Showing papers in "Journal of the American Academy of Child and Adolescent Psychiatry in 2009"
TL;DR: Type or intensity of 14 months of treatment for ADHD in childhood does not predict functioning 6 to 8 years later, and early ADHD symptom trajectory regardless of treatment type is prognostic, implying that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis.
Abstract: Objectives To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). Method Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. Results In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. Conclusions Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0–9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.
1,070 citations
TL;DR: These findings support the use of the SDQ as a genuinely dimensional measure of child mental health and provide the first explicit evaluation of the dimensionality of the total difficulties score of the Strengths and Difficulties Questionnaire.
Abstract: Objective To provide the first explicit evaluation of the dimensionality of the total difficulties score of the Strengths and Difficulties Questionnaire (SDQ), a widely used measure of child mental health. We do so by validating the SDQ across its full range against the prevalence of clinical disorder. Method We use two large ( n = 18,415) nationally-representative surveys of children and adolescents aged 5 to 16 years in the general British population. Strengths and Difficulties Questionnaires were completed separately by parents, teachers, and children aged 11 to 16 years, and children also received a multi-informant clinician-rated clinical diagnosis. Approximately 7,912 children from the baseline survey were also reassessed for clinical diagnosis at 3-year follow-up. Results Across the full range of the parent, teacher, and youth SDQ, children with higher total difficulty scores have greater psychopathology as judged by the prevalence of clinical disorder. This was true cross-sectionally and also in predicting to disorder status 3 years later. There was no evidence of threshold effects for the SDQ at either high or low scores, but rather the odds of disorder increased at a constant rate across the range (odds ratios between 1.14 and 1.28 per 1-point increase in SDQ score). Conclusions Our findings support the use of the SDQ as a genuinely dimensional measure of child mental health.
719 citations
TL;DR: The infants of depressed mothers scored the poorest on all three outcomes at 9 months-lowest social engagement, less mature regulatory behaviors and more negative emotionality, and highest cortisol reactivity-with anxious dyads scoring less optimally than the controls on maternal sensitivity and infant social engagement.
Abstract: Objective To examine the effects of maternal depression on infant social engagement, fear regulation, and cortisol reactivity as compared with maternal anxiety disorders and controls and to assess the role of maternal sensitivity in moderating the relations between maternal depression and infant outcome. Methods Using an extreme-case design, 971 women reported symptoms of anxiety and depression after childbirth and 215 of those at the high and low ends were reevaluated at 6 months. At 9 months, mothers diagnosed with a major depressive disorder ( n = 22) and anxiety disorders ( n = 19) and matched controls reporting no symptoms across the postpartum year ( n = 59) were visited at home. Infant social engagement was observed during mother–infant interaction, emotion regulation was microcoded from a fear paradigm, and mother's and infant's cortisol were sampled at baseline, reactivity, and recovery. Results The infants of depressed mothers scored the poorest on all three outcomes at 9 months—lowest social engagement, less mature regulatory behaviors and more negative emotionality, and highest cortisol reactivity—with anxious dyads scoring less optimally than the controls on maternal sensitivity and infant social engagement. Fear regulation among the children of anxious mothers was similar to that of the controls and their stress reactivity to infants of depressed mothers. Effect of major depressive disorder on social engagement was moderated by maternal sensitivity, whereas two separate effects of maternal disorder and mother sensitivity emerged for stress reactivity. Conclusions Pathways leading from maternal depression to infant outcome are specific to developmental achievement. Better understanding of such task-specific mechanisms may help devise more specifically targeted interventions.
619 citations
TL;DR: The large gap between the age at which children can be identified and when they actually are identified suggests a critical need for further research, innovation, and improvement in this area of clinical practice.
Abstract: Objective: At what age are children with an autism spectrum disorder (ASD) identified by community providers? What factors influence the timing of when children are identified with ASDs? This study examined the timing of when children with ASDs are identified. Method: Data came from 13 sites participating in the Centers for Disease Control and Prevention’s 2002 multisite ongoing autism surveillance program, the Autism and Developmental Disabilities Monitoring Network. Survival analysis was used to examine factors that influence the timing of community-based identification and diagnosis. Result: Data from health and education records reveal that the median age of identification was 5.7 years (SE 0.08 years). Parametric survival models revealed that several factors were associated with a younger age of identification: being male, having an IQ of 70 or lower, and having experienced developmental regression. Significant differences in the age of identification among the 13 sites were also discovered. Conclusions: The large gap between the age at which children can be identified and when they actually are identified suggests a critical need for further research, innovation, and improvement in this area of clinical practice. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):474Y483. Key Words: pervasive child development disorders, autism, diagnosis, epidemiology, survival analysis. Timely community-based identification of children with an autism spectrum disorder (ASD) has important implications for individual development, clinical practice, and policy decisions. Identification is a broad construct that includes both clinical diagnoses of ASD and eligibility-related designations of ASD for public services, including early intervention and special education. The American Academy of Pediatrics recently emphasized the importance of early identification of ASDs and recommended close developmental observation at
546 citations
TL;DR: In this paper, a meta-analysis of subjective and objective sleep studies in children with Attention Deficit/Hyperactivity disorder (ADHD) versus controls was performed, which indicated that children with ADHD had significantly higher bedtime resistance (Z = 6.94, p z = 9.15, p =.031), difficulties with early morning awakenings, and daytime sleepiness compared with the controls.
