Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment

OBJECTIVE

To test the hypothesis that intensive multimodal psychosocial intervention (that includes academic assistance and psychotherapy) combined with methylphenidate significantly enhances the academic performance and emotional status of children with attention-deficit/hyperactivity disorder (ADHD) compared with methylphenidate alone and with methylphenidate combined with nonspecific psychosocial treatment (attention control).

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to receive one of three treatments: (1) methylphenidate alone, (2) methylphenidate plus psychosocial treatment that included academic remediation, organizational skills training, and psychotherapy as well as parent training and counseling and social skills training, or (3) methylphenidate plus attention control treatment. Children's function was assessed through academic testing, parent ratings of homework problems, and self-ratings of depression and self-esteem.

RESULTS

No advantage was found on any measure of academic performance or emotional status for the combination treatment over methylphenidate alone and over methylphenidate plus attention control. Significant improvement occurred across all treatments and was maintained over 2 years.

CONCLUSIONS

In stimulant-responsive young children with ADHD without learning and conduct disorders, there is no support for academic assistance and psychotherapy to enhance academic achievement or emotional adjustment. Significant short-term improvements were maintained over 2 years.

Design and rationale of controlled study of long-term methylphenidate and multimodal psychosocial treatment in children with ADHD

OBJECTIVE

To describe the rationale, methodology, and sample characteristics of a dual-site treatment study (New York and Montreal) of children with attention-deficit/hyperactivity disorder (ADHD) conducted between 1990 and 1995. The hypotheses were that (1) methylphenidate combined with comprehensive multimodal psychosocial treatment was superior to methylphenidate alone in improving multiple functions and (2) the efficacy of the psychosocial intervention resulted from its specific components and not from nonspecific treatment effects.

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to methylphenidate, were randomized for 2 years to (1) methylphenidate treatment alone; (2) methylphenidate combined with multimodal psychosocial treatment that included parent training and counseling, academic assistance, psychotherapy, and social skills training; or (3) methylphenidate plus attention control treatment that excluded specific aspects of the psychosocial intervention. Children were switched to single-blind placebo after 12 months; methylphenidate was reinstituted when clinically indicated. Assessments included ratings by parents, teachers, children, and psychiatrists; school observations in academic and gym classes; and academic performance tests. Almost 80% of families completed the 2-year study. Companion papers present treatment effects.

CONCLUSIONS

A comprehensive 2-year psychosocial treatment was delivered successfully to children with ADHD and their families.

Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment

OBJECTIVE

To test the hypotheses that in children with attention-deficit/hyperactivity disorder (ADHD) (1) symptoms of ADHD, oppositional defiant disorder, and overall functioning are significantly improved by methylphenidate combined with intensive multimodal psychosocial treatment compared with methylphenidate alone and with methylphenidate plus attention control and (2) more children receiving combined treatment can be taken off methylphenidate.

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to (1) methylphenidate alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, psychotherapy, and academic assistance, or (3) methylphenidate plus attention psychosocial control treatment. Assessments included parent, teacher, and psychiatrist ratings, and observations in academic and gym classes.

RESULTS

Combination treatment did not lead to superior functioning and did not facilitate methylphenidate discontinuation. Significant improvement occurred across all treatments and continued over 2 years.

CONCLUSIONS

In stimulant-responsive children with ADHD, there is no support for adding ambitious long-term psychosocial intervention to improve ADHD and oppositional defiant disorder symptoms. Significant benefits from methylphenidate were stable over 2 years.

Children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment: impact on parental practices

OBJECTIVE

To test the hypothesis that multimodal psychosocial intervention, which includes parent training, combined with methylphenidate significantly enhances the behavior of parents of children with attention-deficit/hyperactivity disorder (ADHD), compared with methylphenidate alone and compared with methylphenidate and nonspecific psychosocial treatment (attention control).

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate therapy were randomized for 2 years to receive either (1) methylphenidate treatment alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, academic assistance, and psychotherapy; or (3) methylphenidate plus attention control treatment. Parents rated their knowledge of parenting principles and negative and positive parenting behavior. Children rated their parents' behavior.

