Showing papers in "Journal of the American Academy of Child and Adolescent Psychiatry in 2002"

Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

Abstract: This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.

Race differences in the age at diagnosis among medicaid-eligible children with autism.

Abstract: Objective: To examine racial differences in the age at which Medicaid-eligible children first receive an autistic disorder (AD) diagnosis and to examine time in mental health treatment until an AD diagnosis was received. Method: Philadelphia Medicaid specialty mental health claims identified 406 children who received services in 1999 for AD. Claims from 1993–1999 were used to identify the date of first mental health visit, first receipt of AD diagnosis, and number of visits occurring between those dates. Linear regression was used to examine the relationship among race, age at first diagnosis of AD, time in mental health treatment, and number of visits until the diagnosis was made. Results: On average, white children received the AD diagnosis at 6.3 years of age, compared with 7.9 years for black children ( p p = .005); however, after adjusting for age, sex, and time eligible for Medicaid, black children required more time in treatment before receiving the diagnosis. Conclusions: Important disparities exist in the early detection and treatment of autism. These disparities may be the result of differences in help-seeking, advocacy and support, and clinician behaviors.

Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II.

Abstract: Objective: To review empirical findings on oppositional defiant disorder (ODD) and conduct disorder (CD). Method: Selected summaries of the literature over the past decade are presented. Results: Research on ODD and CD during the past decade has addressed the complexity involved in identifying the primary risk factors and developmental pathways to disruptive behavior disorders (DBD). In some domains, research is entering an entirely new phase because of the availability of new technologies. In others, larger data sets and more complicated methodological and statistical techniques are testing increasingly complex models.Yet questions remain regarding the most useful subtyping systems, the identification of the most significant risk factors, and the relationships between risk factors from multiple domains. Conclusions: Convincing evidence of causal linkages remains elusive. Research has questioned the notion that CD is intractable, especially when multiple domains of risk and impairment are the targets of intervention. It is apparent that there is not one single causative factor; thus it is not likely that one single modality will suffice to treat CD. Future steps will involve the restructuring of diagnostic criteria to capture adequate subtypes and indicators, clarification of the neurological underpinnings of the disorder, and refinement in the models available to explain the varied pathways to DBD. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(11):1275‐1293. Key Words: oppositional defiant disorder, conduct disorder, risk factors, treatment.

Barriers to children's mental health services.

Abstract: Objective To examine the characteristics associated with barriers to children's mental health services, focusing on the effect of children's psychosocial problems on parents. Method Data come from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated the index child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to children's mental health services. Results More than 35% of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7%, 23.3%, and 25.9%, respectively). Although parenting difficulties were associated with all barriers (structural: OR=10.63, 95% CI: 2.37, 47.64; mental health: OR=8.31, 95% CI: 1.99, 34.79; services: OR=5.22, 95% CI: 1.56, 17.51), additional responsibilities related to attendance at meetings was associated only with structural barriers (OR = 5.49, 95% CI: 1.22, 24.59). Conclusions Researchers and policymakers interested in increasing children's access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services, in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their child's psychosocial problems.

Antenatal Anxiety Predicts Child Behavioral/Emotional Problems Independently of Postnatal Depression

Abstract: Objective To examine the hypothesis that the effects of postnatal depression on children's behavioral/emotional problems are explained by antenatal maternal mood. Method The current study investigated this hypothesis in the Avon Longitudinal Study of Parents and Children, a prospective, community-based study that has followed a cohort of women since pregnancy (n = 7,144) who delivered their baby between April 1, 1991, and December 31, 1992. Self-report measures of maternal anxiety and depression were assessed at repeated intervals in pregnancy and the postnatal period. Children's behavioral/emotional problems were assessed by parent report at age 4 years. Results After controlling for smoking, alcohol use, birth weight for gestational age, maternal age, child sex, and socioeconomic status, postnatal depression at 8 weeks (OR = 2.27 [1.55-3.31]) and 8 months (OR = 1.68 [1.12-2.54]) was associated with children's behavioral/emotional problems. Subsequent analyses that included antenatal maternal mood indicated that antenatal anxiety in late pregnancy and not antenatal depression was also independently associated with behavioral/emotional problems at age 4 (OR = 1.72 [1.14-2.59]); 8 week postnatal depression remained a significant predictor after antenatal maternal mood was statistically controlled for (OR = 1.56 [1.04-2.32]). Conclusions Antenatal anxiety and postnatal depression represent separate risks for behavioral/emotional problems in children and act in an additive manner.

Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial.

Abstract: Background: This report presents results from the acute treatment phase of a clinical trial designed to confirm efficacy of a fixed dose of 20 mg of fluoxetine in children and adolescents with major depressive disorder (MDD). Method: After a 3-week screening period, 122 children and 97 adolescents with MDD ( DSM-IV ) were randomly assigned to placebo or fluoxetine. After a 1-week placebo lead-in, fluoxetine-treated patients received fluoxetine 10 mg/day for 1 week, then fluoxetine 20 mg/day for 8 weeks. Results: Fluoxetine was associated with greater mean improvement in Children's Depression Rating Scale-Revised (CDRS-R) score than placebo after 1 week ( p p p = .093). Significantly more fluoxetine-than placebo-treated patients completed acute treatment ( p = .001). There were no significant differences between treatment groups in discontinuations due to adverse events ( p = .408). Conclusions: Fluoxetine 20 mg daily appears to be well tolerated and effective for acute treatment of MDD in child and adolescent outpatients. Fluoxetine is the only antidepressant that has demonstrated efficacy in two placebo-controlled, randomized clinical trials of pediatric depression.

Maturation of Brain Function Associated With Response Inhibition

Abstract: Objective: To investigate the developmental trajectory of response inhibition and, more specifically, whether there is a dissociation of function in the prefrontal cortex over the course of development of executive function and associated response inhibition abilities. Method: Nineteen typically developing subjects, ranging in age from 8 to 20, performed a Go/NoGo task while behavioral and functional magnetic resonance imaging (fMRI) data were collected. Results: All subjects performed the task with few errors of omission and commission. No relationship between accuracy and age emerged, but the ability to inhibit responses more quickly significantly improved with age. Analyses of fMRI data revealed a positive correlation between activation and age in the left inferior frontal gyrus/insula/orbitofrontal gyrus, and a negative correlation between activation and age in the left middle/superior frontal gyri. Conclusions: These data provide the first evidence of dissociable processes occurring in the prefrontal cortex during development of executive functions associated with response inhibition: (1) Younger subjects activate more extensively than older subjects in discrete regions of the prefrontal cortex, presumably due to increased demands and inefficient recruitment of brain regions subserving executive functions including working memory. (2) Older subjects show increasingly focal activation in specific regions thought to play a more critical role in response inhibition.

Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems

Abstract: Objective: The objective of the study was to examine specificity, order of appearance, and developmental changes in the relationships between sleep problems and behavioral problems in children. Method: Four hundred ninety children were selected from a large-scale longitudinal study of children growing up in adoptive and nonadoptive (biological) families in Colorado. Parental ratings of children’s sleep and behavioral problems on the Child Behavior Checklist were obtained from ages 4 to 15 years. Results: Sleep problems decreased from age 4 years to mid-adolescence, but there was modest stability of individual differences across this age range (r = 0.29). Regression analyses indicated that sleep problems at age 4 predicted behavioral/emotional problems in mid-adolescence after accounting for child sex, adoptive status, and stability of behavioral/ emotional problems. Finally, the correlation between sleep problems and depression/anxiety increased significantly during this age period from r = 0.39 at age 4 years to r = 0.52 at mid-adolescence. Conclusions: Early sleep problems may forecast behavioral/emotional problems, and there may be important developmental change in the overlap between sleep problems and behavioral/emotional problems.

Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health.