Abstract: Objective To perform a meta-analysis of subjective (i.e., based on questionnaires) and objective (i.e., using poly-somnography or actigraphy) studies comparing sleep in children with attention-deficit/hyperactivity disorder (ADHD) versus controls. Method We searched for subjective and objective sleep studies (1987–2008) in children with ADHD (diagnosed according to standardized criteria). Studies including subjects pharmacologically treated or with comorbid anxiety/depressive disorders were excluded. Results Sixteen studies, providing 9 subjective and 15 objective parameters and including a total pooled sample of 722 children with ADHD versus 638 controls, were retained. With regard to subjective items, the meta-analysis indicated that children with ADHD had significantly higher bedtime resistance ( z = 6.94, p z = 9.38, p z = 2.15, p = .031), difficulties with morning awakenings ( z = 5.19, p z = 2.05, p = .040), and daytime sleepiness ( z = 1.96, p = .050) compared with the controls. As for objective parameters, sleep onset latency (on actigraphy), the number of stage shifts/hour sleep, and the apnea-hypopnea index were significantly higher in the children with ADHD compared with the controls ( z = 3.44, p = .001; z = 2.43, p = .015; z = 3.47, p = .001, respectively). The children with ADHD also had significantly lower sleep efficiency on polysomnography ( z = 2.26, p = .024), true sleep time on actigraphy ( z = 2.85, p = .004), and average times to fall asleep for the Multiple Sleep Latency Test ( z = 6.37, p Conclusions The children with ADHD are significantly more impaired than the controls in most of the subjective and some of the objective sleep measures. These results lay the groundwork for future evidence-based guidelines on the management of sleep disturbances in children with ADHD.
515 citations
TL;DR: Aripiprazole was efficacious and generally safe and well tolerated in the treatment of children and adolescents with irritability associated with autistic disorder.
Abstract: Objective To evaluate the short-term efficacy and safety of aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Method Two hundred eighteen children and adolescents (aged 6–17 years) with a diagnosis of autistic disorder, and with behaviors such as tantrums, aggression, self-injurious behavior, or a combination of these symptoms, were randomized 1:1:1:1 to aripiprazole (5, 10, or 15 mg/day) or placebo in this 8-week double-blind, randomized, placebo-controlled, parallel-group study. Efficacy was evaluated using the caregiver-rated Aberrant Behavior Checklist Irritability subscale (primary efficacy measure) and the clinician-rated Clinical Global Impressions–Improvement score. Safety and tolerability were also assessed. Results At week 8, all aripiprazole doses produced significantly greater improvement than placebo in mean Aberrant Behavior Checklist Irritability subscale scores (5 mg/day, −12.4; 10 mg/day, −13.2; 15 mg/day, −14.4; versus placebo, −8.4; all p p Conclusions Aripiprazole was efficacious and generally safe and well tolerated in the treatment of children and adol escents with irritability associated with autistic disorder. J. Am. Acad. Child Adolesc. Psychiatry , 2009;48(11):1110–1119.
477 citations
TL;DR: Findings suggesting that stable maternal-reported early BI predicts lifetime SAD have important implications for the early identification and prevention of SAD.
Abstract: Objective: Behavioral inhibition (BI), a temperamental style identifiable in early childhood, is considered a risk factor for the development of anxiety disorders, particularly social anxiety disorder (SAD). However, few studies examining this question have evaluated the stability of BI across multiple developmental time points and followed participants into adolescenceVthe developmental period during which risk for SAD onset is at its peak. The current study used a prospective longitudinal design to determine whether stable early BI predicted the presence of psychiatric disorders and continuous levels of social anxiety in adolescents. It was hypothesized that stable BI would predict the presence of adolescent psychiatric diagnoses, specifically SAD. Method: Participants included 126 adolescents aged 14 to 16 years who were first recruited at 4 months of age from hospital birth records. Temperament was measured at multiple time points between the ages of 14 months and 7 years. In adolescence, diagnostic interviews were conducted with parents and adolescents, and continuous measures of adolescent- and parent-reported social anxiety were collected. Results: Stable maternal-reported early BI was associated with 3.79 times increased odds of a lifetime SAD diagnosis, but not other diagnoses, during adolescence (95% confidence interval 1.18Y12.12). Stable maternal-reported early BI also predicted independent adolescent and parent ratings of ongoing social anxiety symptoms. Conclusions: Findings suggesting that stable maternal-reported early BI predicts lifetime SAD have important implications for the early identification and prevention of SAD. J. Am. Acad. Child Adolesc.
459 citations
TL;DR: When examining childhood bullying behavior as a risk factor for later suicide attempts and completed suicides, each sex has a different risk profile.
Abstract: Objective There are no previous studies about the association of childhood bullying behavior with later suicide attempts and completed suicides among both sexes. The aim was to study associations between childhood bullying behaviors at age 8 years and suicide attempts and completed suicides up to age 25 years in a large representative population-based birth cohort. Method The sample includes 5,302 Finnish children born in 1981. Information about bullying was gathered at age 8 years from self-report, as well as parent and teacher reports. Information about suicide attempts requiring hospital admission and completed suicides was gathered from three different Finnish registries until the study participants were 25 years old. Regression analyses were conducted to determine whether children who experience childhood bullying behaviors are at risk for later suicide attempts and completed suicides after controlling for baseline conduct and depression symptoms. Results The association between bullying behavior at age 8 years and later suicide attempts and completed suicides varies by sex. Among boys, frequent bullying and victimization are associated with later suicide attempts and completed suicides but not after controlling for conduct and depression symptoms; frequent victimization among girls is associated with later suicide attempts and completed suicides, even after controlling for conduct and depression symptoms. Conclusions When examining childhood bullying behavior as a risk factor for later suicide attempts and completed suicides, each sex has a different risk profile.
412 citations
TL;DR: Investigation of bullying in the Environmental Risk (E-Risk) Longitudinal Twin Study showed that socioenvironmental factors are associated with children's risk for becoming involved in bullying over and above their own behaviors.
