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Showing papers in "Journal of the American Academy of Child and Adolescent Psychiatry in 2012"


Journal ArticleDOI
TL;DR: Short measures on the Autism Spectrum Quotient (AQ) and the Quantitative Checklist for Autism in Toddlers (Q-CHAT) with good test accuracy have potential to aid referral decision making for specialist assessment and should be further evaluated.
Abstract: Objective Frontline health professionals need a "red flag" tool to aid their decision making about whether to make a referral for a full diagnostic assessment for an autism spectrum condition (ASC) in children and adults. The aim was to identify 10 items on the Autism Spectrum Quotient (AQ) (Adult, Adolescent, and Child versions) and on the Quantitative Checklist for Autism in Toddlers (Q-CHAT) with good test accuracy. Method: A case sample of more than 1,000 individuals with ASC (449 adults, 162 adolescents, 432 children and 126 toddlers) and a control sample of 3,000 controls (838 adults, 475 adolescents, 940 children, and 754 toddlers) with no ASC diagnosis participated. Case participants were recruited from the Autism Research Centre's database of volunteers. The control samples were recruited through a variety of sources. Participants completed full-length versions of the measures. The 10 best items were selected on each instrument to produce short versions. Results: At a cut-point of 6 on the AQ-10 adult, sensitivity was 0.88, specificity was 0.91, and positive predictive value (PPV) was 0.85. At a cut-point of 6 on the AQ-10 adolescent, sensitivity was 0.93, specificity was 0.95, and PPV was 0.86. At a cut-point of 6 on the AQ-10 child, sensitivity was 0.95, specificity was 0.97, and PPV was 0.94. At a cut-point of 3 on the Q-CHAT-10, sensitivity was 0.91, specificity was 0.89, and PPV was 0.58. Internal consistency was >0.85 on all measures. Conclusions: The short measures have potential to aid referral decision making for specialist assessment and should be further evaluated.

551 citations


Journal ArticleDOI
TL;DR: MBT-A was more effective than TAU in reducing self-harm and depression, explained by improved mentalization and reduced attachment avoidance and reflected improvement in emergent BPD symptoms and traits.
Abstract: Objective We examined whether mentalization-based treatment for adolescents (MBT-A) is more effective than treatment as usual (TAU) for adolescents who self-harm. Method A total of 80 adolescents (85% female) consecutively presenting to mental health services with self-harm and comorbid depression were randomly allocated to either MBT-A or TAU. Adolescents were assessed for self-harm, risk-taking and mood at baseline and at 3-monthly intervals until 12 months. Their attachment style, mentalization ability and borderline personality disorder (BPD) features were also assessed at baseline and at the end of the 12-month treatment. Results MBT-A was more effective than TAU in reducing self-harm and depression. This superiority was explained by improved mentalization and reduced attachment avoidance and reflected improvement in emergent BPD symptoms and traits. Conclusions MBT-A may be an effective intervention to reduce self-harm in adolescents. Clinical trial registration information —The emergence of personality disorder traits in adolescents who deliberately self harm and the potential for using a mentalisation based treatment approach as an early intervention for such individuals: a randomised controlled trial; http://www.controlled-trials.com; ISRCTN95266816.

534 citations


Journal ArticleDOI
TL;DR: This was the first trial to demonstrate that early behavioral intervention is associated with normalized patterns of brain activity, which was associated with improvements in social behavior, in young children with autism spectrum disorder.
Abstract: Objective A previously published randomized clinical trial indicated that a developmental behavioral intervention, the Early Start Denver Model (ESDM), resulted in gains in IQ, language, and adaptive behavior of children with autism spectrum disorder. This report describes a secondary outcome measurement from this trial, EEG activity. Method Forty-eight 18- to 30-month-old children with autism spectrum disorder were randomized to receive the ESDM or referral to community intervention for 2 years. After the intervention (age 48 to 77 months), EEG activity (event-related potentials and spectral power) was measured during the presentation of faces versus objects. Age-matched typical children were also assessed. Results The ESDM group exhibited greater improvements in autism symptoms, IQ, language, and adaptive and social behaviors than the community intervention group. The ESDM group and typical children showed a shorter Nc latency and increased cortical activation (decreased α power and increased θ power) when viewing faces, whereas the community intervention group showed the opposite pattern (shorter latency event-related potential [ERP] and greater cortical activation when viewing objects). Greater cortical activation while viewing faces was associated with improved social behavior. Conclusions This was the first trial to demonstrate that early behavioral intervention is associated with normalized patterns of brain activity, which is associated with improvements in social behavior, in young children with autism spectrum disorder.

521 citations


Journal ArticleDOI
TL;DR: Girls are less likely than boys to meet diagnostic criteria for ASD at equivalently high levels of autistic-like traits, which might reflect gender bias in diagnosis or genuinely better adaptation/compensation in girls.
Abstract: Objective This study aimed to explore sex differences in autistic traits in relation to diagnosis, to elucidate factors that might differentially impact whether girls versus boys meet diagnostic criteria for autism or a related autism spectrum disorder (ASD). Method Data from a large population-based sample of children were examined. Girls and boys (aged 10–12 years) meeting diagnostic criteria for an ASD were compared with those failing to meet diagnostic criteria despite very high scores on a trait measure of ASD, the Childhood Autism Spectrum Test (CAST). Information about behavioral difficulties as reported by teachers, and early estimates of intellectual functioning, were compared. Results Girls, but not boys, meeting diagnostic criteria for ASD showed significantly more additional problems (low intellectual level, behavioral difficulties) than peers with similarly high CAST scores who did not meet diagnostic criteria. Conclusions These data suggest that, in the absence of additional intellectual or behavioral problems, girls are less likely than boys to meet diagnostic criteria for ASD at equivalently high levels of autistic-like traits. This might reflect gender bias in diagnosis or genuinely better adaptation/compensation in girls.