Abstract: Objective To describe the range of depressive symptoms reported by adolescents in a nationally representative U.S. sample and to examine factors associated with persistent depressive symptoms. Method Secondary analysis was done on National Longitudinal Study of Adolescent Health (AddHealth) data from 13,568 adolescents who completed the initial survey in 1995 and follow-up 1 year later. Main outcomes of Center for Epidemiologic Studies-Depression Scale (CES-D) scores were analyzed by χ 2 comparisons and sample-weighted logistic regression. Results Over 9% of adolescents reported moderate/severe depressive symptoms at baseline (CES-D ≥ 24). Females, older adolescents, and ethnic minority youths were more likely to report depressive symptoms at baseline. Only 3% of adolescents with low initial CES-D scores (CES-D Conclusions Depressive symptoms are common in adolescents and have a course that is difficult to predict. Most adolescents with minimal symptoms of depression maintain their status and appear to be at low risk for depression; however, adolescents with moderate/severe depressive symptoms warrant long-term follow-up and reevaluation.

Neuropsychological executive functions and DSM-IV ADHD subtypes.

Abstract: Objective To evaluate and compare a focused set of component neuropsychological executive functions in the DSM-IV attention-deficit/hyperactivity disorder combined (ADHD-C) and inattentive (ADHD-I) subtypes. Method The Stop task, Tower of London, Stroop task, Trailmaking Test, and output speed measures were completed by 105 boys and girls aged 7–12 classified as either DSM-IV ADHD-C ( n = 46), ADHD-I ( n = 18), or community control ( n = 41). Results Both subtypes had deficits on output speed. A group × gender interaction was observed on the Stop task: boys with ADHD-C were impaired versus boys with ADHD-I, whereas girls in the two subtypes did not differ. The ADHD-C type had a deficit in planning. Neither ADHD group had a deficit in interference control per se, although they were slower than controls on the Stroop tasks. Conclusions ADHD-I shares neuropsychological deficits with ADHD-C in the domain of output speed; on most domains the subtypes did not differ. Neuropsychological distinctions between these ADHD subtypes may be few, depending on which domain of executive functioning is assessed, and these distinctions differ by gender. In the case of boys, the two subtypes may be distinguished by the specificity of motor inhibition deficits to ADHD-C.

Emergence of Gender Differences in Depression During Adolescence: National Panel Results From Three Countries

Abstract: Objective: Although the gender gap in depression among adults is well established, the age at which this phenomenon appears during adolescence is less clear. To address this, the authors present a cross-national examination of the emergence of the gender gap in depression during adolescence using national longitudinal panel data from Canada, Great Britain, and the United States. Method: The two-wave, 1994-1996 Canadian National Population Health Survey uses a diagnostic measure across a 24-month interval, providing 12-month prevalence rates of major depressive disorder. The British Youth Panel measures depressive symptomatology across five annual waves beginning in 1995. The two-wave, 1995-1996 National Longitudinal Study of Adolescent Health uses a measure of depressive symptomatology across a 12-month interval. Results: Females have significantly higher rates of depression for each sample overall. When samples are decomposed by age, the gender gap in depression consistently emerges by age 14 across all three national samples, irrespective of the measure used or whether categorical cutoffs or untransformed scale scores are used to assess depressive symptomatology. Conclusions: There is a consistent pattern in the onset of the gender gap in depression at age 14 across all three countries and measures. This consistency provides important etiologic clues concerning underlying causes of depression and identifies at what age diagnosis, treatment, and intervention strategies should be directed.

Case-Control Study of Attention-Deficit Hyperactivity Disorder and Maternal Smoking, Alcohol Use, and Drug Use During Pregnancy

Abstract: Objective To address the putative association between attention-deficit hyperactivity disorder (ADHD) and prenatal exposure to maternal cigarette smoking, drugs of abuse, and alcohol attending to potential confounding by familial ADHD, maternal depression, conduct disorder, and indicators of social adversity in the environment. Method A retrospective, hospital-based, case-control study was conducted with 280 ADHD cases and 242 non-ADHD controls of both genders. The case and control children and their relatives were systematically assessed with structured diagnostic interviews. Logistic regression analysis was used to determine the adjusted effect of prenatal exposure to substance use and ADHD. Results ADHD cases were 2.1 times (95% confidence interval=1.1–4.1; p = .02) more likely to have been exposed to cigarettes and 2.5 times (95% confidence interval=1.1–5.5; p = .03) more likely to have been exposed to alcohol in utero than were the non-ADHD control subjects. Adjustment by familial psychopathology, Rutter's indicators of social adversity, and comorbid conduct disorder did not account for the effect of prenatal exposure to alcohol or the products of cigarettes. Conclusions ADHD may be an additional deleterious outcome associated with prenatal exposure to alcohol independently of the association between prenatal exposure to nicotine and smoke products and other familial risk factors for the disorder.