Abstract: OBJECTIVE:: To test whether school, neighborhood, and family factors are independently associated with children's involvement in bullying, over and above their own behaviors that may increase their risk for becoming involved in bullying. METHOD:: We examined bullying in the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative 1994-1995 birth cohort of 2,232 children. We used mother and teacher reports to identify children who experienced bullying between the ages of 5 and 7 years either as victims, bullies, or bully-victims. We collected information about school characteristics from the Department for Children, Schools and Families. We collected reports from mothers about children's neighborhood and home environments and reports from mothers and teachers about children's internalizing and externalizing problems when they were 5 years old. RESULTS:: Multinomial logistic regressions showed that over and above other socioenvironmental factors and children's behavior problems, school size was associated with an increased risk for being a victim of bullying, problems with neighbors was associated with an increased risk for being a bully-victim, and family factors (e.g., child maltreatment, domestic violence) were associated with all groups of children involved in bullying. CONCLUSIONS:: Socioenvironmental factors are associated with children's risk for becoming involved in bullying over and above their own behaviors. Intervention programs aimed at reducing bullying should extend their focus beyond schools to include local communities and families. Language: en
355 citations
TL;DR: A developmental model of mental disorder whereby oppositionality is an interim shared manifestation of different dimensions of psychopathology with distinct outcomes is suggested.
Abstract: Objective: Oppositional behavior in youths is one of the strongest predictors of a wide range of psychiatric disorders. We test the hypothesis that oppositionality encompasses an Irritable, a Headstrong, and a Hurtful dimension, each with distinct predictions. Method: Longitudinal design combining data from two British national surveys and their respective 3-year follow-ups (N = 7,912). The Developmental and Well-Being Assessment was used to generate DSM-IV diagnoses. Results: The Irritable dimension was the sole predictor of emotional disorders at follow-up and was particularly associated with distress disorders (depression and anxiety) rather than fear disorders (phobias, separation anxiety, and panic disorder), both before and after adjustment for baseline psychopathology. The Headstrong dimension was the only predictor of attention-deficit/hyperactivity disorder at follow-up. Both Headstrong and Hurtful predicted conduct disorder, although only the Headstrong dimension did so after adjustment for baseline psychopathology. The Hurtful dimension was the strongest predictor of aggressive conduct disorder symptoms. Conclusions: Our data suggest a developmental model of mental disorder whereby oppositionality is an interim shared manifestation of different dimensions of psychopathology with distinct outcomes. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(4):404Y412. Key Words: oppositional defiant disorder, depression, comorbidity, emotional disorders, attention-deficit/hyperactivity disorder.
349 citations
TL;DR: Biological risk does not closely follow DSM phenotypes, and core neurobiological processes are likely common for subsets of these two heterogeneous clinical groups, with particular attention to childhood-onset schizophrenia.
Abstract: Objective To highlight emerging evidence for clinical and biological links between autism/pervasive developmental disorder (PDD) and schizophrenia, with particular attention to childhood-onset schizophrenia (COS). Method Clinical, demographic, and brain developmental data from the National Institute of Mental Health (and other) COS studies and selected family, imaging, and genetic data from studies of autism, PDD, and schizophrenia were reviewed. Results In the two large studies that have examined this systematically, COS is preceded by and comorbid with PDD in 30% to 50% of cases. Epidemiological and family studies find association between the disorders. Both disorders have evidence of accelerated trajectories of anatomic brain development at ages near disorder onset. A growing number of risk genes and/or rare small chromosomal variants (microdeletions or duplications) are shared by schizophrenia and autism. Conclusions Biological risk does not closely follow DSM phenotypes, and core neurobiological processes are likely common for subsets of these two heterogeneous clinical groups. Long-term prospective follow-up of autistic populations and greater diagnostic distinction between schizophrenia spectrum and autism spectrum disorders in adult relatives are needed.
TL;DR: The retrospective NCS-A data on the development of psychopathology can additionally complement data from longitudinal studies based on more geographically restricted samples and serve as a useful baseline for future prospective studies of the onset and progression of mental disorders in adulthood.
Abstract: Objective This article presents an overview of the background and measures used in the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Method The NCS-A is a national psychiatric epidemiological survey of adolescents aged 13 to 17 years. Results The NCS-A was designed to provide the first nationally representative estimates of the prevalence, correlates, and patterns of service use for DSM-IV mental disorders among U.S. adolescents and to lay the groundwork for follow-up studies of risk and protective factors, consequences, and early expressions of adult mental disorders. The core NCS-A diagnostic interview, the World Health Organization Composite International Diagnostic Interview, is a fully structured research diagnostic interview designed for use by trained lay interviewers. A multiconstruct, multimethod, and multi-informant battery was also included to assess risk and protective factors and barriers to service use. Design limitations due to the NCS-A evolving as a supplement to an ongoing survey of mental disorders of U.S. adults include restricted age range of youths, cross-sectional assessment, and lack of full parental/surrogate informant reports on youth mental disorders and correlates. Conclusions Despite these limitations, the NCS-A contains unparalleled information that can be used to generate national estimates of prevalence and correlates of adolescent mental disorders, risk and protective factors, patterns of service use, and barriers to receiving treatment for these disorders. The retrospective NCS-A data on the development of psychopathology can additionally complement data from longitudinal studies based on more geographically restricted samples and serve as a useful baseline for future prospective studies of the onset and progression of mental disorders in adulthood.
TL;DR: A specific intervention for adolescents at high risk for repeated suicide attempts has been developed and manual based, and further testing of its efficacy seems feasible.
