Showing papers in "Journal of the American Academy of Child and Adolescent Psychiatry in 1997"

Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial Reliability and Validity Data

Abstract: Objective To describe the psychometric properties of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL) interview, which surveys additional disorders not assessed in prior K-SADS, contains improved probes and anchor points, includes diagnosis-specific impairment ratings, generates DSM-III-R and DSM-IV diagnoses, and divides symptoms surveyed into a screening interview and five diagnostic supplements. Method Subjects were 55 psychiatric outpatients and 11 normal controls (aged 7 through 17 years). Both parents and children were used as informants. Concurrent validity of the screen criteria and the K-SADS-PL diagnoses was assessed against standard self-report scales. Interrater ( n = 15) and test-retest ( n = 20) reliability data were also collected (mean retest interval: 18 days; range: 2 to 38 days). Results Rating scale data support the concurrent validity of screens and K-SADS-PL diagnoses. Interrater agreement in scoring screens and diagnoses was high (range: 93% to 100%). Test-retest reliability κ coefficients were in the excellent range for present and/or lifetime diagnoses of major depression, any bipolar, generalized anxiety, conduct, and oppositional defiant disorder (.77 to 1.00) and in the good range for present diagnoses of posttraumatic stress disorder and attention-deficit hyperactivity disorder (.63 to .67). Conclusion Results suggest the K-SADS-PL generates reliable and valid child psychiatric diagnoses. J. Am. Acad. Child Adolesc. Psychiatry , 1997, 36(7): 980–988.

The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale Construction and Psychometric Characteristics

Abstract: Objective To develop a reliable and valid child and parent self- report instrument to screen children with anxiety disorders. Method An 85-item questionnaire was administered to 341 outpatient children and adolescents and 300 parents. Utilizing item analyses and factor analyses, the original scale was reduced to 38 items. A subsample of children ( n = 88) and parents ( n = 86) was retested an average of 5 weeks (4 days to 15 weeks) after the initial screening. Results The child and parent Screen for Child Anxiety Related Emotional Disorders (SCARED) both yielded five factors: somatic/panic, general anxiety, separation anxiety, social phobia, and school phobia. For the total score and each of the five factors, both the child and parent SCARED demonstrated good internal consistency (α = .74 to .93), test-retest reliability (intraclass correlation coefficients=.70 to .90), discriminative validity (both between anxiety and other disorders and within anxiety disorders), and moderate parent-child agreement ( r = .20 to .47, p Conclusions The SCARED shows promise as a screening instrument for anxiety disorders. Future studies using the SCARED in community samples are indicated.

The Multidimensional Anxiety Scale for Children (MASC): Factor Structure, Reliability, and Validity

Abstract: Objective To describe the history, factor structure, reliability, and validity of the Multidimensional Anxiety Scale for Children (MASC). Method In two separate school-based population studies, principal-components factor analysis was used, first, to test a theory-driven factor structure, and second, to develop an empirically derived factor structure for the MASC. In a separate study using a clinical population, test-retest reliability at 3 weeks and 3 months, interrater concordance, and convergent and divergent validity were examined. Results The final version of the MASC consists of 39 items distributed across four major factors, three of which can be parsed into two subfactors each. Main and subfactors include (1) physical symptoms (tense/restless and somatic/autonomic), (2) social anxiety (humiliation/rejection and public performance fears), (3) harm avoidance (perfectionism and anxious coping), and (4) separation anxiety. The MASC factor structure, which presumably reflects the in vivo structure of pediatric anxiety symptoms, is invariant across gender and age and shows excellent internal reliability. As expected, females show greater anxiety on all factors and subfactors than males. Three-week and 3-month test-retest reliability was satisfactory to excellent. Parent-child agreement was poor to fair. Concordance was greatest for easily observable symptom clusters and for mother-child over father-child or father-mother pairs. Shared variance with scales sampling symptom domains of interest was highest for anxiety, intermediate for depression, and lowest for externalizing symptoms, indicating adequate convergent and divergent validity. Conclusion The MASC is a promising self-report scale for assessing anxiety in children and adolescents.