National Trends in the Use of Psychotropic Medications by Children

Abstract: Objectives Little information exists on national trends in the use of psychotropic medication by children and adolescents. The objective of this report is to compare patterns and predictors of psychotropic medication use by children and adolescents in the United States in 1987 and 1996. Method An analysis of medication use data is presented from two nationally representative surveys of the general population focusing on children 18 years of age and younger who used one or more prescribed psychotropic medication during the survey years. Rates of stimulant, antidepressant, and other psychotropic medication use are reported. Results The overall annual rate of psychotropic medication use by children increased from 1.4 per 100 persons in 1987 to 3.9 in 1996 ( p Conclusion Between 1987 and 1996, there was a marked expansion in use of psychotropic medications by children, especially stimulants and antidepressants.

Psychological measures of prenatal stress as predictors of infant temperament.

Abstract: Objective: To examine, in a prospective study, whether maternal stress during pregnancy is related to infant temperament. Method: Self-report data on various aspects of prenatal stress were collected from nulliparous women in early pregnancy. Infant temperament was measured at 3 and 8 months by direct observation and by parent report. Results: Complete data were available for 170 term-born infants. Pregnancy-specific anxiety explained 3.3% of the variance of attention regulation at 3 months. Perceived stress and pregnancy anxiety taken together explained 5% of the variance of attention regulation at 8 months. Perceived stress accounted for 8.2% of the variance of difficult behavior of the 3-month-old infant. All results were adjusted for covariates. Conclusions: Increased maternal prenatal stress seems to be associated with temperamental variation of young infants and may be a risk factor for psychopathology later in life.

A Double-Blind, Randomized, Placebo-Controlled Study of Quetiapine as Adjunctive Treatment for Adolescent Mania

Abstract: Objective: This randomized, double-blind, placebo-controlled study examined the efficacy and tolerability of quetiapine in combination with divalproex (DVP) for acute mania in adolescents with bipolar disorder. It was hypothesized that DVP in combination with quetiapine would be more effective than DVP alone for treating mania associated with adolescent bipolar disorder. Furthermore, it was hypothesized that quetiapine would be well tolerated. Method: Thirty manic or mixed bipolar I adolescents (12–18 years) received an initial DVP dose of 20 mg/kg and were randomly assigned to 6 weeks of combination therapy with quetiapine, which was titrated to 450 mg/day ( n = 15) or placebo ( n = 15). Primary efficacy measures were change from baseline to endpoint in Young Mania Rating Scale (YMRS) score and YMRS response rate. Safety and tolerability were assessed weekly. Results: The DVP + quetiapine group demonstrated a statistically significantly greater reduction in YMRS scores from baseline to endpoint than the DVP + placebo group ( F 1,27 = 5.04, p = .03). Moreover, YMRS response rate was significantly greater in the DVP + quetiapine group than in the DVP + placebo group (87% versus 53%; Fisher exact test, p = .05). No significant group differences from baseline to endpoint in safety measures were noted. Sedation, rated as mild or moderate, was significantly more common in the DVP + quetiapine group than in the DVP + placebo group. Conclusions: The findings of this study indicate that quetiapine in combination with DVP is more effective for the treatment of adolescent bipolar mania than DVP alone. In addition, the results suggest that quetiapine is well tolerated when used in combination with DVP for the treatment of mania.