Abstract: Objective To describe the elements of a manual-based cognitive-behavioral therapy for suicide prevention (CBT-SP) and to report its feasibility in preventing the recurrence of suicidal behavior in adolescents who have recently attempted suicide. Method The CBT-SP was developed using a risk reduction and relapse prevention approach and theoretically grounded in principles of cognitive-behavioral therapy, dialectical behavioral therapy, and targeted therapies for suicidal youths with depression. The CBT-SP consists of acute and continuation phases, each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan development, skill building, psychoeducation, family intervention, and relapse prevention. Results The CBT-SP was administered to 110 recent suicide attempters with depression aged 13 to 19 years (mean 15.8 years, SD 1.6) across five academic sites. Twelve or more sessions were completed by 72.4% of the sample. Conclusions A specific intervention for adolescents at high risk for repeated suicide attempts has been developed and manual based, and further testing of its efficacy seems feasible. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(10):1005–1013.
TL;DR: This overview will touch on methodological issues relevant to magnetic resonance imaging studies of brain anatomy, summarize MRI findings of neuroanatomic changes during childhood and adolescence, and discuss possible influences on brain development trajectories.
Abstract: Many psychiatric disorders, including some with adult onset such as schizophrenia, are increasingly being conceptualized as stemming from anomalies of neurodevelopment. To explore neurodevelopmental hypotheses of illness, it is useful to have well-characterized data regarding typical maturation to serve as a “yardstick” from which to assess possible deviations. Studies of typical development, and the influences on that development, may also unveil the timing and mechanisms of brain maturation guiding the way for novel interventions.
In this overview, we will touch on methodological issues relevant to magnetic resonance imaging (MRI) studies of brain anatomy, summarize MRI findings of neuroanatomic changes during childhood and adolescence, and discuss possible influences on brain development trajectories.
As indicated in the previous articles of this series, one of the first steps in measuring brain morphometric characteristics in a conventional anatomic MRI is to classify (or “segment”) individual voxels (the smallest elements of different MRI signals—usually approximately 1 mL) as corresponding to CSF, white matter (WM), or gray matter (GM). Once categorized by tissue type, various parcellations can be performed to derive volumes at the level of lobes (e.g., frontal, temporal, parietal, occipital); regions defined by gyral, sulcal, or GM, WM, and CSF boundaries (e.g., caudate nucleus); or individual voxels.
Segmentation and parcellation of MRIs was originally exclusively done by trained individuals outlining particular regions of interest (frequently abbreviated as ROIs) by hand. Although having a highly trained individual manually identify brain regions is considered the closest thing to a “gold standard” available, the time and anatomic expertise necessary for training raters and performing this type of analysis can be prohibitive. This has motivated many laboratories to develop computer algorithms capable of automatically classifying regions of MRI images as belonging to different tissue types and anatomic regions. The rapid progress in this area has made it feasible to perform the type of large scale studies necessary to capture many of the changes associated with typical and atypical brain development. Automated methods have also opened the door to innovative ways of looking at brain structure, such as analyzing the shape and thickness of the cortical sheet.
However, the fidelity of automated methods depends on the clarity of the borders between structures, which in turn is determined by a combination of the anatomy of a particular structure and the quality of the MRI image. For example, the amygdala and hippocampus are difficult for automated methods to separate properly because they represent adjacent GM structures. In cases such as these, hand measurements may still be the best approach, although even human raters may need considerable experience before they can consistently identify the borders of such structures on conventional MRI.
The data for this overview are largely derived from 387 typically developing subjects (829 scans) participating in an ongoing longitudinal study at the Child Psychiatry Branch of the National Institute of Mental Health. Begun in 1989 by Markus Kruesi, M.D., and Judith Rapoport, M.D., the study design is for participants aged 3 to 30 years to come to the National Institutes of Health at approximately 2-year intervals for brain imaging, psychological and behavioral assessment, and collection of DNA. The emphasis on this single source is not to devalue the many excellent contributions of other investigators but to provide an integrated account from the world’s largest collection of child and adolescent brain MRI scans with data acquired using uniform screening/assessment batteries, the same scanner, and the same methods of image analyses. We have supplemented with references to studies by other laboratories, although a complete review of the field is beyond the scope of this article.
TL;DR: Logistic regression analysis documented that consideration of CIDI symptom-level data significantly improved prediction of some K-SADS diagnoses, and generally good concordance was found with blinded clinical diagnoses.
Abstract: Objective To report results of the clinical reappraisal study of lifetime DSM-IV diagnoses based on the fully structured lay-administered World Health Organization Composite International Diagnostic Interview (CIDI) Version 3.0 in the U.S. National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Method Blinded clinical reappraisal interviews with a probability subsample of 347 NCS-A respondents were administered using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) as the gold standard. The DSM-IV /CIDI cases were oversampled, and the clinical reappraisal sample was weighted to adjust for this oversampling. Results Good aggregate consistency was found between CIDI and K-SADS prevalence estimates, although CIDI estimates were meaningfully higher than K-SADS estimates for specific phobia (51.2%) and oppositional defiant disorder (38.7%). Estimated prevalence of any disorder, in comparison, was only slightly higher in the CIDI than K-SADS (8.3%). Strong individual-level CIDI versus K-SADS concordance was found for most diagnoses. Area under the receiver operating characteristic curve, a measure of classification accuracy not influenced by prevalence, was 0.88 for any anxiety disorder, 0.89 for any mood disorder, 0.84 for any disruptive behavior disorder, 0.94 for any substance disorder, and 0.87 for any disorder. Although area under the receiver operating characteristic curve was unacceptably low for alcohol dependence and bipolar I and II disorders, these problems were resolved by aggregation with alcohol abuse and bipolar I disorder, respectively. Logistic regression analysis documented that consideration of CIDI symptom-level data significantly improved prediction of some K-SADS diagnoses. Conclusions These results document that the diagnoses made in the NCS-A based on the CIDI have generally good concordance with blinded clinical diagnoses.
TL;DR: Medication plus PT resulted in greater reduction of serious maladaptive behavior than MED in children with PDDs, with a lower risperidone dose.