RESULTS

Psychosocial treatment led to significantly better knowledge of parenting principles but did not enhance parenting practices, as rated by parents and children. Significant improvement in mothers' negative parenting occurred across all treatments and was maintained.

CONCLUSIONS

In nonconduct-disordered, stimulant-treated children with ADHD, parent training does not improve self-rated parental behavior. The benefits of brief stimulant treatment for negative parental behavior are sustained with extended treatment.

Does stimulant treatment place children at risk for adult substance abuse? A controlled, prospective follow-up study

The sensitization hypothesis posits a neuroadaptation model in which exposure to stimulants results in dopamine system alterations that, in turn, increase sensitivity to the reinforcing effects of the previously experienced drug. This study examines whether stimulant treatment in childhood confers increased risk for substance use and abuse in later life, as the model predicts. Children, ages 7-12 years, with developmental reading disorders but no other psychiatric diagnoses were randomly assigned to methylphenidate treatment (n = 43) or matching placebo (n = 66) for 12-18 weeks. At 16-year follow-up (mean age 26 years), 94% of probands and 129 normal comparisons were evaluated by trained clinicians who were blind to group and treatment status. There were no significant differences between groups on the prevalence of substance use disorder (abuse or dependence) for any of the seven drug categories studied. There were no significant group differences among substance abusers regarding age at onset, duration, or number of episodes of substance abuse and dependence. Significantly more normals (60%) than treated (46%) and untreated probands (41%) ever used stimulants in adolescence or adulthood. Findings from this randomized trial contradict the notion that stimulant treatment in childhood leads to substance use or abuse in later life. The sensitization hypothesis is not supported.

Persistence of Attention-Deficit/Hyperactivity Disorder into adulthood: what have we learned from the prospective follow-up studies?

OBJECTIVES

Longitudinal studies of children with Attention-Deficit/Hyperactivity Disorder (ADHD) into adolescence have all reported high rates of ADHD. However, findings from studies into adulthood are inconsistent. This article reviews factors that may account for disparate rates found in adult follow-ups, and recommends optimal methodologies for prospective studies of children with ADHD in particular and childhood mental disorders in general.

METHOD

Follow-up studies of children with ADHD into adulthood are critically reviewed to identify factors that influence adult ADHD prevalence estimates.

RESULTS

Four factors are identified: (1) ascertainment procedure, (2) attrition rate, (3) reporting source, and (4) disorder criteria.

CONCLUSIONS

Estimates of the proportion of children with ADHD who will experience symptoms of the childhood syndrome in adulthood are likely to vary considerably, as a function of multiple factors. Several recommendations are made for designing future follow-up investigations.

The Liebowitz social anxiety scale for children and adolescents: an initial psychometric investigation

OBJECTIVE

To examine the psychometric properties of a newly developed clinician rating scale, the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA).

METHOD

A total of 154 children and adolescents participated in an assessment consisting of a diagnostic interview, the LSAS-CA, and other measures of psychopathology and impairment. Sixty-one of these children also participated in a second LSAS-CA administration, by a different rater blind to diagnosis, within 7 days of the initial assessment.

RESULTS

High internal consistency (alpha =.90-.97 for full sample and.83-.95 for social phobia group) and test-retest reliability (intraclass correlation coefficient = 0.89-0.94) were obtained for LSAS-CA total and subscale scores. LSAS-CA scores had stronger associations with measures of social anxiety and general impairment than with a measure of depression. Subjects with social anxiety disorder had significantly higher LSAS-CA scores than subjects with other anxiety disorders and healthy controls. A LSAS-CA cutoff score of 22.5 represented the best balance of sensitivity and specificity when distinguishing between individuals with social phobia and normal controls, whereas a cutoff of 29.5 was optimal for distinguishing social phobia from other anxiety disorders.

CONCLUSION

Initial findings suggest that the LSAS-CA is a reliable and valid instrument for the assessment of social anxiety disorder.