Children's Yale-Brown Obsessive Compulsive Scale: Reliability and Validity

Abstract: Objective To evaluate the reliability and validity of a semistructured measure of obsessive-compulsive symptom severity in children and adolescents with obsessive-compulsive disorder (OCD). Method Sixty-five children with OCD (25 girls and 40 boys, aged 8 to 17 years) were assessed with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Interrater agreement was assessed by four raters in a subsample (n = 24). Discriminant and convergent validity were assessed by comparing CY-BOCS scores to self-ratings of depression, anxiety, and obsessive-compulsive symptoms. Results Internal consistency was high, measuring .87 for the 10 items. The intraclass correlations for the CY-BOCS Total, Obsession, and Compulsion scores were .84, .91, and .68, suggesting good to excellent interrater agreement for subscale and total scores. The CY-BOCS Total score showed a significantly higher correlation with a self-report of obsessive-compulsive symptoms (r = .62 for the Leyton survey) compared with the Children's Depression Inventory (r = .34) and the Children's Manifest Anxiety Scale (r = .37) (p = .02 and .05, respectively). Conclusions The CY-BOCS yields reliable and valid subscale and total scores for obsessive-compulsive symptom severity in children and adolescents with OCD. Reliability and validity appear to be influenced by age of the child and the hazards associated with integrating data from parental and patient sources.

Validity of the Childhood Trauma Questionnaire in an Adolescent Psychiatric Population

Abstract: Objective To present initial findings on the validity of a recently developed maltreatment inventory, the Childhood Trauma Questionnaire (CTQ), in a sample of adolescent psychiatric patients. Method Three hundred ninety-eight male and female adolescents (aged 12 to 17 years) admitted to the inpatient service of a private psychiatric hospital were given the CTQ as part of a larger test battery. Structured interviews were also conducted with the primary therapists of 190 of the patients to obtain ratings of abuse and neglect based on all available data, including clinical interviews with patients and their relatives and information from referring clinicians and agencies. Results Principal-components analysis of the CTQ items yielded five rotated factors-emotional abuse, emotional neglect, sexual abuse, physical abuse, and physical neglect-closely replicating the factor structure in an earlier study of adult patients. The internal consistency of the CTQ factors was extremely high both in the entire sample and in every subgroup examined. When CTQ factor scores were compared with therapists' ratings in a series of logistic regression analyses, relationships between the two sets of variables were highly specific, supporting the convergent and discriminant validity of the CTQ. Finally, when therapists' ratings were used as the validity criterion, the CTQ exhibited good sensitivity for all forms of maltreatment, and satisfactory or better levels of specificity. Conclusions These initial findings suggest that the CTQ is a sensitive and valid screening questionnaire for childhood trauma in an adolescent psychiatric inpatient setting.

Gender differences in ADHD: A meta-analysis and critical review

Abstract: Objective To quantitatively review and critically evaluate literature examining gender differences in attention-deficit hyperactivity disorder (ADHD). Method A meta-analysis of relevant research based on 18 studies meeting inclusion criteria was performed. Domains evaluated included primary symptomatology, intellectual and academic functioning, comorbid behavior problems, social behavior, and family variables. Results Gender differences were not found in impulsivity, academic performance, social functioning, fine motor skills, parental education, or parental depression. However, compared with ADHD boys, ADHD girls displayed greater intellectual impairment, lower levels of hyperactivity, and lower rates of other externalizing behaviors; it was not possible to evaluate the extent to which referral bias affected these findings. Some gender differences were clearly mediated by the effects of referral source; among children with ADHD identified from nonreferred populations, girls with ADHD displayed lower levels of inattention, internalizing behavior, and peer aggression than boys with ADHD, while girls and boys with ADHD identified from clinic-referred samples displayed similar levels of impairment on these variables. Conclusions The need for future research examining gender differences in ADHD is strongly indicated, with attention to methodological limitations of the current literature, including the potential confounding effects of referral bias, comorbidity, developmental patterns, diagnostic procedures, and rater source.