Abstract: Objective Many children with pervasive developmental disorders (PDDs) have serious, functionally impairing behavioral problems. We tested whether combined treatment (COMB) with risperidone and parent training (PT) in behavior management is superior to medication alone (MED) in improving severe behavioral problems in children with PDDs. Method This 24-week, three-site, randomized, parallel-groups clinical trial enrolled 124 children, aged 4 through 13 years, with PDDs, accompanied by frequent tantrums, self-injury, and aggression. The children were randomized 3:2 to COMB ( n = 75) or MED ( n = 49). The participants received risperidone monotherapy from 0.5 to 3.5 mg/day (with switch to aripiprazole if risperidone was ineffective). Parents in the COMB group ( n = 75; 60.5%) received a mean of 10.9 PT sessions. The primary measure of compliance was the Home Situations Questionnaire (HSQ) score. Results Primary: intent-to-treat random effects regression showed that COMB was superior to MED on HSQ ( p = .006) [effect size at week 24 ( d ) = 0.34]. The HSQ score declined from 4.31 (±1.67) to 1.23 (±1.36) for COMB compared with 4.16 (±1.47) to 1.68 (±1.36) for MED. Secondary: groups did not differ on Clinical Global Impressions–Improvement scores at endpoint; compared with MED, COMB showed significant reductions on Aberrant Behavior Checklist Irritability ( d = 0.48; p = .01), Stereotypic Behavior ( d = 0.23; p = .04), and Hyperactivity/Noncompliance subscales ( d = 0.55; p = .04). Final risperidone mean dose for MED was 2.26 mg/day (0.071 mg/kg), compared with 1.98 mg/day for COMB (0.066 mg/kg) ( p = .04). Conclusions Medication plus PT resulted in greater reduction of serious maladaptive behavior than MED in children with PDDs, with a lower risperidone dose.
TL;DR: The VIQ scores are negatively associated with age and rates of mood, and psychotic disorders increase dramatically during young adulthood, and neuropsychiatric deficits in individuals with VCFS seem to follow a developmental pattern.
Abstract: OBJECTIVE: Velocardiofacial syndrome (VCFS) is associated with cognitive deficits and high rates of schizophrenia and other neuropsychiatric disorders. We report the data from two large cohorts of individuals with VCFS from Israel and Western Europe to characterize the neuropsychiatric phenotype from childhood to adulthood in a large sample. METHOD: Individuals with VCFS (n = 172) aged 5 to 54 years were evaluated with structured clinical interviews for psychiatric disorders and age-appropriate versions of the Wechsler intelligence tests. RESULTS: The frequency of psychiatric disorders was high and remarkably similar between samples. Psychotic disorders and depression were uncommon during childhood but increased in rates during adulthood (depressive disorders: 40.7% in young adults [aged 18-24 years]; psychotic disorders: 32.1% in adults [age >24 years]). Cognitive scores were inversely associated with age in subjects with VCFS, including patients without psychosis. Specifically, Verbal IQ (VIQ) scores negatively correlated with age, and the subjects with VCFS and psychotic disorders had significantly lower VIQ scores than nonpsychotic VCFS subjects. CONCLUSIONS: Neuropsychiatric deficits in individuals with VCFS seem to follow a developmental pattern. The VIQ scores are negatively associated with age and rates of mood, and psychotic disorders increase dramatically during young adulthood. The data presented here support careful monitoring of psychiatric symptoms during adolescence and young adulthood in VCFS. Prospective longitudinal studies are needed to examine the nature of age-related cognitive changes and their association with psychiatric morbidity in VCFS.
TL;DR: Maternal cannabis use during pregnancy resulted in more pronounced growth restriction than maternal tobacco use and with lower birth weight, and maternal cannabis use was not associated with fetal growth restriction.
Abstract: Objective Cannabis is the most commonly consumed illicit drug among pregnant women. Intrauterine exposure to cannabis may result in risks for the developing fetus. The importance of intrauterine growth on subsequent psychological and behavioral child development has been demonstrated. This study examined the relation between maternal cannabis use and fetal growth until birth in a population-based sample. Method Approximately 7,452 mothers enrolled during pregnancy and provided information on substance use and fetal growth. Fetal growth was determined using ultrasound measures in early, mid-, and late pregnancy. Additionally, birth weight was assessed. Results Maternal cannabis use during pregnancy was associated with growth restriction in mid-and late pregnancy and with lower birth weight. This growth reduction was most pronounced for fetuses exposed to continued maternal cannabis use during pregnancy. Fetal weight in cannabis-exposed fetuses showed a growth reduction of −14.44 g/week (95% confidence interval −22.94 to −5.94, p = .001) and head circumference (−0.21 mm/week, 95% confidence interval −0.42 to 0.02, p = .07), compared with nonexposed fetuses. Maternal cannabis use during pregnancy resulted in more pronounced growth restriction than maternal tobacco use. Paternal cannabis use was not associated with fetal growth restriction. Conclusions Maternal cannabis use, even for a short period, may be associated with several adverse fetal growth trajectories.
TL;DR: The NCS-A is a rich nationally representative dataset that will substantially increase understanding of the mental health and well-being of adolescents in the United States and show that the use of replacement schools for originally selected schools that refused to participate did not introduce bias into prevalence estimates.
Abstract: Objective To present an overview of the design and field procedures of the National Comorbidity Survey Replication Adolescent Supplement (NCS-A) Method The NCS-A is a nationally representative face-to-face household survey of the prevalence and correlates of DSM-IV mental disorders among US adolescents (aged 13–17 years) that was performed between February 2001 and January 2004 by the Survey Research Center of the Institute for Social Research at the University of Michigan The sample was based on a dual-frame design that included 904 adolescent residents of the households that participated in the National Comorbidity Survey Replication (response rate 859%) and 9,244 adolescent students selected from a representative sample of 320 schools in the same nationally representative sample of counties as the National Comorbidity Survey Replication (response rate 747%) Results Comparisons of sample and population distributions on census sociodemographic variables and, in the school sample, school characteristics documented only minor differences that were corrected with poststratification weighting Comparisons of DSM-IV disorder prevalence estimates among household versus school sample respondents in counties that differed in the use of replacement schools for originally selected schools that refused to participate showed that the use of replacement schools did not introduce bias into prevalence estimates Conclusions The NCS-A is a rich nationally representative dataset that will substantially increase understanding of the mental health and well-being of adolescents in the United States
TL;DR: Very preterm children exhibit higher rates of behavior problems early in development, in particular internalizing and dysregulation problems and poorer competence.