Children, stress, and context: integrating basic, clinical, and experimental prevention research

Findings from the Watamura, Donzella, Alwin, and Gunnar (this issue) study support the growing recognition of the importance of context on physiology and affective and behavioral regulation early in human development. This discussion focuses on the role of context and development on hypothalamic-pituitary-adrenal (HPA) axis regulation in young children. Discussed in this article are the Watamura et al. findings with regard to relevant animal studies, extension of these observations to samples of children at elevated risk for psychopathology, and experimental prevention studies with young children. It is contended that environmental factors operating at key points in development may shape affective and behavioral regulation as well as HPA axis function in children, much as environmental factors have been shown to shape HPA axis regulation in animals.

Preventive intervention for urban, low-income preschoolers at familial risk for conduct problems: a randomized pilot study

Conducted a pilot study to test the feasibility of a prevention program for promoting parenting in families of preschoolers at high risk for behavior problems. Risk status was based on a family history of antisocial behavior and residence in a low-income, urban community. Thirty preschoolers (ages 21/2 to 5) and their parents were randomly assigned to a 1-year, home- and clinic-based intervention or to a no-intervention control condition. Despite families' multiple risk factors, high rates of attendance and satisfaction were achieved. Relative to controls, intervention parents were observed to be significantly more responsive and use more positive parenting practices. Results support the feasibility of engaging high-risk families in an intensive prevention program. The meaningful changes achieved in parenting suggest that a preventive approach is promising for families with multiple risk factors.

Anxiety sensitivity among children of parents with anxiety disorders: a controlled high-risk study

We investigated whether parental anxiety was related to anxiety sensitivity (AS) in offspring. Subjects were 261 offspring (aged 6-17 years) of parents with lifetime DSM-IV anxiety and/or mood disorders, and 79 offspring of parents with no lifetime anxiety, mood, or psychotic disorder. Parents and offspring were interviewed by blind clinicians. Children were administered the Child Anxiety Sensitivity Index (CASI). There were no significant differences between CASI scores of the offspring of parents with anxiety and/or mood disorders, and offspring of comparison parents. We conclude that parental anxiety or mood disorder does not predispose offspring to high anxiety sensitivity.

Accuracy of adult recall of childhood attention deficit hyperactivity disorder

OBJECTIVE

Although reports of childhood status are necessary for making a diagnosis of adult attention deficit hyperactivity disorder (ADHD), systematic investigation of the accuracy of retrospective self-reports has been limited. This study examined accuracy of adult recall of childhood ADHD.

METHOD

Participants were from a controlled, prospective 16-year follow-up of children with ADHD. At a mean age of 25 years, 176 probands (85% of the 207 subjects in the initial cohort) and 168 non-ADHD comparison subjects were interviewed by clinicians who were unaware of the subjects' childhood status. Subjects were asked about specific childhood ADHD behaviors, and the diagnosis of childhood ADHD was retrospectively established.

RESULTS

Seventy-eight percent of the probands and 11% of the comparison subjects were identified as having childhood ADHD. Six symptoms demonstrated high discriminating power in differentiating the subject groups: distractibility, concentration difficulties, complaints of inattention, acting before thinking, being on the go, and fidgeting/squirming. When findings were adjusted for the prevalence of ADHD in the general population, the power of prediction was low. Positive predictive value was 0.27, i.e., of all adults retrospectively given a diagnosis of childhood ADHD, only 27% would be correctly identified. As expected, positive predictive value increased with increases in the estimated prevalence of ADHD.

CONCLUSIONS

Retrospective diagnoses of childhood ADHD made on the basis of self-reports will in most cases be invalid in settings such as epidemiological surveys and primary care facilities. Greater accuracy can be expected in settings in which childhood ADHD is frequent. The results stress the importance of obtaining contemporaneous information on childhood symptoms in establishing a childhood history of ADHD. Future directions and implications for DSM-V are discussed.

Relationship between separation anxiety disorder, parental panic disorder, and atopic disorders in children: a controlled high-risk study

OBJECTIVE

To test the hypotheses that rates of atopic disorders are elevated in offspring of parents with panic disorder (PD) and in children with separation anxiety disorder (SAD).