Attention-Deficit Hyperactivity Disorder: A Category or a Continuum? Genetic Analysis of a Large-Scale Twin Study

Abstract: Objective To investigate heritability and continuum versus categorical approaches to attention-deficit hyperactivity disorder (ADHD), using a large-scale twin sample. Method A cohort of 1,938 families with twins and siblings aged 4 to 12 years, recruited from the Australian National Health and Medical Research Council Twin Registry, was assessed for ADHD using a DSM-III-R-based maternal rating scale. Probandwise concordance rates and correlations in monozygotic and dizygotic twins and siblings were calculated, and heritability was examined using the De Fries and Fulker regression technique. Results There was a narrow (additive) heritability of 0.75 to 0.91 which was robust across familial relationships (twin, sibling, and twin-sibling) and across definitions of ADHD as part of a continuum or as a disorder with various symptom cutoffs. There was no evidence for nonadditive genetic variation or for shared family environmental effects. Conclusions These findings suggest that ADHD is best viewed as the extreme of a behavior that varies genetically throughout the entire population rather than as a disorder with discrete determinants. This has implications for the classification of ADHD and for the identification of genes for this behavior, as well as implications for diagnosis and treatment.

Implication of right frontostriatal circuitry in response inhibition and attention-deficit/hyperactivity disorder

Abstract: Objective To examine the relation between specific frontostriatal structures (prefrontal cortex and basal ganglia) and response inhibition deficits observed in attention-deficit/hyperactivity disorder (ADHD). Method Children with ADHD and age-matched normal controls were scanned using magnetic resonance imaging (MRI) and tested on three response inhibition tasks. Behavioral performance was correlated with MRI-based anatomical measures of frontostriatal circuitry (prefrontal cortex and basal ganglia) implicated in ADHD. Results First, significant differences in performance by children with ADHD and normal volunteers were observed on all three response inhibition tasks. Second, performance on these tasks correlated only with those anatomical measures of frontostriatal circuitry observed to be abnormal in children with ADHD (e.g., the region of the prefrontal cortex, caudate, and globus pallidus, but not the putamen) in the authors' previous study. Third, significant correlations between task performance and anatomical measures of the prefrontal cortex and caudate nuclei were predominantly in the right hemisphere, supporting a role of right frontostriatal circuitry in response inhibition and ADHD. Conclusion The data suggest a role of the right prefrontal cortex in suppressing responses to salient, but otherwise irrelevant events while the basal ganglia appear to be involved in executing these behavioral responses.

Comorbidity in ADHD: Implications for Research, Practice, and DSM-V

Abstract: Objective Since the introduction of DSM-III/III-R , clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research, and future classification approaches. Method The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment, and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria. Results The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless, available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD, aggressive subtype, and (2) ADHD, anxious subtype. Conclusions Additional studies of the frequency of comorbidity and associated factors are greatly needed, to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors. J. Am. Acad. Child Adolesc. Psychiatry , 1997, 36(8):1065–1079.

Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Attention-Deficit/Hyperactivity Disorder

Abstract: These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperacitivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7% Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and α-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

Child and adolescent anxiety disorders and early attachment

Abstract: Objective The major aim of this research is to determine whether infants who were anxiously/resistantly attached in infancy develop more anxiety disorders during childhood and adolescence than infants who were securely attached. To test different theories of anxiety disorders, newborn temperament and maternal anxiety were included in multiple regression analyses. Method Infants participated in Ainsworth's Strange Situation Procedure at 12 months of age. The Schedule for Affective Disorders and Schizophrenia for School-Age Children was administered to the 172 children when they reached 17.5 years of age. Maternal anxiety and infant temperament were assessed near the time of birth. Results The hypothesized relation between anxious/resistant attachment and later anxiety disorders was confirmed. No relations with maternal anxiety and the variables indexing temperament were discovered, except for a composite score of nurses' ratings designed to access "high reactivity," and the Neonatal Behavioral Assessment Scale clusters of newborn range of state and inability to habituate to stimuli. Anxious/resistant attachment continued to significantly predict child/adolescent anxiety disorders, even when entered last, after maternal anxiety and temperament, in multiple regression analyses. Conclusion The attachment relationship appears to play an important role in the development of anxiety disorders. Newborn temperament may also contribute. J. Am. Acad. Child Adolesc. Psychiatry, 1997, 36(5):637–644.