513 citations


Journal ArticleDOI
TL;DR: Evidence that both younger child age at the start of intervention and a greater number of intervention hours were positively related to the degree of improvement in children's behavior for most variables has implications for clinical practice, service delivery, and public policy.
Abstract: Objective: This study was carried out to examine the efficacy of a 12-week, low-intensity (1-hour/wk of therapist contact), parent-delivered intervention for toddlers at risk for autism spectrum disorders (ASD) aged 14 to 24 months and their families. Method: A randomized controlled trial involving 98 children and families was carried out in three different sites investigating the efficacy of a parent delivery of the Early Start Denver Model (P-ESDM), which fosters parental use of a child-centered responsive interaction style that embeds many teaching opportunities into play, compared to community treatment as usual. Assessments were completed at baseline and 12 weeks later, immediately after the end of parent coaching sessions. Results: There was no effect of group assignment on parent‐child interaction characteristics or on any child outcomes. Both groups of parents improved interaction skills, and both groups of children demonstrated progress. Parents receiving P-ESDM demonstrated significantly stronger working alliances with their therapists than did the community group. Children in the community group received significantly more intervention hours than those in the P-ESDM group. For the group as a whole, both younger child age at the start of intervention and a greater number of intervention hours were positively related to the degree of improvement in children’s behavior for most variables. Conclusions: Parentimplemented intervention studies for early ASD thus far have not demonstrated the large effects seen in intensive-treatment studies. Evidence that both younger age and more intervention hours positively affect developmental rates has implications for clinical practice, service delivery, and public policy. J. Am. Acad. Child Adolesc. Psychiatry, 2012;51(10): 1052‐1065. Key Words: Early Start Denver Model (ESDM), early intervention, toddler, parent‐child interaction, autism

488 citations


Journal ArticleDOI
TL;DR: It is proposed that BI is one of the largest single risk factors for developing SAD, given that 15% of all children show extreme BI, and that almost half of these inhibited children will eventually develop SAD.
Abstract: Objective Behavioral inhibition (BI) has been associated with increased risk for developing social anxiety disorder (SAD); however, the degree of risk associated with BI has yet to be systematically examined and quantified. The goal of the present study was to quantify the association between childhood BI and risk for developing SAD. Method A comprehensive literature search was conducted to identify studies that assessed both BI and SAD. Meta-analyses were performed to estimate the odds ratio (OR) of the association between BI and SAD in children. Results Seven studies met inclusion criteria. BI was associated with a greater than sevenfold increase in risk for developing SAD (odds ratio=7.59, p Conclusions Identifying early developmental risk factors is critical for preventing psychiatric illness. Given that 15% of all children show extreme BI, and that almost half of these inhibited children will eventually develop SAD, we propose that BI is one of the largest single risk factors for developing SAD.

448 citations


Journal ArticleDOI
TL;DR: Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum and a more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.
Abstract: Objective This study evaluated the potential impact of proposed DSM-5 diagnostic criteria for autism spectrum disorder (ASD). Method The study focused on a sample of 933 participants evaluated during the DSM-IV field trial; 657 carried a clinical diagnosis of an ASD, and 276 were diagnosed with a non-autistic disorder. Sensitivity and specificity for proposed DSM-5 diagnostic criteria were evaluated using field trial symptom checklists as follows: individual field trial checklist items (e.g., nonverbal communication); checklist items grouped together as described by a single DSM-5 symptom (e.g., nonverbal and verbal communication); individual DSM-5 criterion (e.g., social-communicative impairment); and overall diagnostic criteria. Results When applying proposed DSM-5 diagnostic criteria for ASD, 60.6% (95% confidence interval: 57%–64%) of cases with a clinical diagnosis of an ASD met revised DSM-5 diagnostic criteria for ASD. Overall specificity was high, with 94.9% (95% confidence interval: 92%–97%) of individuals accurately excluded from the spectrum. Sensitivity varied by diagnostic subgroup (autistic disorder=0.76; Asperger's disorder=0.25; pervasive developmental disorder—not otherwise specified=0.28) and cognitive ability (IQ Conclusions Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum. Revised criteria improve specificity but exclude a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder. A more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.

433 citations


Journal ArticleDOI
TL;DR: The present article highlights the clinical assessment and reviews and summarizes the evidence base for treatment and specific recommendations are provided for assessment, cognitive behavioral therapy, pharmacotherapy, combined treatment, and other interventions.
Abstract: Research in etiology, neurobiology, genetics, clinical correlates, and evidence-based treatments in children and adolescents with obsessive-compulsive disorder indicate a need for the revision of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder first published a decade ago. The present article highlights the clinical assessment and reviews and summarizes the evidence base for treatment. Based on this evidence, specific recommendations are provided for assessment, cognitive behavioral therapy, pharmacotherapy, combined treatment, and other interventions.