METHOD

Rates of atopic disorders were assessed in 343 offspring (aged 6-17 years) of parents with PD, nonpanic psychiatric disorders, and no psychiatric disorder. Lifetime history of atopic disorders was determined by parental responses to a clinician-administered questionnaire assessing medical treatment for asthma and allergies. Logistic regression analyses assessed the association between atopic disorders and parental PD, and between atopic disorders and probable or definite childhood SAD. Analyses controlled for age, sex, socioeconomic status, and treatment for other medical illnesses.

RESULTS

Increased rates of atopic disorders were found in offspring of parents with PD (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.27-5.16, p = .009) and in children with SAD (OR = 2.71, 95% Cl = 1.22-6.03, p = .015). Associations remained significant when both parental PD and SAD were included in the model, suggesting that each contributed independently to increased rates of atopy. The interaction of parental PD and child SAD was not significant.

CONCLUSIONS

Atopic disorders in children are associated with parental PD and with childhood SAD. Results do not appear to support that having both childhood SAD and a parent with PD confers increased risk for atopic disorders above and beyond either condition alone.

Young adult outcome of children with "situational" hyperactivity: a prospective, controlled follow-up study

To examine the importance of symptom pervasiveness in ADHD, we conducted a prospective, 12-year follow-up study of boys (ages 6-12) considered hyperactive at school and home (Pervasive ADHD), boys considered hyperactive by teachers but not parents (School Only ADHD), boys considered hyperactive by parents but not teachers (Home Only ADHD), and nonhyperactive comparisons. Follow-up was completed on 82-94% participants. Clinicians interviewed participants and their parents, blind to childhood status. At follow-up, antisocial disorder was significantly more prevalent among Pervasive and School Only ADHD (29% for both) than Home Only ADHD (0%) and comparisons (8%). In a similar manner, severity of behavioral problems distinguished groups (Pervasive, School > Home, comparisons), as did educational attainment and academic performance (poorest for Pervasive and School). These findings stress the validity of teacher reports in the diagnosis of ADHD.

School-based behavioral treatment for social anxiety disorder in adolescents: results of a pilot study

OBJECTIVE

To provide preliminary estimates of feasibility and effectiveness for school-based behavioral treatment in adolescents with social anxiety disorder.

METHOD

Six adolescents with social anxiety disorder were treated in a 14-session group treatment program conducted at their school. Assessments were conducted at baseline and after treatment.

RESULTS

All participants were classified as treatment responders (markedly or moderately improved). Half of the participants did not meet diagnostic criteria for social phobia after treatment. Clinician severity ratings, as measured by the Anxiety Disorders Interview Schedule for Children for DSM-IV: Child Version and the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA), decreased significantly after intervention, with effect sizes of 2.5 and 1.8, respectively. All LSAS-CA scale scores decreased significantly after treatment. Self-reported social phobia symptoms on the Social Phobia and Anxiety Inventory for Children were not significantly reduced. Fear and avoidance ratings of the 10 most feared situations significantly decreased after treatment, with effect sizes of 1.5 for anxiety and 2.1 for avoidance.

CONCLUSIONS

This study provides preliminary support for the promise of school-based behavioral intervention for treating social phobia in adolescents. The school environment may be a rich and innovative setting for implementation of behavioral treatment because this is the setting where adolescents with social phobia endure the most distress.

Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial

OBJECTIVE

To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression.

METHOD

After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores.

RESULTS

Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects.

CONCLUSIONS

Paroxetine is generally well tolerated and effective for major depression in adolescents.