Is psychopathology associated with the timing of pubertal development

Abstract: Objective This investigation tested whether the timing of pubertal development was associated with concurrent and prior experiences of psychopathology (symptoms and disorders) in adolescent boys and girls. Method A large ( N = 1,709) community sample of high school students were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children as adapted for use in epidemiological studies. Adolescents also completed a questionnaire battery covering a range of psychosocial variables. Results Analyses tested whether pubertal timing was associated with present and lifetime history of mental disorders, psychological symptoms, and psychosocial functioning. As hypothesized, early-maturing girls and late-maturing boys showed more evidence of psychopathology than other same-gender adolescents. Conclusions Early-maturing girls had the poorest current and lifetime history of adjustment problems, indicating that this pattern of pubertal development merits attention by mental health providers and researchers.

Child and Adolescent Bipolar Disorder: A Review of the Past 10 Years

Abstract: Objective To provide a review of the epidemiology, phenomenology, natural course, comorbidity, neurobiology, and treatment of child and adolescent bipolar disorder (BP) for the past 10 years. This review is provided to prepare applicants for recertification by the American Board of Psychiatry and Neurology. Method Literature from Medline and other searches for the past 10 years, earlier relevant articles, and the authors' experience and ongoing National Institute of Mental Health-funded project "Phenomenology and Course of Pediatric Bipolarity" were used. Results Age-specific, developmental (child, adolescent, and adult) DSM-IV criteria manifestations; comorbidity and differential diagnoses; and episode and course features are provided. Included are age-specific examples of childhood grandiosity, hypersexuality, and delusions. Differential diagnoses (e.g., specific language disorders, sexual abuse, conduct disorder [CD], schizophrenia, substance abuse), suicidality, and BP-II are discussed. Conclusions Available data strongly suggest that prepubertal-onset BP is a nonepisodic, chronic, rapid-cycling, mixed manic state that may be comorbid with attentiondeficit hyperactivity disorder (ADHD) and CD or have features of ADHD and/or CD as initial manifestations. Systematic research on pediatric BP is in its infancy and will require ongoing and future studies to provide developmentally relevant diagnostic methods and treatment.

ADHD is associated with early initiation of cigarette smoking in children and adolescents.

Abstract: Objective The association between attention-deficit hyperactivity disorder (ADHD) and cigarette smoking in children and adolescents was evaluated. Method Subjects were 6− to 17-year-old boys with DSM-III-R ADHD ( n = 128) and non-ADHD comparison boys ( n = 109) followed prospectively for 4 years into mid-adolescence. Information on cigarette smoking was obtained in a standardized manner blind to the proband's clinical status. Cox proportional hazard models were used to predict cigarette smoking at follow-up using baseline characteristics as predictors. Results ADHD was a significant predictor of cigarette smoking at follow-up into mid-adolescence. Our findings also revealed that ADHD was associated with an early initiation of cigarette smoking. This was the case even after controlling for socioeconomic status, IQ, and psychiatric comorbidity. In addition, among children with ADHD, there was a significant positive association between cigarette smoking and conduct, major depressive, and anxiety disorders. Conclusions ADHD, particularly the comorbid subtype, is a significant risk factor for early initiation of cigarette smoking in children and adolescents. Considering the prevalence and early childhood onset of ADHD, these findings highlight the importance of smoking prevention and cessation programs for children and adolescents with ADHD.