Abstract: Objective Children born very preterm are reported to have an increased frequency of social, emotional, and behavioral problems at school age compared with their peers born at term. The primary aim of this study was to compare social-emotional difficulties and competencies of very preterm and full-term children at 2 years' corrected age. In addition, the relation between perinatal variables and early behavior problems was also examined to help identify those very preterm children most at risk. Method At 2 years' corrected age, the parents of 188 very preterm (gestational age Results The very preterm children at 2 years demonstrated significantly higher internalizing and dysregulation scores and lower competence scores than peers born at term. There was no significant difference in externalizing scores between groups. Female sex, lower birth weight z score, white matter abnormalities, and postnatal corticosteroids were significantly associated with lower competence scores in the very preterm group. Conclusions Very preterm children exhibit higher rates of behavior problems early in development, in particular internalizing and dysregulation problems and poorer competence.
TL;DR: Methylphenidate seems to offer the greatest and most immediate improvement of ADHD symptoms and does not seem to worsen tic symptoms, and alpha-2 agonists offer the best combined improvement in both tic and ADHD symptoms.
Abstract: Objective The Food and Drug Administration currently requires the package inserts of most psychostimulant medications to list the presence of a tic disorder as a contraindication to their use. Approximately half of children with Tourette's syndrome experience comorbid attention-deficit/hyperactivity disorder (ADHD). We sought to determine the relative efficacy of different medications in treating ADHD and tic symptoms in children with both Tourette's syndrome and ADHD. Method We conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of medications in the treatment of ADHD in the children with comorbid tics. We used a random effects meta-analysis with standardized mean difference as our primary outcome to estimate the effect size of pharmaceutical agents in the treatment of ADHD symptoms and tics. Results Our meta-analysis included nine studies involving 477 subjects. We assessed the efficacy of six medications—dextroamphetamine, methylphenidate, alpha-2 agonists (clonidine and guan facine), desipramine, atomoxetine, and deprenyl. Methylphenidate, alpha-2 agonists, desipramine, and atomoxetine demonstrated efficacy in improving ADHD symptoms in children with comorbid tics. Alpha-2 agonists and atomoxetine significantly improved comorbid tic symptoms. Although there was evidence that supratherapeutic doses of dextroamphetamine worsens tics, there was no evidence that methylphenidate worsened tic severity in the short term. Conclusions Methylphenidate seems to offer the greatest and most immediate improvement of ADHD symptoms and does not seem to worsen tic symptoms. Alpha-2 agonists offer the best combined improvement in both tic and ADHD symptoms. Atomoxetine and desipramine offer additional evidence-based treatments of ADHD in children with comorbid tics. Supratherapeutic doses of dextroamphetamine should be avoided.
TL;DR: The 6-month morbid risks for suicidal events and for reattempts were lower than those in other comparable samples, suggesting that this intervention should be studied further.
Abstract: Objective: To identify the predictors of suicidal events and attempts in adolescent suicide attempters with depression treated in an open treatment trial. Method: Adolescents who had made a recent suicide attempt and had unipolar depression (n = 124) were either randomized (n = 22) or given a choice (n = 102) among three conditions. Two participants withdrew before treatment assignment. The remaining 124 youths received a specialized psychotherapy for suicide attempting adolescents (n = 17), a medication algorithm (n = 14), or the combination (n = 93). The participants were followed up 6 months after intake with respect to rate, timing, and predictors of a suicidal event (attempt or acute suicidal ideation necessitating emergency referral). Results: The morbid risks of suicidal events and attempts on 6-month follow-up were 0.19 and 0.12, respectively, with a median time to event of 44 days. Higher self-rated depression, suicidal ideation, family income, greater number of previous suicide attempts, lower maximum lethality of previous attempt, history of sexual abuse, and lower family cohesion predicted the occurrence, and earlier time to event, with similar findings for the outcome of attempts. A slower decline in suicidal ideation was associated with the occurrence of a suicidal event. Conclusions: In this open trial, the 6-month morbid risks for suicidal events and for reattempts were lower than those in other comparable samples, suggesting that this intervention should be studied further. Important treatment targets include suicidal ideation, family cohesion, and sequelae of previous abuse. Because 40% of events occurred with 4 weeks of intake, an emphasis on safety planning and increased therapeutic contact early in treatment may be warranted. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(10):000Y000.
TL;DR: Above-average verbal IQ seems to confer protection against social communication impairments in female subjects but not in male subjects, and social communicative deficits are of prognostic significance, in terms of behavioral adjustment at school, for boys and girls.