Open fluoxetine treatment of mixed anxiety disorders in children and adolescents

An open-label pilot study examined fluoxetine treatment in 16 outpatients (9-18 years old) with mixed anxiety disorders. Following nonresponse to psychotherapy, fluoxetine monotherapy was started at 5 mg daily and was increased weekly by 5 or 10 mg daily for 6-9 weeks until improvement occurred or to a maximum of 40 mg (children under 12) or 80 mg (adolescents). Among patients on fluoxetine, severity of illness ratings were "much improved" (mean final Clinical Global Impression scale score 2.8 +/- 0.7). Clinical improvement occurred in 10 of 10 patients with current separation anxiety disorder, 8 of 10 with social phobia, 4 of 6 with specific phobia, 3 of 5 with panic disorder, and 1 of 7 with generalized anxiety disorder. Mean time to improvement was 5 weeks. Mean doses were 24 mg (0.7 mg/kg) for children and 40 mg (0.71 mg/kg) for adolescents. Side effects were transient and included drowsiness (31% of patients), sleep problems (19%), decreased appetite (13%), nausea (13%), abdominal pain (13%), and excitement (13%). No patient developed disinhibition, akathisia, or suicidality. These preliminary findings suggest fluoxetine effectiveness in separation anxiety disorder and social phobia. Youths with only one anxiety disorder appeared to respond to lower doses of fluoxetine than patients with multiple anxiety disorders (0.49 +/- 0.14 versus 0.80 +/- 0.28 mg/kg, p < 0.05).

Carcinogenicity assays of wood dust and wood additives in rats exposed by long-term inhalation

OBJECTIVE

This study evaluates whether wood dust and/or wood preservatives develop a carcinogenic potential against the tissues of the airways of rats.

METHODS

The formation of tumors of the respiratory tract after exposure to wood dust was studied in six groups of approximately 60 female Fischer 344 rats exposed by long-term inhalation to mean concentrations of (1) 18 mg/m3 of untreated oak wood dust, (2) wood preservatives containing ca. 1 microgram/m3 lindane and 0.2 microgram/m3 of pentachlorophenol (PCP) in the exposure air, or lindane and 18 micrograms/m3 of PCP (group lindane/PCP vapors, and group oak wood treated with lindane/PCP), (3) 21 or 39 micrograms/m3 of sodium dichromate (calculated as CrO3, group chromate aerosol and group oak wood with chromate), and 72 micrograms/m3 of N-nitrosodimethylamine vapors as positive control. The negative control group consisted of 115 animals (sham-exposed).

RESULTS

Tumors of the nasal cavity developed in two rats exposed to chromate aerosol or in combination with wood dust (2/102, 2%). Malignant tumors of the lower respiratory tract were induced only in exposed groups of rats (three adenocarcinomas of the lung and four bronchiolar lung carcinomas, 7/254, 2.8%). More respiratory tract tumors were observed in rats exposed to chromate or wood with chromate (5/102, 5%), also in groups exposed to oak wood dust (oak untreated, oak + chromate, oak + lindane/PCP; together 5/155, 3.2%). Analysis of 'unpreserved' oak wood dust revealed up to 5 micrograms/m3 of chromate. When this exposure was taken into account, eight of nine animals with respiratory tract tumors (including nasal cavity) had exposure to chromate, while only one tumor occurred in the group lindane/PCP. Otherwise the incidence of systemic tumors was increased in animals exposed to lindane/PCP, due in particular to a significantly increased incidence of liver tumors (OR = 3.7; 1.24-11.3; P = 0.019). Fatal (mucoepidermoid) tumors were induced by N-nitrosodimethylamine (NDMA) in the positive control (14/46, 30%). No such tumors of the respiratory tract were observed in the negative control.

CONCLUSIONS

Tumors in the respiratory tract were found only in exposed animals, predominantly in the groups which inhaled oak wood dust and chromate stain. Chromate may play a decisive role for the etiology of tumors of the nasal cavity in wood workers. This assumption should be supported by further dose-response studies.