At Risk for Anxiety: I. Psychopathology in the Offspring of Anxious Parents

Abstract: Objective and Method Children of parents with anxiety disorders, depressive disorders, mixed anxiety/depressive disorders, and no psychiatric disorder were assessed with semistructured interviews to determine rates of overall psychopathology and to determine specifically the presence of anxiety disorders. Results Children of the three “high-risk” groups were significantly more likely to have a diagnosable disorder (including anxiety disorders) than offspring of normal parents, but there were no differences among the children from the three parental diagnostic groups. However, when examined specifically for anxiety disorders, offspring of anxious parents were significantly more likely to have only anxiety disorders. Offspring of depressed or mixed anxious/depressed parents had a broader range of disorders and more comorbid disorders. Family socioeconomic status was related to the probability that a child would have a disorder. Conclusions Anxiety disorders are common among offspring of anxious and depressed parents. However, when a parent has depression, children exhibit a broader range of psychopathology than when a parent has an anxiety disorder alone. J. Am. Acad. Child Adolesc. Psychiatry, 1997, 36(7):918–924.

Is ADHD a risk factor for psychoactive substance use disorders : Findings from a four-year prospective follow-up study

Abstract: Objective To evaluate whether attention-deficit hyperactivity disorder (ADHD) is a risk factor for psychoactive substance use disorders (PSUD), attending to issues of psychiatric comorbidity, family history, and adversity. Method Using assessments from multiple domains, the authors examined 140 ADHD and 120 normal control subjects at baseline and 4 years later. Drug and alcohol abuse and dependence were operationally defined. Results No differences were detected in the rates of alcohol or drug abuse or dependence or in the rates of abuse of individual substances between the groups; both ADHD and control probands had a 15% rate of PSUD. Conduct and bipolar disorders predicted PSUD, independently of ADHD status. Family history of substance dependence and antisocial disorders was associated with PSUD in controls but less clearly so in ADHD probands. Family history of ADHD was not associated with risk for PSUD. ADHD probands had a significantly shorter time period between the onsets of abuse and dependence compared with controls (1.2 years versus 3 years, p Conclusions Adolescents with and without ADHD had a similar risk for PSUD that was mediated by conduct and bipolar disorder. Since the risk for PSUD has been shown to be elevated in adults with ADHD when compared with controls, a sharp increase in PSUD is to be expected in grown-up ADHD children during the transition from adolescence to adulthood.

Parent management training: Evidence, outcomes, and issues.

Abstract: Objective To describe and evaluate parent management training (PMT) as a treatment technique for oppositional, aggressive, and antisocial behavior. Method Recent research is reviewed on the efficacy of PMT; factors that contribute to treatment outcome; the range of outcomes related to child, parents, and family; and variations of treatment currently in use. Limitations are also discussed related to the impact of treatment, clinical application, and dissemination of treatment. Results and Conclusions PMT is one of the more well-investigated treatment techniques for children and adolescents. Notwithstanding the large number of controlled studies attesting to its efficacy, fundamental questions remain about the magnitude, scope, and durability of impact.

Psychopathy and conduct problems in children : II. Implications for subtyping children with conduct problems

Abstract: Objective To test whether the presence of callous and unemotional (CU) traits designates a unique subgroup of children with conduct problems that corresponds more closely to adult conceptualizations of psychopathy. Method A clinic-referred sample of 120 children between the ages of 6 and 13 years were assessed using parent and teacher ratings of CU traits, as well as parent and teacher report on a structured interview assessing oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms. Results A cluster analysis of the ratings of CU traits and ODD/CD symptoms revealed four clusters of children, two of which had high rates of ODD and CD symptoms. One of these conduct problem clusters also exhibited high levels of CU traits ( n = 11). These children had a greater number and variety of conduct problems, a stronger history of police contacts, and a stronger parental history of antisocial personality disorder, despite being of higher intelligence than other children with significant conduct problems ( n = 29). Conclusion: The presence of CU traits with significant conduct problems seems to designate a unique subgroup of antisocial children who show a very severe pattern of antisocial behavior and who correspond more closely to adult conceptualizations of psychopathy.