The Pediatric Anxiety Rating Scale (PARS): Development and Psychometric Properties

Abstract: OBJECTIVE To describe the development and psychometric properties of the Pediatric Anxiety Rating Scale (PARS), a clinician-rated instrument for assessing the severity of anxiety symptoms associated with common DSM-IV anxiety disorders (social phobia, separation anxiety disorder, and generalized anxiety disorder) in children. METHOD As part of a multisite study of the efficacy of fluvoxamine, 128 children (aged 6-17) and their parents were interviewed weekly with the PARS. Data from multiple raters on a subsample of children (using live and videotaped interviews) were used to evaluate interrater reliability. Internal consistency, test-retest reliability, and validity (convergent, divergent) also were evaluated. RESULTS The PARS showed high interrater reliability, adequate test-retest reliability, and fair internal consistency. Convergent and divergent validity were satisfactory. PARS scores were sensitive to treatment and paralleled change in other measures of anxiety symptoms and global improvement. CONCLUSIONS The PARS is a useful clinician-rated instrument for assessing pediatric anxiety symptoms, severity, and impairment, particularly in treatment studies. Further study of the psychometric properties is warranted.

Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents.

Abstract: Objective: The incidence of self-injurious behavior (SIB) in adolescent psychiatric inpatients has been reported to be as high as 61%, yet few data exist on the characteristics and functional role of SIB in this population. Because of the repetitive nature of SIB and its potential to increase in severity, features of SIB and its specific reinforcing effects were examined. Method: Participants were 42 self-injuring adolescents admitted to a hospital over a 4 month period. Data sources consisted of self-report questionnaires and medical chart review. Results: Mean age was 15.7 ± 1.5 years. Reported urges to self-injure were almost daily in 78.6% of the adolescents ( n = 33), with acts occurring more than once a week in 83.3% ( n = 35). The two primary reasons endorsed for engaging in self-injury were "to cope with feelings of depression" (83.3%, n = 35) and "to release unbearable tension" (73.8%, n = 31). Of the sample, 97.6% ( n = 41) endorsed three or more addictive symptoms. Conclusions: SIB in hospitalized adolescents serves primarily to regulate dysphoric affect and displays many addictive features. Those with clinically elevated levels of internalized anger appear at risk for more addictive features of this behavior.

Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders.

Abstract: Objective Although several treatments for adolescent substance abuse have been identified as promising by reviewers and federal agencies, treatment effects extending beyond 12 months have not been demonstrated in randomized clinical trials. The primary purpose of this report was to examine the 4-year outcomes of an evidence-based treatment of substance-abusing juvenile offenders. Method Eighty of 118 substance-abusing juvenile offenders participated in a follow-up 4 years after taking part in a randomized clinical trial comparing multisystemic therapy (MST) with usual community services. A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of the participating young adults. Results Analyses demonstrated significant long-term treatment effects for aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes. Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of marijuana abstinence for MST participants (55% versus 28% of young adults). Long-term treatment effects were not observed for psychiatric symptoms. Conclusions Findings provide some support for the long-term effectiveness of an evidenced-based family-oriented treatment of substance-abusing juvenile offenders. The clinical, research, and policy implications of these findings are noted.

Psychiatric Comorbidity and Functioning in Clinically Referred Preschool Children and School-Age Youths With ADHD

Abstract: Objective Although the literature documents that attention-deficit/hyperactivity disorder (ADHD) commonly onsets prior to age 6, little is known about the disorder in preschool children. We evaluated the clinical characteristics, psychiatric comorbidity, and functioning of preschool children and school-age youths with ADHD referred to a pediatric psychiatric clinic for evaluation. Method Structured psychiatric interviews assessing lifetime psychopathology by DSM-III-R criteria were completed with parents about their children. Family, social, and overall functioning were also assessed at intake. Results We identified 165 children with ADHD aged 4 to 6 years (preschool children) and 381 youths aged 7 to 9 years (school-age) with ADHD. Despite being younger, preschool children had similar rates of comorbid psychopathology compared with school-age youths with ADHD. There was an earlier onset of ADHD and co-occurring psychopathology in the preschool children compared to school-age youths. Both preschool children and school-age youths had substantial impairment in school, social, and overall functioning. Conclusions The results of this study suggest that despite being significantly younger, clinically referred preschool children with ADHD are reminiscent of school-age youths with ADHD in the quality of ADHD, high rates of comorbid psychopathology, and impaired functioning. Follow-up of these clinically referred preschool children with ADHD to evaluate the stability of their diagnoses, treatment response, and their long-term outcome are necessary.