Abstract: Objective The proportion of schoolchildren with mild social communicative deficits far exceeds the number diagnosed with an autistic spectrum disorder (ASD) We aimed to ascertain both the population distribution of such deficits and their association with functional adaptation and cognitive ability in middle childhood Method The parent-report Social and Communication Disorders Checklist was administered to participants ( n = 8,094) in the Avon Longitudinal Study of Parents and Children We correlated impairment severity with independent clinical diagnoses of ASD, cognitive abilities, and teacher-rated maladaptive behavior Results Social and Communication Disorders Checklist scores were continuously distributed in the general population; boys had mean scores 30% higher than girls Social communicative deficits were associated with functional impairment at school, especially in domains of hyperactivity and conduct disorders A sex-by-verbal IQ interaction effect occurred: verbal IQ was protective against social communication impairments across the range of abilities in female subjects only In male subjects, this protective effect did not exist for those with above-average verbal IQ Conclusions Social communicative deficits are of prognostic significance, in terms of behavioral adjustment at school, for boys and girls Their high general population prevalence emphasizes the importance of measuring such traits among clinically referred children who do not meet diagnostic ASD criteria Above-average verbal IQ seems to confer protection against social communication impairments in female subjects but not in male subjects
TL;DR: Combined treatment with CBT and antidepressant medication may be more advantageous for adolescents whose depression is comorbid with other disorders, and consideration of moderators in clinical decision making can contribute to a more personalized and effective approach to treatment.
Abstract: Objective To advance knowledge regarding strategies for treating selective serotonin reuptake inhibitor (SSRI)-resistant depression in adolescents, we conducted a randomized controlled trial evaluating alternative treatment strategies. In primary analyses, cognitive-behavioral therapy (CBT) combined with medication change was associated with higher rates of positive response to short-term (12-week) treatment than medication alone. This study examines predictors and moderators of treatment response, with the goal of informing efforts to match youths to optimal treatment strategies. Method Youths who had not improved during an adequate SSRI trial ( N = 334) were randomized to an alternative SSRI, an alternative SSRI plus CBT, venlafaxine, or venlafaxine plus CBT. Analyses examined predictors and moderators of treatment response. Results Less severe depression, less family conflict, and absence of nonsuicidal self-injurious behavior predicted better treatment response status. Significant moderators of response to CBT + medication (combined) treatment were number of comorbid disorders and abuse history; hopelessness was marginally significant. The CBT/combined treatment superiority over medication alone was more evident among youths who had more comorbid disorders (particularly attention-deficit/hyperactivity disorder and anxiety disorders), no abuse history, and lower hopelessness. Further analyses revealed a stronger effect of combined CBT + medication treatment among youths who were older and white and had no nonsuicidal self-injurious behavior and longer prestudy pharmacotherapy. Conclusions Combined treatment with CBT and antidepressant medication may be more advantageous for adolescents whose depression is comorbid with other disorders. Given the additional costs of adding CBT to medication, consideration of moderators in clinical decision making can contribute to a more personalized and effective approach to treatment.
TL;DR: Guanfacine extended-release was effective in reducing symptoms of ADHD, and adverse events were mild to moderate, did not interfere with improvements in attention, and rarely led to discontinuation.
Abstract: Objective This study compared the efficacy of guanfacine extended release (GXR), a selective α 2A -adrenoceptor agonist, with placebo in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Method This double-blind, 9-week, dose-ranging, parallel-design, multicenter trial randomized 6- to 17-year-olds with ADHD to once-daily oral GXR in 1 -, 2-, 3-, and 4-mg doses or placebo. Primary outcome was change in total ADHD Rating Scale–IV score from baseline to endpoint. Secondary outcomes included changes in scores of hyperactive/impulsive and inattentive subscales; clinician and parent ratings; duration of clinical effect; and safety measures. Results Statistically significant reductions in ADHD Rating Scale-IV scores were observed from baseline to endpoint at all doses of GXR, with effect sizes ranging from 0.43 to 0.62. In subjects receiving GXR, mean heart rate and systolic and diastolic blood pressure decreased as the dose of GXR increased and then returned toward baseline during the dose-maintenance and dose-tapering phases of the trial. Most frequent treatment-emergent adverse events (≥ 5%) were somnolence, headache, fatigue, sedation, dizziness, irritability, upper abdominal pain, and nausea. Somnolence, sedation, and fatigue adverse events emerged within the first 2 weeks of dosing and generally resolved by study end. Conclusions Guanfacine extended-release was effective in reducing symptoms of ADHD. Adverse events were mild to moderate, did not interfere with improvements in attention, and rarely led to discontinuation.
TL;DR: Media literacy can be an effective intervention for reducing shape and weight concern and other eating disorder risk factors long-term in a universal mixed-sex, young adolescent population.
Abstract: Objective Recent eating disorder prevention efforts have targeted high-risk females in late adolescence (>15 years). Methodologically rigorous evaluations of prevention programs directed to younger, mixed-sex, universal audiences are largely absent. The primary objective was to evaluate a theoretically informed media literacy program delivered to a mixed-sex, universal, young adolescent audience. Method Five hundred forty Grade 8 students (mean age 13.62 years, SD 0.37 years) from 4 schools participated with a total of 11 classes receiving the 8-lesson media literacy program (126 girls and 107 boys) and 13 comparison classes receiving their normal school lessons (147 girls and 160 boys). Shape and weight concern (primary outcome variable) and seven additional eating disorder risk factors (e.g., dieting, media internalization) were measured with validated questionnaires at baseline, postprogram, and 6- and 30-month follow-up. Results Linear mixed model analyses were conducted using a 2 (group: media literacy program, control) × 3 (time: postprogram, 6-month follow-up, 30-month follow-up) × 2 (sex: girls, boys) mixed within-between design, with baseline entered as a covariate. Main effects for group, favoring the media literacy program, were found for shape and weight concern (effect size [ES] = 0.29), dieting (ES = 0.26), body dissatisfaction (ES = 0.20), ineffectiveness (ES = 0.23), and depression (ES = 0.26). Conclusion: Media literacy can be an effective intervention for reducing shape and weight concern and other eating disorder risk factors long-term in a universal mixed-sex, young adolescent population. More evaluations of methodologically sound prevention programs are required with this demographic. J. Am. Acad. Child Adolesc. Psychiatry , 2009;48(6):652-661.