Macrocephaly in Children and Adults With Autism

Abstract: Objective To explore the frequency and onset of macrocephaly in autism and its relationship to clinical features. Method Head circumferences at birth, during early childhood, and at the time of examination were studied in a community-based sample of autistic children and adults. The authors investigated whether head circumference at the time of examination was associated with clinical features. Results Fourteen percent of the autistic subjects had macrocephaly: 11% of males and 24% of females. In most, the macrocephaly was not present at birth; in some it became apparent in early and middle childhood as a result of increased rate of head growth. A small relationship was noted between head circumference percentile and less severe core features of autism. Neither macrocephaly nor head circumference percentile was associated with nonverbal IQ, verbal status, seizure disorder, neurological soft signs, or minor physical anomalies in the autistic subjects. Conclusion Macrocephaly is common in autism and usually is not present at birth. Rates of head growth may be abnormal in early and middle childhood in some (37%) children with autism. Macrocephaly does not define a homogeneous subgroup of autistic individuals according to clinical features.

Correspondence Between Adolescent Report and Parent Report of Psychiatric Diagnostic Data

Abstract: Objective To examine the degree of agreement between parent and adolescent report of major psychiatric disorders in the adolescent (14 to 18 years of age) Method A total of 281 parent-adolescent pairs were interviewed separately regarding psychopathology in the adolescent Results The k values for parent-adolescent agreement on the disorders ranged from 19 for alcohol abuse/dependence to 79 for conduct disorder, with an average k of 42 Excellent agreement was found for conduct disorder and the core symptom of anorexia; good agreement was found for separation anxiety disorders, attention-deficit/hyperactivity disorder, oppositional defiant disorder, substance abuse/dependence, and the core symptom for bulimia; poor agreement was found for major depression, dysthymia, anxiety disorders other than separation anxiety, alcohol abuse/dependence, and the infrequent core symptoms of bipolar and obsessive-compulsive disorders Parent-adolescent agreement was not influenced by gender, current adolescent age, parental education level, disorder onset age, or severity of disorder Conclusions For detecting cases of adolescent psychopathology, there are clear advantages to the current consensus position that combines adolescent and parent report, especially for externalizing disorders However, if forced to choose one informant, assessing the adolescent will result in the detection of more diagnosed cases J Am Acad Child Adolesc Psychiatry, 1997, 36(5):610–619

Comparisons of problems reported by parents of children in 12 cultures: total problems, externalizing, and internalizing.

Abstract: Objective To compare parent-reported problems for children in 12 cultures. Method Child Behavior Checklists were analyzed for 13,697 children and adolescents, aged 6 through 17 years, from general population samples in Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States. Results Comparisons of 12 cultures across ages 6 through 11 and 9 cultures across ages 6 through 17 yielded medium effect sizes for cross-cultural variations in Total Problem, Externalizing, and Internalizing scores. Puerto Rican scores were the highest, while Swedish scores were the lowest. With great cross-cultural consistency, Total and Externalizing scores declined with age, while Internalizing scores increased; boys obtained higher Total and Externalizing scores but lower Internalizing scores than girls. Cross-cultural correlations were high among the mean item scores. Conclusions Empirically based assessment provides a robust methodology for assessing and comparing problems reported for children from diverse cultures. Age and gender variations are cross-culturally consistent. Although clinical cutoff points should not necessarily be uniform across all cultures, empirically based assessment offers a cost-effective way to identify problems for which children from diverse cultural backgrounds may need help.

Posttraumatic Stress Disorder in Incarcerated Juvenile Delinquents

Abstract: Objective To assess the prevalence of posttraumatic stress disorder (PTSD) in severely delinquent subjects and to measure associated personality characteristics. Method Eighty-five incarcerated boys (mean age 16.6, SD=1.2) with mostly violent offenses were studied. The sample was representative of the California Youth Authority population. They received a standard psychiatric screen, a semistructured interview for PTSD, and self-report questionnaires measuring personality traits and defenses. A nonclinical sex- and age-matched group was used for comparing psychometrics. Results Subjects suffered from PTSD at higher rates than other adolescent community samples and at higher rates than those found in county probation camps. Thirty-two percent fulfilled criteria for PTSD, 20% partial criteria. One half of the subjects described the witnessing of interpersonal violence as the traumatizing event. Psychometric results converged in the predicted way: Subjects with PTSD showed elevated distress, anxiety, depression, and lowered restraint, impulse control, and suppression of aggression; they had high levels of immature defenses such as projection, somatization, conversion, dissociation, and withdrawal. Conclusions PTSD occurs at high rates in delinquents, and this finding has implications for management and treatment. Personality characteristics that might put individuals at risk for the development of PTSD were identified.