Electroencephalographic asymmetries in adolescents with major depression: influence of comorbidity with anxiety disorders

This study examined whether adolescents with major depressive disorder (MDD) display the abnormal electroencephalographic (EEG) alpha asymmetries found in depressed adults. Resting EEG was recorded in 25 right-handed female outpatients (19 with MDD, 11 of whom also had a current anxiety disorder; 6 with anxiety disorders only) and 10 non-ill controls. In contrast to the non-ill controls, adolescents having MDD but no anxiety disorder showed alpha asymmetry indicative of less activation over right than over left posterior sites. Within the MDD patient group, comorbid anxiety disorders reduced the posterior alpha asymmetry, supporting the potential importance of evaluating anxiety in studies of regional brain activation in adolescent MDD. These preliminary findings are similar to those from adult studies that suggest that MDD is associated with right parietotemporal hypoactivation.

Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group

BACKGROUND

To examine the relationship between respiratory regulation and childhood anxiety disorders, this study considered the relationship between anxiety disorders and symptoms during carbon dioxide (CO(2)) exposure, CO(2) sensitivity in specific childhood anxiety disorders, and the relationship between symptomatic and physiological responses to CO(2).

METHODS

Following procedures established in adults, 104 children (aged 9-17 years), including 25 from a previous study, underwent 5% CO(2) inhalation. The sample included 57 probands with an anxiety disorder (social phobia, generalized anxiety disorder, separation anxiety disorder, and panic disorder) and 47 nonill comparison subjects. Symptoms of anxiety were assessed before, during, and after CO(2) inhalation.

RESULTS

All children tolerated the procedure well, experiencing transient or no increases in anxiety symptoms. Children with an anxiety disorder, particularly separation anxiety disorder, exhibited greater changes in somatic symptoms during inhalation of CO(2)-enriched air, relative to the comparison group. During CO(2) inhalation, symptom ratings were positively correlated with respiratory rate increases, as well as with levels of tidal volume, minute ventilation, end-tidal CO(2), and irregularity in respiratory rate during room-air breathing.

CONCLUSIONS

Childhood anxiety disorders, particularly separation anxiety disorder, are associated with CO(2) hypersensitivity, as defined by symptom reports. Carbon dioxide hypersensitivity is associated with physiological changes similar to those found in panic disorder. These and other data suggest that certain childhood anxiety disorders may share pathophysiological features with adult panic disorder.

Adolescent depression: controlled desipramine treatment and atypical features

The study was designed to test the efficacy of desipramine in adolescents with major depression (MDD). In addition, we assessed the presence of atypical features of MDD, consisting of mood reactivity and two of four associated features (rejection sensitivity, hyperphagia, hypersomnia, and leaden paralysis). Patients were randomized to desipramine (DMI) or placebo for 6 weeks, provided they failed to improve (e.g., meeting MDD criteria and a Hamilton Depression Scale score > or = 18) after 2 weeks on single blind placebo. Of 94 adolescents (ages 13-18) who were diagnosed as having MDD, 64 entered the study and 62 received placebo for 2 weeks. Of these, 45 were randomized to DMI or placebo. Completed analyses did not reveal significant improvement for the active treatment compared to the placebo. A large proportion of adolescents responded to placebo (50%), suggesting the need for very large samples to detect differential treatment efficacy, should it exist. A relatively high rate of atypical depression was observed (47% in the 64 patients entered). In view of the demonstrated specificity of monoamine oxidase inhibitor efficacy in adults with atypical features of MDD, this clinical subtype may have relevance to future investigation of therapeutic interventions in adolescent MDD.