TL;DR: Although the overall trend is toward lower rates of binge Drinking among youths, likely a result of a higher legal drinking age and other changes in alcohol policy, little improvement has occurred for college students, and increases in binge drinking among women has offset improvements among youths.
Abstract: Objective To evaluate trends in the past 30–day prevalence of binge drinking by age, sex, and student status, among youths and young adults in the United States between 1979 and 2006, a period that encompasses the federally mandated transition to a uniform legal drinking age of 21 years, and other policy changes aimed at curbing underage drinking. Method Data were analyzed from 20 administrations of the National Survey on Drug Use and Health, yielding a pooled sample of more than 500,000 subjects. Trends in relative risk for four different age groups, stratified by sex, relative to the 24- to 34-year-old reference group were calculated. We also examined trends in risk for binge drinking associated with student status (among college-age students) and race/ethnicity. Results Significant reductions in relative risk for binge drinking over time were observed for 12- to 20-year-old males, but no changes were observed for females in this age range, and binge drinking among minority females increased. Risk for binge drinking increased among 21- to 23-year-old women, with college women outpacing nonstudents in this age range. Trends also indicate that no reduction in binge drinking occurred for college men. Conclusions Although the overall trend is toward lower rates of binge drinking among youths, likely a result of a higher legal drinking age and other changes in alcohol policy, little improvement has occurred for college students, and increases in binge drinking among women has offset improvements among youths. Understanding these specific demographic trends will help inform prevention efforts.
TL;DR: Factor mixture analyses provide evidence that the CBCL AP syndrome varies along a severity continuum of mild to moderate to severe attention problems and provides evidence that ADHD diagnoses exist on a continuum rather than as discrete categories.
Abstract: Objective: To investigate whether items assessing attention problems provide evidence of quantitative differences or categorically distinct subtypes of attention problems (APs) and to investigate the relation of empirically derived latent classes to DSM-IV diagnoses of subtypes of attention-deficit/hyperactivity disorder (ADHD), for example, combined subtype, predominantly inattentive type, and predominantly hyperactive/impulsive type. Method: Data on attention problems were obtained from maternal ratings on the Child Behavior Check List (CBCL). Latent class models, which assume categorically different subtypes, and factor mixture models, which permit severity differences, are fitted to data obtained from Dutch boys at age 7 (N = 8,079), 10 (N = 5,278), and 12 years (N = 3,139). The fit of the different models to the data is compared to decide which model, and hence, which corresponding interpretation of AP, is most appropriate. Next, ADHD diagnoses are regressed on latent class membership in a subsample of children. Results: At all the three ages, models that distinguish between three mainly quantitatively different classes (e.g., mild, moderate, and severe attention problems) provide the best fit to the data. Within each class, the CBCL items measure three correlated continuous factors that can be interpreted in terms of hyperactivity/impulsivity, inattentiveness/dreaminess, and nervous behavior. The AP severe class contains all of the subjects diagnosed with ADHDYcombined subtype. Some subjects diagnosed with ADHDY predominantly inattentive type are in the moderate AP class. Conclusions: Factor mixture analyses provide evidence that the CBCL AP syndrome varies along a severity continuum of mild to moderate to severe attention problems. Children affected with ADHD are at the extreme of the continuum. These data are important for clinicians, research scholars, and the framers of the DSM-V as they provide evidence that ADHD diagnoses exist on a continuum rather than as discrete
TL;DR: It is suggested that a brief early intervention delivered through parents can reduce current anxiety and associated risk and may have the potential to alter the developmental trajectory of anxiety in a high-risk group of young children.
Abstract: Objective The current study evaluated the efficacy of early intervention for preschool-aged children selected on the basis of risk who also met diagnostic criteria for anxiety disorders. Method Seventy-one 3- to 4-year-old children were selected based on demonstrating high levels of inhibition and having a parent with a current anxiety disorder. They were randomly allocated to an eight-session parent intervention or waitlist. Results At baseline, all of the children met criteria for one or more anxiety disorders. At 6-month follow-up, the intervention group showed a significantly greater reduction in anxiety disorders and less interference from their anxiety than the waitlist. In addition, children in the intervention condition showed greater reductions in parent and laboratory observed measures of behavioral inhibition. Conclusions The results suggest that a brief early intervention delivered through parents can reduce current anxiety and associated risk and may have the potential to alter the developmental trajectory of anxiety in a high-risk group of young children. J. Am. Acad. Child Adolesc. Psychiatry , 2009;48(6):602-609.
TL;DR: Adolescents with three or more risk factors had an estimated 90% chance of escalating to full-syndrome depressive disorder, compared with 47% of adolescents with fewer than three risk factors and five variables accounted for unique variance in predicting escalation.
Abstract: Objectives Subthreshold depressive disorder is one of the best established risk factors for the onset of full-syndrome depressive disorders. However, many youths with subthreshold depressive disorder do not develop full-syndrome depression. We examined predictors of escalation to full-syndrome depressive disorders in a community sample of 225 adolescents with subthreshold depressive disorder. Method Criteria for subthreshold depressive disorder were an episode of depressed mood or loss of interest or pleasure lasting at least 1 week and at least two of the seven other DSM-IV–associated symptoms for major depression. Participants were assessed four times from mid-adolescence to age 30 years using semistructured diagnostic interviews. Results The estimated risk for escalation to full-syndrome depressive disorders was 67%. Five variables accounted for unique variance in predicting escalation: severity of depressive symptoms, medical conditions/symptoms, history of suicidal ideation, history of anxiety disorder, and familial loading for depression. Adolescents with three or more risk factors had an estimated 90% chance of escalating to full-syndrome depressive disorder, compared with 47% of adolescents with fewer than three risk factors. Conclusions These data may be useful in identifying a subgroup of youths with subthreshold depressive disorder who are at especially high risk for escalating to full-syndrome depressive disorders.