Domestic violence and children: Prevalence and risk in five major U.S. cities.

Abstract: Objective Children witnessing domestic violence is a major national concern. The present study provided data on the prevalence of children's exposure to substantiated cases of adult female assaults in five U.S. cities. Method Data for this study were drawn from the Spouse Assault Replication Program (SARP) database, collected from police officers and female victims of misdemeanor domestic violence. In addition, household demographic data and data on involvement of children in the violent incidents were collected. Data from the SARP households were compared with census data from each city. Results Results indicated that children were disproportionately present in households with domestic violence and that young children were disproportionately represented among these children. Moreover, these children were exposed to excessive levels of additional developmental risk factors and they were involved in the incidents to varying degrees. Conclusions These findings underscore the importance of establishing a more rigorous interdisciplinary, scientific research agenda to inform assessment and treatment efforts for a very vulnerable group of children who witness domestic violence, children aged 0 through 5 years.

Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials.

Abstract: Objective To examine the validity of the DSM-IV requirement of an age of onset of impairment due to symptoms before 7 years of age for the diagnosis of attention-deficit/hyperactivity disorder (ADHD). Method The validity of this criterion was examined in a clinic sample of 380 youths aged 4 through 17 years by comparing youths who met symptom criteria for ADHD and either did or did not display impairment before age 7 years. Results Nearly all youths who met symptom criteria for the predominantly hyperactive-impulsive subtype also met the age of onset of impairment criterion, but 18% of youths who met symptom criteria for the combined type, and 43% of youths who met symptom criteria for the predominantly inattentive type, did not manifest impairment before 7 years. For the latter two subtypes, requiring impairment before age 7 years reduced the accuracy of identification of currently impaired cases of ADHD and reduced agreement with clinicians' judgments. Conclusions These findings raise questions about the validity of the DSM-IV definition of age of onset of ADHD. Marked differences in the ages of onset of both symptoms and impairment for the three subtypes of ADHD support the validity of distinguishing among these subtypes in DSM-IV .

Subtypes of Aggression and Their Relevance to Child Psychiatry

Abstract: Objective To review the evidence for qualitatively distinct subtypes of human aggression as they relate to childhood psychopathology. Method Critical review of the pertinent literature. Results In humans, as well as in animals, the term aggression encompasses a variety of behaviors that are heterogeneous for clinical phenomenology and neurobiological features. No simple extrapolation of animal subtypes to humans is possible, mainly because of the impact of complex cultural variables on behavior. On the whole, research into subtypes of human aggression has been rather limited. A significant part of it has been conducted in children. Clinical observation, experimental paradigms in the laboratory, and cluster/factor-analytic statistics have all been used in an attempt to subdivide aggression. A consistent dichotomy can be identified between an impulsive-reactive-hostile-affective subtype and a controlled-proactive-instrumental-predatory subtype. Although good internal consistency and partial descriptive validity have been shown, these constructs still need full external validation, especially regarding their predicting power of comorbidity, treatment response, and long-term prognosis. Conclusions Our understanding and treatment of children and adolescents with aggressive behavior can benefit from research on subtypes of aggression. The differentiation between the impulsive-affective and controlled-predatory subtype as qualitatively different forms of aggressive behavior has emerged as the most promising construct. Specific therapeutic hypotheses could be tested in this context and contribute to a full validation of these concepts.

Posttraumatic stress disorder in children: a review of the past 10 years.