371 citations


Journal ArticleDOI
TL;DR: Results supported the validity of proposed DSM-5 criteria for ASD as provided in Phase I Field Trials criteria and supported a relaxed algorithm, which may improve identification of ASD, decreasing societal costs through appropriate early diagnosis and maximizing intervention resources.
Abstract: Objective The primary aim of the present study was to evaluate the validity of proposed DSM-5 criteria for autism spectrum disorder (ASD). Method We analyzed symptoms from 14,744 siblings (8,911 ASD and 5,863 non-ASD) included in a national registry, the Interactive Autism Network. Youth 2 through 18 years of age were included if at least one child in the family was diagnosed with ASD. Caregivers reported symptoms using the Social Responsiveness Scale and the Social Communication Questionnaire. The structure of autism symptoms was examined using latent variable models that included categories, dimensions, or hybrid models specifying categories and subdimensions. Diagnostic efficiency statistics evaluated the proposed DSM-5 algorithm in identifying ASD. Results A hybrid model that included both a category (ASD versus non-ASD) and two symptom dimensions (social communication/interaction and restricted/repetitive behaviors) was more parsimonious than all other models and replicated across measures and subsamples. Empirical classifications from this hybrid model closely mirrored clinical ASD diagnoses (90% overlap), implying a broad ASD category distinct from non-ASD. DSM-5 criteria had superior specificity relative to DSM-IV-TR criteria (0.97 versus 0.86); however sensitivity was lower (0.81 versus 0.95). Relaxing DSM-5 criteria by requiring one less symptom criterion increased sensitivity (0.93 versus 0.81), with minimal reduction in specificity (0.95 versus 0.97). Conclusions Results supported the validity of proposed DSM-5 criteria for ASD as provided in Phase I Field Trials criteria. Increased specificity of DSM-5 relative to DSM-IV-TR may reduce false positive diagnoses, a particularly relevant consideration for low base rate clinical settings. Phase II testing of DSM-5 should consider a relaxed algorithm, without which as many as 12% of ASD-affected individuals, particularly females, will be missed. Relaxed DSM-5 criteria may improve identification of ASD, decreasing societal costs through appropriate early diagnosis and maximizing intervention resources.

370 citations


Journal ArticleDOI
TL;DR: The role of prefrontal cortical networks in the behavior and cognitive functions that are compromised in childhood neurodevelopmental disorders and how these map into the neuroimaging evidence of circuit abnormalities in these disorders.
Abstract: Objective This article aims to review basic and clinical studies outlining the roles of prefrontal cortical (PFC) networks in the behavior and cognitive functions that are compromised in childhood neurodevelopmental disorders and how these map into the neuroimaging evidence of circuit abnormalities in these disorders. Method Studies of animals, normally developing children, and patients with neurodevelopmental disorders were reviewed, with focus on neuroimaging studies. Results The PFC provides "top–down" regulation of attention, inhibition/cognitive control, motivation, and emotion through connections with posterior cortical and subcortical structures. Dorsolateral and inferior PFC regulate attention and cognitive/inhibitory control, whereas orbital and ventromedial structures regulate motivation and affect. PFC circuitries are very sensitive to their neurochemical environment, and small changes in the underlying neurotransmitter systems, e.g. by medications, can produce large effects on mediated function. Neuroimaging studies of children with neurodevelopmental disorders show altered brain structure and function in distinctive circuits respecting this organization. Children with attention-deficit/hyperactivity disorder show prominent abnormalities in the inferior PFC and its connections to striatal, cerebellar, and parietal regions, whereas children with conduct disorder show alterations in the paralimbic system, comprising ventromedial, lateral orbitofrontal, and superior temporal cortices together with specific underlying limbic regions, regulating motivation and emotion control. Children with major depressive disorder show alterations in ventral orbital and limbic activity, particularly in the left hemisphere, mediating emotions. Finally, children with obsessive-compulsive disorder appear to have a dysregulation in orbito-fronto-striatal inhibitory control pathways, but also deficits in dorsolateral fronto-parietal systems of attention. Conclusions Altogether, there is a good correspondence between anatomical circuitry mediating compromised functions and patterns of brain structure and function changes in children with neuropsychiatric disorders. Medications may optimize the neurochemical environment in PFC and associated circuitries, and improve structure and function.

355 citations


Journal ArticleDOI
TL;DR: Interventions to prevent mental disorders and psychological symptoms in the offspring of parents with mental disorders appear to be effective.
Abstract: Objective Mental illness in parents affects the mental health of their children. A systematic review and a meta-analysis of the effectiveness of interventions to prevent mental disorders or psychological symptoms in the offspring were performed. Method The Cochrane, MEDLINE, EMBASE, and PsycINFO databases were searched for randomized controlled trials of interventions in parents with mental disorders. Outcomes in the child included incident mental disorders of the same nature and internalizing (negative emotions, depressive symptoms, anxiety) or externalizing (hyperactivity, aggressiveness, behavioral problems) symptoms. Relative risks and standardized mean differences in symptom scores were combined in random-effects meta-analysis. Results Thirteen trials including 1,490 children were analyzed. Interventions included cognitive, behavioral, or psychoeducational components. Seven trials assessed the incidence of mental disorders and seven trials assessed symptoms. In total 161 new diagnoses of mental illness were recorded, with interventions decreasing the risk by 40% (combined relative risk 0.60, 95% CI 0.45–0.79). Symptom scores were lower in the intervention groups: standardized mean differences were −0.22 (95% CI −0.37 to −0.08) for internalizing symptoms ( p = .003) and −0.16 (95% confidence interval −0.36 to 0.04) for externalizing symptoms ( p = .12). Conclusions Interventions to prevent mental disorders and psychological symptoms in the offspring of parents with mental disorders appear to be effective.

Journal ArticleDOI
TL;DR: Despite a wide range in the magnitude of the cost estimates, this study indicates that ADHD has a substantial economic impact in the United States.
Abstract: Objective Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent mental disorders in children in the United States and often persists into adulthood with associated symptomatology and impairments. This article comprehensively reviews studies reporting ADHD-related incremental (excess) costs for children/adolescents and adults and presents estimates of annual national incremental costs of ADHD. Method A systematic search for primary United States-based studies published from January 1, 1990 through June 30, 2011 on costs of children/adolescents and adults with ADHD and their family members was conducted. Only studies in which mean annual incremental costs per individual with ADHD above non-ADHD controls were reported or could be derived were included. Per-person incremental costs were adjusted to 2010 U.S. dollars and converted to annual national incremental costs of ADHD based on 2010 U.S. Census population estimates, ADHD prevalence rates, number of household members, and employment rates by age group. Results Nineteen studies met the inclusion criteria. Overall national annual incremental costs of ADHD ranged from $143 to $266 billion (B). Most of these costs were incurred by adults ($105B−$194B) compared with children/adolescents ($38B−$72B). For adults, the largest cost category was productivity and income losses ($87B−$138B). For children, the largest cost categories were health care ($21B−$44B) and education ($15B−$25B). Spillover costs borne by the family members of individuals with ADHD were also substantial ($33B−$43B). Conclusion Despite a wide range in the magnitude of the cost estimates, this study indicates that ADHD has a substantial economic impact in the United States. Implications of these findings and future directions for research are discussed.