Long-term prognosis in attention-deficit/hyperactivity disorder

The authors have traced the developmental course of ADHD from childhood to adulthood, showing that it is a bumpy road for many. In early and middle adolescence, relative deficits are seen in academic and social functioning, ADHD symptoms remain problematic in two thirds to three quarters of these children, and antisocial behaviors, in some cases amounting to CD, are common. Many of these same difficulties persist into the late teenage years. Deficits continue to be observed in academic and social domains (compared with controls, probands exhibit lower grades, more courses failed, worse performance on standardized tests, have fewer friends, and are rated less adequate in psychosocial adjustment). About two fifths continue to experience ADHD symptoms to a clinically significant degree. One quarter to one third have a diagnosed antisocial disorder, and two thirds of these individuals are arrested. Also, drug abuse is observed in a significant minority of these youths. Importantly, the greatest risk factor for the development of antisocial behavior and substance abuse by the late teenage years is the maintenance of ADD symptoms. When evaluated in their mid-twenties, dysfunctions are apparent in these same areas. Compared with controls, probands complete less schooling, hold lower-ranking occupations, and continue to suffer from poor self-esteem and social skills deficits. In addition, significantly more probands than controls exhibit an antisocial personality and, perhaps, a substance use disorder in adulthood. Furthermore, many do not outgrow all facets of their childhood syndrome. These relative deficits, however, do not tell the whole story of the ADHD child's adult fate. Indeed, nearly all probands were gainfully employed. Furthermore, some had achieved a higher-level education (e.g., completed Master's degree, enrolled in medical school) and occupation (e.g., accountant, stock broker). In addition, a full two thirds of these children showed no evidence of any mental disorder in adulthood. In conclusion, although ADHD children, as a group, fare poorly compared with their non-ADHD counterparts, the childhood syndrome does not preclude attaining high educational and vocational goals, and most children no longer exhibit clinically significant emotional or behavioral problems once they reach their mid-twenties.

Cerebral laterality in adolescent major depression

This study tests the hypothesis that adolescents with major depression exhibit abnormalities in cerebral asymmetry previously found among adults. Perceptual asymmetry was assessed through tests of verbal and non-verbal dichotic listening in four groups - 48 adolescents with major depression, 22 adolescent comparisons with no history of Axis I disorders, 149 adults with major depression, and 57 comparison adults with no history of Axis I disorders. Data from adults have been previously reported. In both age groups, subjects with major depression were further divided based on the presence or absence of an anxiety disorder. Procedures used to collect perceptual asymmetry data in adolescents and adults were identical. In both age groups, depressed and healthy subjects showed perceptual asymmetry in expected directions for verbal and non-verbal dichotic tasks. Depressed and comparison subjects differed in performance on the Fused-Word Test, though these differences varied as a function of anxiety and developmental level. Relative to comparisons, both adolescents and adults with major depression exhibited an increased right ear/left hemisphere advantage for fused words. Adults but not adolescents with comorbid major depressive and anxiety disorders exhibited a reduced right ear/left hemisphere advantage for fused words. These findings suggest similarities and differences across development in the relationship between cerebral laterality and psychopathology. Further studies using longitudinal and family-based designs, as well as various measures of regional brain activity, are needed to enhance understanding of associations between cerebral laterality and psychopathology across development.

Middle Stone Age stratigraphy and excavations at Die Kelders Cave 1 (Western Cape Province, South Africa): the 1992, 1993, and 1995 field seasons

Die Kelders Cave 1, first excavated under the direction of Franz Schweitzer in 1969-1973, was re-excavated between 1992 and 1995 by a combined team from the South African Museum, SUNY at Stony Brook, and Stanford University. These renewed excavations enlarged the artefactual and faunal samples from the inadequately sampled and less intensively excavated lower Middle Stone Age (MSA) layers, increased our understanding of the complex site formation processes within the cave, enlarged the hominid sample from the MSA deposits, and generated ESR, TL, and OSL dates for the MSA layers. Importantly, these new excavations dramatically improved our comprehension of the vertical and lateral characteristics of the MSA stratigraphy. Surface plotting of the MSA layers has led to the identification of at least two major zones of subsidence that significantly warped the layers, draping some along the eroding surface contours of major blocks of fallen limestone roof rock. A third zone of subsidence is probably present in the older excavations. Dramatic roof falls of very large limestone blocks occurred at least twice-once in the middle of Layer 4/5 where the roof blocks were only slightly weathered after collapse, and at the top of Layer 6 where the blocks weathered heavily after collapse, producing a zone of decomposed rock around the blocks. Many of the sandy strata are cut by small and localized faults and slippages. All of the strata documented by Schweitzer's excavations are present throughout the exposed area to the west of his excavated area, where many of them thicken and become more complex. Layer 6, the thickest MSA layer, becomes less diagenetically altered and compressed to the west.