Abstract: OBJECTIVE: To review current knowledge about the clinical presentation, assessment, and treatment of posttraumatic stress disorder (PTSD) in children. METHOD: The literature on PTSD in children is examined. RESULTS: Over the past 10 years, PTSD has been described in children exposed to a variety of traumatic experiences. Little is known about the epidemiology of the disorder in children. Partial symptomatology and comorbidity are common. A variety of factors influence response to trauma and affect recovery. They include characteristics of the stressor and exposure to it; individual factors such as gender, age and developmental level, and psychiatric history; family characteristics; and cultural factors. Since the condition is likely to occur after disaster situations, much of the literature describes the child's response to disaster and interventions tend to include efforts within schools and/or communities. A number of clinical approaches have been used to treat the condition. CONCLUSIONS: While assessment has been studied extensively, the longitudinal course of PTSD and treatment effectiveness have not been. Biological correlates of the condition also warrant greater attention. Language: en

Toward a Broader Definition of the Age-of-Onset Criterion for Attention-Deficit Hyperactivity Disorder

Abstract: Objective To critique the age-of-onset criterion (AOC) for the diagnosis of attention-deficit hyperactivity disorder (ADHD). Method The specific AOC of 7 years for symptoms producing impairment as part of the diagnostic criteria is examined from historical, empirical, conceptual, and pragmatic perspectives. Results No support could be found for the continued use of this criterion for either clinical or research diagnostic purposes. While both empirical and conceptual grounds exist for viewing ADHD as a disorder that typically has its onset of symptoms during childhood, no support exists for the selection of age 7 years for onset of a valid disorder, either for symptom onset or for onset of impairment. Conclusions Several reasons favor dispensing with a precise AOC, either for symptom onset or onset of impairment, not the least of which is that it is scientifically indefensible, poses unwarranted practical problems for the study of older adolescents and adults, and may be arbitrarily discriminatory. Until such time as an empirical justification can be marshaled for a precise AOC for ADHD, the current AOC should be either abandoned or generously broadened to include onset of symptoms during the entire childhood years, in keeping with its conceptualization as a childhood-onset disorder.

Sex Reassignment of Adolescent Transsexuals: A Follow-up Study

Abstract: Objective: To investigate postoperative functioning of the first 22 consecutive adolescent transsexual patients of our gender clinic who underwent sexreassignment surgery. Method: The subjects were interviewed by an independent psychologist and filled out a test battery containing questionnaires on their psychological, social, and sexual functioning. All subjects had undergone surgery no less than 1 year before the study took place. Twelve subjects had started hormone treatment between 16 and 18 years of age. The posttreatment data of each patient were compared with his or her own pretreatment data. Results: Postoperatively the group was no longer gender-dysphoric; they scored in the normal range with respect to a number of different psychological measures and they were socially functioning quite well. Not a single subject expressed feelings of regret concerning the decision to undergo sexreassignment. Conclusions: Starting the sexreassignment procedure before adulthood results in favorable postoperative functioning, provided that careful diagnosis takes place in a specialized gender team and that the criteria for starting the procedure early are stringent.

Educational and Occupational Outcome of Hyperactive Boys Grown Up

Abstract: Objective Little is known about the adult outcome of attention-deficit hyperactivity disorder (ADHD), a very prevalent childhood disorder that is known to affect deleteriously academic performance and other areas of child functioning. This study represents a third wave of evaluations that examine the long-term educational achievement and occupational rank of children with ADHD. Method This is a prospective follow-up of white boys of average intelligence whose ADHD was clinically diagnosed according to systematic criteria at an average age of 7 years. Follow-up intervals range from 15 to 21 years (mean, 17 years). At average age 24 years, 85 probands (representing 82% of the childhood cohort) and 73 controls (94%) were directly interviewed by trained clinicians who were blind to group membership. Results First, probands completed significantly less formal schooling than controls (about 2 years less, on average). Second, probands had lower-ranking occupational positions than controls. Finally, these disadvantages were not accounted for by adult mental status. Conclusions The present study suggests that childhood ADHD predisposes to specific disadvantages and continues to affect important functional domains unrelated to current psychiatric diagnosis.