Journal ArticleDOI
TL;DR: Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents and further research is needed to elucidate neurobehavioral underpinnings of anhedonia and to test treatments that target anhedonian in the context of overall treatment of depression.
Abstract: Objective To identify symptom dimensions of depression that predict recovery among selective serotonin reuptake inhibitor (SSRI) treatment–resistant adolescents undergoing second-step treatment. Method The Treatment of Resistant Depression in Adolescents (TORDIA) trial included 334 SSRI treatment–resistant youth randomized to a medication switch, or a medication switch plus CBT. This study examined five established symptom dimensions (Child Depression Rating Scale—Revised) at baseline as they predicted recovery over 24 weeks of acute and continuation treatment. The two indices of recovery that were evaluated were time to remission and number of depression-free days. Results Multivariate analyses examining all five depression symptom dimensions simultaneously indicated that anhedonia was the only dimension to predict a longer time to remission, and also the only dimension to predict fewer depression-free days. In addition, when anhedonia and CDRS-total score were evaluated simultaneously, anhedonia continued to uniquely predict longer time to remission and fewer depression-free days. Conclusions Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents. Further research is needed to elucidate neurobehavioral underpinnings of anhedonia, and to test treatments that target anhedonia in the context of overall treatment of depression. Clinical trial registration information—Treatment of SSRI-Resistant Depression in Adolescents (TORDIA); http://www.clinicaltrials.gov; NCT00018902

Journal ArticleDOI
TL;DR: The study findings suggest that focusing on joint attention and play skills in comprehensive treatment models is important for long-term spoken language outcomes.
Abstract: Objective This study examines the cognitive and language outcomes of children with an autism spectrum disorder (ASD) over a 5-year period after receiving targeted early interventions that focused on joint attention and play skills. Method Forty children from the original study (n = 58) had complete data at the 5-year follow-up. Results In all, 80% of children had achieved functional use of spoken language with baseline play level predicting spoken language at the 5-year follow-up. Of children who were using spoken language at age 8 years, several baseline behaviors predicted their later ability, including earlier age of entry into the study, initiating joint attention skill, play level, and assignment to either the joint attention or symbolic play intervention group. Only baseline play diversity predicted cognitive scores at age 8 years. Conclusions This study is one of the only long-term follow-up studies of children who participated in preschool early interventions aimed at targeting core developmental difficulties. The study findings suggest that focusing on joint attention and play skills in comprehensive treatment models is important for long-term spoken language outcomes.

Journal ArticleDOI
TL;DR: An association between advancing maternal age and risk of autism is supported, and the meta-regression suggested a stronger maternal age effect in the studies with more male offspring and for children diagnosed in later years.
Abstract: Objective We conducted a meta-analysis of epidemiological studies investigating the association between maternal age and autism. Method Using recommended guidelines for performing meta-analyses, we systematically selected, and extracted results from, epidemiological scientific studies reported before January 2012. We calculated pooled risk estimates comparing categories of advancing maternal age with and without adjusting for possible confounding factors. We investigated the influence of gender ratio among cases, ratio of infantile autism to autism spectrum disorder (ASD), and median year of diagnosis as effect moderators in mixed-effect meta-regression. Results We found 16 epidemiological papers fulfilling the a priori search criteria. The meta-analysis included 25,687 ASD cases and 8,655,576 control subjects. Comparing mothers ≥35 years with mothers 25 to 29 years old, the crude relative risk (RR) for autism in the offspring was 1.52 (95% confidence interval [CI] = 1.12–1.92). Comparing mothers ≥35 with mothers 25 to 29, the adjusted relative risk (RR) for autism in the offspring was 1.52 (95% CI=1.12–1.92). For mothers Conclusions The results of this meta-analysis support an association between advancing maternal age and risk of autism. The RR increased monotonically with increasing maternal age. The association persisted after the effects of paternal age and other potential confounders had been considered, supporting an independent relation between higher maternal age and autism.

Journal ArticleDOI
TL;DR: The overlapping cognitive deficits may be used to further unravel the shared etiological underpinnings of ASD and ADHD, and the nonoverlapping deficits may indicate why some children develop ADHD despite their enhanced risk for ASD.
Abstract: Objective Autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Given the heterogeneity of both disorders, several more homogeneous ASD–ADHD comorbidity subgroups may exist. The current study examined whether such subgroups exist, and whether their overlap or distinctiveness in associated comorbid symptoms and cognitive profiles gives support for a gradient overarching disorder hypothesis or a separate disorders hypothesis. Method Latent class analysis was performed on Social Communication Questionnaire (SCQ) and Conners' Parent Rating Scale (CPRS-R:L) data for 644 children and adolescents (5 through 17 years of age). Classes were compared for comorbid symptoms and cognitive profiles of motor speed and variability, executive functioning, attention, emotion recognition, and detail-focused processing style. Results Latent class analysis revealed five classes: two without behavioral problems, one with only ADHD behavior, and two with both clinical symptom levels of ASD and ADHD but with one domain more prominent than the other (ADHD[+ASD] and ASD[+ADHD]). In accordance with the gradient overarching disorder hypothesis were the presence of an ADHD class without ASD symptoms and the absence of an ASD class without ADHD symptoms, as well as cognitive functioning of the simple ADHD class being less impaired than that of both comorbid classes. In conflict with this hypothesis was that there was some specificity of cognitive deficits across classes. Conclusions The overlapping cognitive deficits may be used to further unravel the shared etiological underpinnings of ASD and ADHD, and the nonoverlapping deficits may indicate why some children develop ADHD despite their enhanced risk for ASD. The two subtypes of children with both ASD and ADHD behavior will most likely benefit from different clinical approaches.