Child and Adolescent Problems Predict DSM-IV Disorders in Adulthood: A 14-Year Follow-up of a Dutch Epidemiological Sample

Abstract: Objective Few studies exist that examine continuities between child and adult psychopathology in unselected samples. This study prospectively examined the adult outcomes of psychopathology in an epidemiological sample of children and adolescents across a 14-year period. Method In 1983, parent ratings of behavioral and emotional problems were obtained for 1,578 children and adolescents aged 4 through 16 years from the Dutch general population. At follow-up, 14 years later, subjects were reassessed with a standardized DSM-IV interview. Results High levels of childhood problems predicted an approximate 2-to 6-fold increased risk for adulthood DSM-IV diagnoses. The associations between specific childhood problems and adulthood diagnoses were complex. Social Problems in girls predicted later DSM-IV disorder. Rule-breaking behavior in boys predicted both mood disorders and disruptive disorders in adulthood. Conclusions High levels of childhood behavioral and emotional problems are related to DSM-IV diagnoses in adulthood. The strongest predictor of disorders in adulthood was childhood rule-breaking behavior. Attention Problems did not predict any of the DSM-IV categories when adjusted for the associations with other Child Behavior Checklist scales.

Sensation Seeking, Puberty, and Nicotine, Alcohol, and Marijuana Use in Adolescence

Abstract: Objective: To examine the relationship among nicotine, alcohol, and marijuana use; level of sensation seeking (SS); and pubertal development. Method: Subjects were early and middle adolescent males and females recruited from a psychiatric clinic ( n = 77) and two general pediatric clinics ( n = 131). SS was measured by using the Sensation Seeking Scale for Children. Pubertal development was measured with a modified Pubertal Development Scale that was completed by the adolescent and his/her parent about the adolescent. Adolescent self-reports of nicotine, alcohol, and marijuana use were also obtained using questionnaires. Results: SS was higher in males and females who reported nicotine and alcohol use and in males who reported marijuana use. SS was positively associated with pubertal development in males and females, even when controlling for age. Furthermore, SS mediated the relationship of pubertal development and drug use in males and females. Conclusions: The observation that SS mediates the relationship between pubertal development and drug use in males and females may contribute to understanding changes in drug use that are seen during adolescence. In addition, SS is associated with drug use and is easily measured in a variety of clinical settings.

Attachment Disturbances in Young Children. I: The Continuum of Caretaking Casualty

Abstract: Objective: To determine whether signs of disordered attachment were greater in young children being reared in more socially depriving caregiving environments. Method: Three groups of children were studied by means of structured interviews with caregivers that were administered over several months in Bucharest, Romania, in 1999: (1) 32 toddlers living in a typical unit (standard care) in a large institution in Bucharest; (2) 29 toddlers living in the same institution on a “pilot unit” designed to reduce the number of adults caring for each child; and (3) 33 toddlers living at home who had never been institutionalized. The presence of attachment disorders and other behavioral problems was assessed by caregiver/ parent report. Results: Children on the typical unit (standard care) had significantly more signs of disordered attachment than children in the other two groups. Both the emotionally withdrawn and the indiscriminately social pattern of attachment disorder were apparent in these children, but cluster analysis suggested that mixed patterns are more typical. Conclusions: The continuum of caretaking casualty is reflected by increasing signs of disordered attachment in toddlers living in more socially depriving environments. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(8):972‐982. Key Words: reactive attachment disorder, inhibited attachment disorder, children in institutions, deprivation, neglect.

Ten-year review of rating scales. II: Scales for internalizing disorders.

