bipolar disorder in childhood and adolescence is commonly associated with impairment in multiple domains, including increased risk of psychiatric hospitalisation, antisocial behaviour, addictions, and suicidal behaviour. There is a need to optimise treatments for childhood patients for whom medication use could be long-term, with concerns about potential overuse and side effects in a population who are undergoing relevant biological, psychological, and social maturational changes.

What is the evidence on pharmaceutical treatments for childhood bipolar disorder?

Moderate quality evidence suggests combined treatment with an anticonvulsant or lithium plus a second-generation antipsychotic was significantly more effective for clinical response than individual treatments.

Moderate to high quality evidence suggests a medium-sized effect of improved mania symptoms with second-generation antipsychotics aripiprazole, olanzapine, risperidone, and ziprasidone compared to placebo. Moderate quality evidence suggests no differences in depression symptoms between the antipsychotic quetiapine and placebo.

Moderate to low quality evidence finds a small effect of improved mania symptoms with mood stabilisers divalproex, lithium, oxcarbazepine, and topiramate compared to placebo.

Second generation antipsychotics may cause more weight gain and drowsiness than mood stabilisers, while mood stabilisers may cause more akathisia (inner restlessness).

Antipsychotics may cause more weight gain and drowsiness than mood stabilisers, while mood stabilisers may cause more akathisia (inner restlessness).

November 2021

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Deficits across various cognitive domains are a common feature of bipolar disorder. These are strongly associated with difficulties in activities of daily living. Early age at onset of the illness is associated with more severe symptoms and poor prognosis than later age at onset. Identifying cognitive deficits in children contributes to the development of specific treatments and rehabilitation approaches.

What is the evidence regarding cognition in children with bipolar disorder?

Moderate quality evidence finds large impairments in global cognition, verbal and visual learning and memory, and working memory in youth with bipolar disorder, compared to youth without the disorder that are of similar age (average 13 years) and IQ (average 104). There were no differences in attention, reasoning, problem solving, and processing speed.

High quality evidence finds a medium to large effect of reduced emotion recognition in youth with bipolar disorder. Moderate quality evidence finds a large effect of reduced theory of mind, which is the ability to infer the mental states of other people.

Moderate quality evidence finds a medium to large effect of poorer accuracy on emotion recognition in youth with bipolar disorder compared to age-matched controls. There was a smaller, non-significant effect of poorer response time. Unmedicated youth showed longer response times than medicated youth. Caucasian youth with bipolar disorder showed both longer response times and poorer accuracy than non-Caucasian youth.

October 2021

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Childhood-onset schizophrenia is defined as schizophrenia with onset prior to the age of 13 years, and early-onset schizophrenia describes schizophrenia between the ages of 13 and 17 years.

What is the evidence for psychosocial treatments for childhood and early-onset schizophrenia?

Moderate quality evidence finds supportive therapy is better than cognitive behavioural therapy for improving symptoms, however cognitive behavioural therapy is better than supportive therapy for improving insight in children with early-onset schizophrenia. Education about the illness may be beneficial for improving symptoms and functioning.

Moderate to low quality evidence finds cognitive remediation can improve verbal memory, executive cognitive functioning (e.g. problem solving), daily living, and general functioning.

September 2020

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Childhood-onset schizophrenia is defined as schizophrenia with onset prior to the age of 13 years, and early-onset schizophrenia describes schizophrenia onset between the ages of 13 and 17 years.

What is the evidence for pharmaceutical treatments for childhood and early-onset schizophrenia?

Compared to first-generation antipsychotics, moderate quality evidence finds a small to medium-sized benefit of second-generation antipsychotics for global and mental state in children and adolescents with schizophrenia. There was greater improvement with standard dose than low-dose antipsychotics, although there are more side effects with standard doses.

Moderate quality evidence finds clozapine was the most effective antipsychotic and fluphenazine was the least effective antipsychotic for symptoms when compared to placebo and other antipsychotics (ziprasidone, loxapine, trifluperazine, asenapine, haloperidol, quetiapine, paliperidone, aripiprazole, risperidone, lurasidone, olanzapine, or molindone). There were few significant differences between the other antipsychotics, with only ziprasidone being less effective for symptoms than olanzapine, molindine and risperidone.

For positive symptoms in particular (e.g. hallucinations and delusions), moderate to high quality evidence finds medium-sized improvements with olanzapine, risperidone, and asenapine, and small improvements with quetiapine, aripiprazole, and paliperidone over placebo. For negative symptoms (e.g. social withdrawal), moderate to low quality evidence finds medium-sized improvements with aripiprazole, asenapine, molindone, olanzapine and risperidone over placebo.

For side effects, moderate quality evidence finds haloperidol, loxapine, risperidone and quetiapine resulted in the most extrapyramidal (movement) symptoms. Olanzapine showed the most weight gain, followed by clozapine, quetiapine, paliperidone, risperidone, asenapine and then aripiprazole. There was less weight gain with lurasidone than with olanzapine, quetiapine, risperidone, asenapine, and paliperidone. Clozapine showed the most sedation, followed by paliperidone, asenapine, loxapine, olanzapine, haloperidol, aripiprazole, and risperidone. Risperidone showed the most prolactin increase, followed by haloperidol, olanzapine, paliperidone, and quetiapine.

October 2020

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