Journal ArticleDOI
TL;DR: In this article, the authors examined the differential roles of transformational (i.e., charismatic) leadership and leader-member exchange on team innovation climate and provider attitudes toward adopting evidence-based practice (EBP).
Abstract: Objective Leadership is important in practice change, yet there are few studies addressing this issue in mental health and social services. This study examined the differential roles of transformational (i.e., charismatic) leadership and leader–member exchange (i.e., the relationship between a supervisor and their direct service providers) on team innovation climate (i.e., openness to new innovations) and provider attitudes toward adopting evidence-based practice (EBP) during a statewide evidence-based practice implementation (EBPI) of an intervention to reduce child neglect. Method Participants were 140 case-managers in 30 teams providing home-based services to families in a statewide child-welfare system. Teams were assigned by region to EBPI or services as usual (SAU) conditions. Multiple group path analysis was used to examine associations of transformational leadership and leader–member exchange with innovation climate and attitudes toward adoption and use of EBP. Results Transformational leadership predicted higher innovation climate during implementation, whereas leader–member exchange predicted higher innovation climate during SAU. Innovation climate was, in turn, associated with more positive attitudes toward EBP for the EBPI group. Conclusions Strategies designed to enhance supervisor transformational leadership have the potential to facilitate implementation efforts by promoting a strong climate for EBPI and positive provider attitudes toward adoption and use of EBP.

Journal ArticleDOI
TL;DR: Daily living skills improved for the individuals with ASD during adolescence and their early 20s, but plateaued during their late 20s; having an intellectual disability was associated with lower initial levels of daily living skills and a slower change over time.
Abstract: Objective This study aimed to investigate the longitudinal course of daily living skills in a large, community-based sample of adolescents and adults with autism spectrum disorders (ASD) over a 10-year period. Method Adolescents and adults with ASD (n = 397) were drawn from an ongoing, longitudinal study of individuals with ASD and their families. A comparison group of 167 individuals with Down syndrome (DS) were drawn from a linked longitudinal study. The Waisman Activities of Daily Living Scale was administered four times over a 10-year period. Results We used latent growth curve modeling to examine change in daily living skills. Daily living skills improved for the individuals with ASD during adolescence and their early 20s, but plateaued during their late 20s. Having an intellectual disability was associated with lower initial levels of daily living skills and a slower change over time. Individuals with DS likewise gained daily living skills over time, but there was no significant curvature in the change. Conclusions Future research should explore what environmental factors and interventions may be associated with continued gains in daily living skills for adults with ASD.

Journal ArticleDOI
TL;DR: Children involved in bullying, in any role, and especially bully/victims and chronic victims, are at increased risk for suicide ideation and suicidal/self-injurious behavior in preadolescence.
Abstract: OBJECTIVE: To study the prospective link between involvement in bullying (bully, victim, bully/victim), and subsequent suicide ideation and suicidal/self-injurious behavior, in preadolescent children in the United Kingdom. METHOD: A total of 6,043 children in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort were assessed to ascertain involvement in bullying between 4 and 10 years and suicide related behavior at 11.7 years. RESULTS: Peer victimization (victim, bully/victim) was significantly associated with suicide ideation and suicidal/self-injurious behavior after adjusting for confounders. Bully/victims were at heightened risk for suicide ideation (odds ratio [OR]; 95% confidence interval [CI]): child report at 8 years (OR = 2.84; CI = 1.81-4.45); child report at 10 years (OR = 3.20; CI = 2.07-4.95); mother report (OR = 2.71; CI = 1.81-4.05); teacher report (OR = 2.79; CI = 1.62-4.81), as were chronic victims: child report (OR = 3.26; CI = 2.24-4.75); mother report (OR = 2.49; CI = 1.64-3.79); teacher report (OR = 5.99; CI = 2.79-12.88). Similarly, bully/victims were at heightened risk for suicidal/self-injurious behavior: child report at 8 years (OR = 2.67; CI = 1.66-4.29); child report at 10 years (OR = 3.34; CI = 2.17-5.15); mother report (OR = 2.09; CI = CI = 1.36-3.20); teacher report (OR = 2.44, CI = 1.39-4.30); as were chronic victims: child report (OR = 4.10; CI = 2.76-6.08); mother report (OR = 1.91; 1.22-2.99); teacher report (OR = 3.26; CI = 1.38-7.68). Pure bullies had increased risk of suicide ideation according to child report at age 8 years (OR = 3.60; CI = 1.46-8.84), suicidal/self-injurious behavior according to child report at age 8 years (OR = 3.02; CI = 1.14-8.02), and teacher report (OR = 1.84; CI = 1.09-3.10). CONCLUSIONS: Children involved in bullying, in any role, and especially bully/victims and chronic victims, are at increased risk for suicide ideation and suicidal/self-injurious behavior in preadolescence. Language: en