Abstract: Objective This article, the second in the Journal' s series of 10-year updates on rating scales, summarizes scales assessing internalizing disorders. Method The authors sampled articles on mood and anxiety disorders over the past 25 years, selected scales with multiple citations over many years, and reviewed their properties. Those with adequate psychometric properties, plus continued wide literature citations or a current special niche, are presented here. Results Rating scales for depression were developed and/or examined in the 1980s. Despite generally strong properties, they lack clear construct validity. Most have parent-report forms that broaden their suitability with youths. Anxiety scales were developed bimodally. Those developed in the 1960s to 1970s were downward modifications of adult scales. They have been criticized for unclear constructs and unsuitability for youths. Newer scales developed in the 1990s have addressed these problems and have parent-report forms. However, their utility is still being determined. Conclusions Rating scales can reliably, validly, and efficiently measure youths' internalizing psychopathology. They have great utility in research, treatment planning, and accountability in practice. However, the user must define the goals of measurement, consider the construct the scale measures, and use the scale within its defined capabilities. The use of more than one scale for a task is recommended.

Attachment-based family therapy for depressed adolescents: a treatment development study.

Abstract: Objective: To design a treatment manual and adherence measure for attachment-based family therapy (ABFT) for adolescent depression and to collect pilot data on the treatment's efficacy. Method: Over a period of 2 years, 32 adolescents meeting DSM-III-R criteria for major depressive disorder (MDD) were randomly assigned to 12 weeks of ABFT or a 6-week, minimal-contact, waitlist control group. The sample was 78% female and 69% African American; 69% were from low-income, inner-city communities. Results: At post-treatment, 81% of the patients treated with ABFT no longer met criteria for MDD, in contrast with 47% of patients in the waitlist group. Mixed factorial analyses of variance revealed that, compared with the waitlist group, patients treated with ABFT showed a significantly greater reduction in both depressive and anxiety symptoms and family conflict. Of the 15 treated cases assessed at the follow-up, 13 patients (87%) continued to not meet criteria for MDD 6 months after treatment ended. Conclusions: ABFT appears to be a promising treatment and worthy of further development.

The Voice DISC-IV With Incarcerated Male Youths: Prevalence of Disorder

Abstract: Objective (1) To accurately assess rate of psychiatric disorder in incarcerated juveniles, and (2) to examine the feasibility of using a self-administered, comprehensive structured psychiatric assessment with those youths. Method In 1999–2000, 292 recently admitted males in secure placement with New Jersey and Illinois juvenile justice authorities provided self-assessments by means of the Voice Diagnostic Interview Schedule for Children-IV, a comprehensive, computerized diagnostic instrument that presents questions via headphones. Results Assessments were well tolerated by youths, staff, and parents; 92% of approached youths agreed. Rates of disorder were comparable to prior diagnostic assessment studies with interviewers. Beyond expectable high rates of disruptive and substance use disorders, youths reported high levels of anxiety and mood disorders, with over 3% reporting a past-month suicide attempt. Youths with substance use disorder were significantly more likely to be incarcerated for substance offenses than were youths with no disorder or those with other, non–substance use disorders. Conclusions Although the study identified rates of disorder generally comparable to those of prior investigations, some differences, understandable in the context of measurement variations, are apparent. Those variations offer recommendations for mental health assessment practices for youths in the justice system that would include using a comprehensive self-report instrument, pooling across parent and youth informants for certain disorders, focusing on current disorder, and flexibility regarding consideration of impairment.

Family discord, parental depression, and psychopathology in offspring: ten-year follow-up.

Abstract: Objective To determine the independent effects of parental depression and family discord on offspring psychopathology among children at high and low risk of depression. Method Family discord factors were assessed when subjects were approximately 17 years old, and offspring diagnoses were assessed about 20 years later. Parental and offspring psychopathology was assessed by interviewers blind to parents' clinical status. The following dimensions of family discord were assessed: poor marital adjustment, parent child discord, low family cohesion, affectionless control, and parental divorce. Results Most family discord factors were associated with parental depression. Among children of depressed parents, none of the measures of family discord had a statistically significant association with offspring major depressive disorder or anxiety disorders. Among children of nondepressed parents, parental affectionless control was associated with an almost fivefold increased risk of major depressive disorder (odds ratio [OR] = 4.8; p ≤ .05) and with more than a 14-fold increased risk of substance use disorders (OR = 14.3; p ≤ .01). Conclusions Parental depression is associated with family discord and is a consistent risk factor for offspring major depressive disorder and anxiety disorders, as shown over a 20-year follow-up of offspring of depressed and nondepressed parents. Family discord factors may be a risk factor for major depressive disorder and substance use disorders in offspring of nondepressed parents.

Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs.

Abstract: Objective To determine whether risperidone is effective in reducing symptoms of disruptive behaviors (such as aggression, impulsivity, defiance of authority figures, and property destruction) associated with conduct disorder, oppositional defiant disorder, and disruptive behavior disorder-not otherwise specified in children with subaverage IQs. Method The trial consisted of a 1-week, single-blind, placebo run-in period and was followed by a 6-week, double-blind, placebo-controlled period. One hundred ten children (aged 5-12 years inclusive) with an IQ of 36-84 with a disruptive behavior disorder and a score of at least 24 on the Conduct Problem subscale of the Nisonger Child Behavior Rating Form (NCBRF) were enrolled. Eighty percent of subjects had comorbid attention-deficit/hyperactivity disorder (ADHD). Risperidone doses ranged from 0.02 to 0.06 mg/kg per day. Subjects were rated on the NCBRF, Aberrant Behavior Checklist, Behavior Problems Inventory, Clinical Global Impressions (CGI), modified California Verbal Learning Test (CVLT), and a continuous performance task (CPT). Results The intention-to-treat analysis of risperidone-treated subjects showed a significant (p Conclusions Risperidone appears to be an adequately tolerated and effective treatment in children with subaverage IQs and severe disruptive behaviors such as aggression and destructive behavior.

Toward an empirical definition of pediatric PTSD: The phenomenology of PTSD symptoms in youth

Abstract: Objective To examine the frequency and intensity of posttraumatic stress disorder (PTSD) symptoms and their relation to clinical impairment, to examine the requirement of meeting all DSM-IV symptom cluster criteria (i.e., criteria B, C, D), and to examine the aggregation of PTSD symptom clusters across developmental stages. Method Fifty-nine children between the ages of 7 and 14 years with a history of trauma and PTSD symptoms were assessed with the Clinician-Administered PTSD Scale for Children and Adolescents. Results Data support the utility of distinguishing between the frequency and the intensity of symptoms in the investigation of the phenomenology of pediatric PTSD. Children fulfilling requirements for two symptom clusters did not differ significantly from children meeting all three cluster criteria with regard to impairment and distress. Reexperience (cluster B) showed increased aggregation with avoidance and numbing (cluster C) and hyperarousal (cluster D) in the later stages of puberty. Conclusions Frequency and intensity of symptoms may both contribute to the phenomenology of pediatric PTSD. Children with subthreshold criteria for PTSD demonstrate substantial functional impairment and distress.

Group and individual cognitive-behavioral therapy for childhood anxiety disorders: a randomized trial.

Abstract: Objective: To compare the efficacy of group and individual cognitive-behavioral therapy (CBT) in children with Axis I anxiety disorders. It was hypothesized that certain subgroups would respond preferentially to one modality. Method: Seventy-eight children aged 8–12 years with diagnosed anxiety disorders were randomly assigned to a 12-week, manual-based program of group or individual CBT, both with parental involvement. Outcomes included child anxiety (child and parent report) and global functioning as estimated by clinicians. Repeated-measures analyses of variance (ANOVAs) were done. The sample was then dichotomized by self-reported social anxiety (high/low) and parent-reported hyperactivity (high/low) using median splits, and diagnostically by generalized anxiety disorder versus phobic disorders. ANOVAs were repeated. Results: Children and parents reported significantly decreased anxiety and clinicians reported significantly improved global functioning regardless of treatment modality. Children reporting high social anxiety reported greater gains in individual treatment than in group treatment ( p Conclusions: Children with anxiety disorders appear to improve with CBT, whether administered in a group or individual format. A subgroup of children reporting high social anxiety may respond preferentially to individual treatment. Replication of these findings is indicated.