Journal ArticleDOI
TL;DR: Adolescence and young adulthood are associated with high levels of caregiver burden in both disorders; in ASD, the level is comparable to that reported by persons caring for individuals with a brain injury.
Abstract: Objective There is increasing recognition that autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are associated with significant costs and burdens. However, research on their impact has focused mostly on the caregivers of young children; few studies have examined caregiver burden as children transition into adolescence and young adulthood, and no one has compared the impact of ASD to other neurodevelopmental disorders (e.g., ADHD). Method We conducted an observational study of 192 families caring for a young person (aged 14 to 24 years) with a childhood diagnosis of ASD or ADHD (n = 101 and n=91, respectively) in the United Kingdom. A modified stress-appraisal model was used to investigate the correlates of caregiver burden as a function of family background (parental education), primary stressors (symptoms), primary appraisal (need), and resources (use of services). Results Both disorders were associated with a high level of caregiver burden, but it was significantly greater in ASD. In both groups, caregiver burden was mainly explained by the affected young person's unmet need. Domains of unmet need most associated with caregiver burden in both groups included depression/anxiety and inappropriate behavior. Specific to ASD were significant associations between burden and unmet needs in domains such as social relationships and major mental health problems. Conclusions Adolescence and young adulthood are associated with high levels of caregiver burden in both disorders; in ASD, the level is comparable to that reported by persons caring for individuals with a brain injury. Interventions are required to reduce caregiver burden in this population.

Journal ArticleDOI
TL;DR: A restriction diet benefits some children with ADHD and effects of food colors were notable were but susceptible to publication bias or were derived from small, nongeneralizable samples.
Abstract: Objective: The role of diet and of food colors in attention-deficit/hyperactivity disorder (ADHD) or its symptoms warrants updated quantitative meta-analysis, in light of recent divergent policy in Europe and the United States. Method: Studies were identified through a literature search using the PubMed, Cochrane Library, and PsycNET databases through February 2011. Twenty-four publications met inclusion criteria for synthetic food colors; 10 additional studies informed analysis of dietary restriction. A random-effects meta-analytic model generated summary effect sizes. Results: Restriction diets reduced ADHD symptoms at an effect of g 0.29 (95% CI, 0.07‐0.53). For food colors, parent reports yielded an effect size of g 0.18 (95% CI, 0.08‐0.24; p .0007), which decreased to 0.12 (95% CI, 0.01‐0.23; p .05) after adjustment for possible publication bias. The effect was reliable in studies restricted to food color additives (g 0.21, 95% CI 0.06‐0.36) but did not survive correction for possible publication bias and was not reliable in studies confined to Food and Drug Administration‐ approved food colors. Teacher/observer reports yielded a nonsignificant effect of 0.07 (95% CI 0.03 to 0.18; p .14). However, high-quality studies confined to color additives yielded a reliable effect (g 0.22, 95% CI 0.10‐0.41, p .030) that survived correction. In psychometric tests of attention, the summary effect size was 0.27 (95% CI 0.07‐0.47; p .007) and survived correction. An estimated 8% of children with ADHD may have symptoms related to synthetic food colors. Conclusions: A restriction diet benefits some children with ADHD. Effects of food colors were notable were but susceptible to publication bias or were derived from small, nongeneralizable samples. Renewed investigation of diet and ADHD is warranted. J. Am. Acad. Child Adolesc. Psychiatry, 2012;51(1):86‐97. Key words: ADHD, meta-analysis, synthetic food color additives, restriction diet

Journal ArticleDOI
TL;DR: Food insecurity is associated with a wide range of adolescent mental disorders independently of other aspects of SES, and the association between food insecurity and mood disorders was strongest in adolescents living in families with a low household income and high relative deprivation.
Abstract: Objective To examine whether food insecurity is associated with past-year DSM-IV mental disorders after controlling for standard indicators of family socioeconomic status (SES) in a U.S. national sample of adolescents. Method Data were drawn from 6,483 adolescent–parent pairs who participated in the National Comorbidity Survey Replication Adolescent Supplement, a national survey of adolescents 13 to 17 years old. Frequency and severity of food insecurity were assessed with questions based on the U.S. Department of Agriculture's Food Security Scale (standardized to a mean of 0, variance of 1). DSM-IV mental disorders were assessed with the World Health Organization Composite International Diagnostic Interview. Associations of food insecurity with DSM-IV /Composite International Diagnostic Interview diagnoses were estimated with logistic regression models controlling for family SES (parental education, household income, relative deprivation, community-level inequality, and subjective social status). Results Food insecurity was highest in adolescents with the lowest SES. Controlling simultaneously for other aspects of SES, standardized food insecurity was associated with an increased odds of past-year mood, anxiety, behavior, and substance disorders. A 1 standard deviation increase in food insecurity was associated with a 14% increase in the odds of past-year mental disorder, even after controlling for extreme poverty. The association between food insecurity and mood disorders was strongest in adolescents living in families with a low household income and high relative deprivation. Conclusions Food insecurity is associated with a wide range of adolescent mental disorders independently of other aspects of SES. Expansion of social programs aimed at decreasing family economic strain might be one useful policy approach for improving youth mental health.

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TL;DR: Lower, not higher, socioeconomic status was associated with an increased risk of ASD, and studies finding the opposite may be underestimating the burden of ASD in lower SES groups.
Abstract: Objective Epidemiological studies in the United States consistently find autism spectrum disorders (ASD) to be overrepresented in high socioeconomic status (SES) families. These findings starkly contrast with SES gradients of many health conditions, and may result from SES inequalities in access to services. We hypothesized that prenatal measures of low, not high, parental SES would be associated with an increased risk of offspring ASD, once biases in case ascertainment are minimized. Method We tested this hypothesis in a population-based study in Sweden, a country that has free universal healthcare, routine screening for developmental problems, and thorough protocols for diagnoses of ASD. In a case-control study nested in a total population cohort of children aged 0 to 17 years living in Stockholm County between 2001 and 2007 (N = 589,114), we matched ASD cases (n = 4,709) by age and sex to 10 randomly selected controls. We retrieved parental SES measures collected at time of birth by record linkage. Results Children of families with lower income, and of parents with manual occupations (OR = 1.4, 95% CI=1.3–1.6) were at higher risk of ASD. No important relationships with parental education were observed. These associations were present after accounting for parental ages, migration status, parity, psychiatric service use, maternal smoking during pregnancy, and birth characteristics; and regardless of comorbid intellectual disability. Conclusions Lower, not higher, socioeconomic status was associated with an increased risk of ASD. Studies finding the opposite may be underestimating the burden of ASD in lower SES groups.

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TL;DR: This study provides evidence for several peripheral biomarkers as being associated with ADHD both in diagnosis and in treatment efficacy, and significant heterogeneity of effect sizes was found for three of the five biomarkers that differentiated ADHD from control subjects.
Abstract: Objective To determine whether peripheral biochemical markers (biomarkers) might differentiate patients with attention-deficit/hyperactivity disorder (ADHD) from non-ADHD individuals. Method We conducted a systematic search and a series of meta-analyses of case-control studies comprising studies from 1969 to 2011. Results We identified 210 studies in the following categories: 71 studies of the main metabolites and metabolism enzymes of monoaminergic neurotransmission pathway; 87 studies of environmental risk factors divided into heavy metals (18 studies), substance/chemical exposures (16 studies), and nutritional factors (trace elements: 29 studies; essential fatty acids: 24 studies); 22 studies of the hypothalamic–pituitary–adrenal axis (HPA) pathway; 31 studies indicated with "other." After screening for the availability for meta-analyses of drug naive/free case-control studies and Bonferroni correction, five comparisons were statistically significant (Norepinephrine [NE], 3-Methoxy-4-hydroxyphenylethylene glycol [MHPG], monoamine oxidase [MAO], Zinc [Zn], cortisol), five of the significant findings found support in studies of response to ADHD medications (NE, MHPG, MAO, b-phenylethylamine [PEA], cortisol), six in studies of symptoms severity (NE, MHPG, MAO, ferritin, Zn, cortisol) and three in studies of neurophysiological or cognitive functioning (lead–ferritin–Zn). No evidence of publication bias was found, whereas significant heterogeneity of effect sizes across studies was found for three of the five biomarkers that differentiated ADHD from control subjects. Suggestive associations were evidenced for neuropeptide Y (NPY), manganese, and dehydroepiandrosterone (DHEA). Conclusions This study provides evidence for several peripheral biomarkers as being associated with ADHD both in diagnosis and in treatment efficacy. Further studies are warranted to replicate these findings, to assess their specificity for ADHD, and to quantify the degree to which they are sufficiently precise to be useful in clinical settings.

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TL;DR: Practice principles and related issues of cultural competence, research needs, and ethics are discussed and influences on sexual orientation, gender nonconformity, and gender discordance, and their developmental relationships to each other, are reviewed.
Abstract: Children and adolescents who are growing up gay, lesbian, bisexual, gender nonconforming, or gender discordant experience unique developmental challenges. They are at risk for certain mental health problems, many of which are significantly correlated with stigma and prejudice. Mental health professionals have an important role to play in fostering healthy development in this population. Influences on sexual orientation, gender nonconformity, and gender discordance, and their developmental relationships to each other, are reviewed. Practice principles and related issues of cultural competence, research needs, and ethics are discussed.

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TL;DR: Findings demonstrate synchrony in the brain response of two individuals within an attachment relationship, and may suggest that human attachment develops within the matrix of biological attunement and brain-to-brain synchrony between attachment partners.
Abstract: Objective Research on the neurobiology of parenting has defined biobehavioral synchrony , the coordination of biological and behavioral responses between parent and child, as a central process underpinning mammalian bond formation. Bi-parental rearing, typically observed in monogamous species, is similarly thought to draw on mechanisms of mother–father synchrony. Method We examined synchrony in mothers' and fathers' brain response to ecologically valid infant cues. Thirty mothers and fathers, comprising 15 couples parenting 4- to 6-month-old infants, were visited at home, and infant play was videotaped. Parents then underwent functional magnetic resonance imaging scanning while observing own-infant compared with standard-infant videos. Coordination in brain response between mothers and fathers was assessed using a voxel-by-voxel algorithm, and gender-specific activations were also tested. Plasma oxytocin and arginine vasopressin, neuropeptides implicated in female and male bonding, were examined as correlates. Results Online coordination in maternal and paternal brain activations emerged in social–cognitive networks implicated in empathy and social cognition. Mothers showed higher amygdala activations and correlations between amygdala response and oxytocin. Fathers showed greater activations in social–cognitive circuits, which correlated with vasopressin. Conclusions Parents coordinate online activity in social–cognitive networks that support intuitive understanding of infant signals and planning of adequate caregiving, whereas motivational–limbic activations may be gender specific. Although preliminary, these findings demonstrate synchrony in the brain response of two individuals within an attachment relationship, and may suggest that human attachment develops within the matrix of biological attunement and brain-to-brain synchrony between attachment partners.

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TL;DR: Among higher-functioning individuals, ASD is a dyad, not a triad, with distinct social communication and repetitive behavior dimensions, as suggested in the proposed DSM-5 criteria, sensory abnormalities are part of the RRB symptom cluster.
Abstract: Objective To use confirmatory factor analysis to test the construct validity of the proposed DSM-5 symptom model of autism spectrum disorder (ASD), in comparison to alternative models, including that described in DSM-IV-TR. Method Participants were 708 verbal children and young persons (mean age, 9.5 years) with mild to severe autistic difficulties. Autistic symptoms were measured using the Developmental, Dimensional and Diagnostic interview (3Di). The fit of the two-factor DSM-5 model, which has a social communication and a restricted, repetitive behavior (RRB) factor, was compared with that of alternative models. In one half of the sample, properties of the DSM-5 model were examined to investigate the validity of specific diagnostic criteria, informing the development of a better fitting DSM-5 model. This was then cross-validated in the remaining "hold-out" half of the sample; and its stability was tested across groups defined by age, sex, and symptom severity. Results The DSM-5 model was superior to the three-factor DSM-IV-TR model. It was improved by the removal of items measuring "play and imagination" and "stereotyped and repetitive use of language." A scale measuring sensory abnormalities was added to the model, and loaded onto its RRB factor. This DSM-5 model fit well in the hold-out sample; was stable across age and sex; and fit adequately in those with clinical and sub-threshold autistic presentations. Conclusions Among higher-functioning individuals, ASD is a dyad, not a triad, with distinct social communication and repetitive behavior dimensions. As suggested in the proposed DSM-5 criteria, sensory abnormalities are part of the RRB symptom cluster.

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TL;DR: Examination of patterns of variability in social visual engagement and their relationship to standardized measures of social disability in a heterogeneous sample of school-aged children with autism spectrum disorders suggests that variability in these early mechanisms of socialization may serve as proximal behavioral manifestations of genetic vulnerabilities.
Abstract: Objective To examine patterns of variability in social visual engagement and their relationship to standardized measures of social disability in a heterogeneous sample of school-aged children with autism spectrum disorders (ASD). Method Eye-tracking measures of visual fixation during free-viewing of dynamic social scenes were obtained for 109 children with ASD (mean age, 10.2 ± 3.2 years), 37 of whom were matched with 26 typically-developing (TD) children (mean age, 9.5 ± 2.2 years) on gender, age, and IQ. The smaller subset allowed between-group comparisons, whereas the larger group was used for within-group examinations of ASD heterogeneity. Results Between-group comparisons revealed significantly attenuated orientation to socially salient aspects of the scenes, with the largest effect size (Cohen's d = 1.5) obtained for reduced fixation on faces. Within-group analyses revealed a robust association between higher fixation on the inanimate environment and greater social disability. However, the associations between fixation on the eyes and mouth and social adaptation varied greatly, even reversing, when comparing different cognitive profile subgroups. Conclusions Although patterns of social visual engagement with naturalistic social stimuli are profoundly altered in children with ASD, the social adaptivity of these behaviors varies for different groups of children. This variation likely represents different patterns of adaptation and maladaptation that should be traced longitudinally to the first years of life, before complex interactions between early predispositions and compensatory learning take place. We propose that variability in these early mechanisms of socialization may serve as proximal behavioral manifestations of genetic vulnerabilities.

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TL;DR: In this article, the authors reported new international findings for parent, teacher, and self-ratings on the Child Behavior Checklist, Youth Self-Report, and Teacher's Report Form, and tested the fit of syndrome models to new data from 17 societies, including previously underrepresented regions.
Abstract: Objective: To build on Achenbach, Rescorla, and Ivanova (2012) by (a) reporting new international findings for parent, teacher, and self-ratings on the Child Behavior Checklist, Youth Self-Report, and Teacher's Report Form; (b) testing the fit of syndrome models to new data from 17 societies, including previously underrepresented regions; (c) testing effects of society gender, and age in 44 societies by integrating new and previous data; (d) testing cross-society correlations between mean item ratings; (e) describing the construction of multisociety norms; (f) illustrating clinical applications. Method: Confirmatory factor analyses (CFAs) of parent, teacher, and self-ratings, performed separately for each society; tests of societal, gender, and age effects on dimensional syndrome scales, DSM-oriented scales, Internalizing, Externalizing, and Total Problems scales; tests of agreement between low, medium, and high ratings of problem items across societies. Results: CFAs supported the tested syndrome models in all societies according to the primary fit index (Root Mean Square Error of Approximation [RMSEA]), but less consistently according to other indices; effect sizes were small-to-medium for societal differences in scale scores, but very small for gender, age, and interactions with society; items received similarly low, medium, or high ratings in different societies; problem scores from 44 societies fit three sets of multisociety norms. Conclusions: Statistically derived syndrome models fit parent, teacher, and self-ratings when tested individually in all 44 societies according to RMSEAs (but less consistently according to other indices). Small to medium differences in scale scores among societies supported the use of low-, medium-, and high-scoring norms in clinical assessment of individual children. J. Am. Acad. Child Aclolesc. Psychiatry; 2012; 51(12):1273-1283.

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TL;DR: This study suggests that co-occurring OCD and ADHD is markedly lower in TS cases derived from population-based samples than has been reported in clinically ascertained TS cases.
Abstract: Objective Recent epidemiologic studies have demonstrated that Tourette syndrome (TS) and chronic tic disorder (CT) are more common than previously recognized. However, few population-based studies have examined the prevalence of co-occurring neuropsychiatric conditions such as obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). We evaluated the prevalence of TS, CT, and their overlap with OCD and ADHD in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Method A total of 6,768 children were evaluated using longitudinal data from mother-completed questionnaires. DSM-IV-TR diagnoses of TS and CT were derived using three levels of diagnostic stringency (Narrow, Intermediate, and Broad). Validity of the case definitions was assessed by comparing gender ratios and rates of co-occurring OCD and ADHD using heterogeneity analyses. Results Age 13 prevalence rates for TS (0.3% for Narrow; 0.7% for Intermediate) and CT (0.5% for Narrow; 1.1% for Intermediate) were consistent with rates from other population-based studies. Rates of co-occurring OCD and ADHD were higher in TS and CT Narrow and Intermediate groups compared with controls but lower than has been previously reported. Only 8.2% of TS Intermediate cases had both OCD and ADHD; 69% of TS Intermediate cases did not have either co-occurring OCD or ADHD. Conclusions This study suggests that co-occurring OCD and ADHD is markedly lower in TS cases derived from population-based samples than has been reported in clinically ascertained TS cases. Further examination of the range of co-occurring neuropsychiatric disorders in population-based TS samples may shed new perspective on the underlying shared pathophysiology of these three neurodevelopmental conditions.