Which aspects of ADHD are associated with tobacco use in early adolescence?

Several studies have found a relationship between attention-deficit hyperactivity disorder (ADHD) and substance use, primarily in the context of co-occurring conduct disorder (CD). However, very few have examined the associations between the individual dimensions of ADHD (hyperactivity-impulsivity and inattention) and substance use, even though these dimensions reflect distinct symptom groupings, both by clinical definition (DSM-IV, American Psychiatric Association, 1994) and through empirical demonstration (Lahey et al., 1988: McBurnett et al., 1999). This longitudinal study examines the relationship between dimensions of ADHD (as described by DSM) and substance use, accounting for other psychopathology and factors potentially related to substance use. Participants were 177 clinic-referred boys (initially between ages 7 and 12) followed up over nine annual phases until all participants had reached age 15. Annual assessment included structured clinical interviews with parent and child and self-report questionnaires of substance use, as well as questionnaires related to family factors and parenting behaviors. Seventy-eight per cent of participants reported use of tobacco, alcohol, marijuana, or other illicit drugs during adolescence, with 51% reporting any tobacco use. The inclusion of CD rendered all bivariate relationships with the full diagnosis of ADHD nonsignificant. However, adolescent inattention, considered independently, was associated with a 2.2 times greater risk for concurrent tobacco use, even after controlling for CD. Even when other factors, selected based on their associations with tobacco use in adolescence, were included in a regression model (concurrent adolescent CD odds ratio [OR] = 6.08), duration of tobacco use by age 12 (OR = 5.11), poor parental communication in childhood (OR = 2.9), African-American ethnicity (inversely predictive; OR = 0.15), inattention (OR = 2.3) remained significantly associated with tobacco use in early adolescence. These findings highlight the importance of considering the risks for comorbid substance use separately by individual dimensions of ADHD.

The DISC Predictive Scales (DPS): efficiently screening for diagnoses

OBJECTIVE

To derive and test a series of brief diagnosis-specific scales to identify subjects who are at high probability of meeting diagnostic criteria and those who may safely be spared more extensive diagnostic inquiry.

METHOD

Secondary data analysis of a large epidemiological data set (n = 1,286) produced a series of gate and contingent items for each diagnosis. Findings were replicated in a second retrospective analysis from a residential care sample (n = 884). The DISC Predictive Scales (DPS) were then used prospectively as a self-report questionnaire in two studies, in which parents (n = 128) and/or adolescents (n = 208) had subsequent diagnostic interviewing with the Diagnostic Interview Schedule for Children or the Schedule for Affective Disorders and Schizophrenia for School-Age Children.

RESULTS

All analyses showed that gate item selection was valid and that any missed cases were due solely to inconsistent reports on the same questions. Screening performance of the full scales was shown to be good, and substantial reductions in scale length were not associated with significant changes in discriminatory power.

CONCLUSIONS

The DPS can accurately determine subjects who can safely be spared further diagnostic inquiry in any diagnostic area. This has the potential to speed up structured diagnostic interviewing considerably. The full DPS can be used to screen accurately for cases of specific DSM-III-R disorders.

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

OBJECTIVE

To review empirical findings on oppositional defiant disorder (ODD) and conduct disorder (CD).

METHOD

Selected summaries of the literature over the past decade are presented.

RESULTS

Evidence supports a distinction between the symptoms of ODD and many symptoms of CD, but there is controversy about whether aggressive symptoms should be considered to be part of ODD or CD. CD is clearly heterogenous, but further research is needed regarding the most useful subtypes. Some progress has been made in documenting sex differences. Symptoms that are more serious, more atypical for the child's sex, or more age-atypical appear to be prognostic of serious dysfunction. Progress has been made in the methods for assessment of ODD and CD, but some critical issues, such as combined information from different informants, remains to be addressed. A proportion of children with ODD later develop CD, and a proportion of those with CD later meet criteria for antisocial personality disorder. ODD and CD frequently co-occur with other psychiatric conditions.

CONCLUSIONS

Although major advances in the study of the prevalence and course of ODD and CD have occurred in the past decade, some key issues remain unanswered.

Childhood obsessive-compulsive disorder in the NIMH MECA study: parent versus child identification of cases. Methods for the Epidemiology of Child and Adolescent Mental Disorders

Abstract-Because as many as 50% of obsessive-compulsive disorder (OCD) cases have had onset by age 15, interest in its detection in childhood is strong. Clinical experience indicates that children often try to keep their OCD secret and that parental report may give marked underestimates. The authors examined the prevalence of childhood OCD in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a four-site community survey which allowed comparison of both parent and child report of the child's OCD and related symptoms and disorders. OCD cases, based on structured interviews (DISC-2.3 with DSM-III-R criteria) with 1,285 caretaker-child pairs, were identified separately for parent and child (aged 9 through 17) informants from the MECA database. Cases were then examined for demographic characteristics, for obsessive-compulsive symptoms and other diagnoses reported in cases "missed" by one reporter, and for comorbid disorders. Of a total of 35 (2.7%) identified cases, four (0.3%) were identified by the parent and 32 (2.5%) were identified by the child, with only one overlapping case. In general, when OCD cases were "missed" by one reporter, that reporter did not substitute another disorder. These findings support clinical data that children with OCD often hide their illness and underscore the importance of child interviews for its detection.

Age and gender differences in oppositional behavior and conduct problems: a cross-sectional household study of middle childhood and adolescence

Behavior problems among youths cannot be understood without explaining their age and gender differences, but age and gender differences cannot be explained until they have been accurately described. In a household survey of 1,285 youths aged 9 to 17 years, there were no gender differences in oppositional behavior, but aggression, property offenses, and status offenses were more common among boys. Levels of oppositional behavior were greater at younger ages, aggression peaked near the middle of this age range, and property and status offenses were more prevalent at older ages. These findings are generally consistent with developmental models of conduct problems but are inconsistent with a recent model of gender differences and raise questions about the external validity of current taxonomies.

Risk behavior in a community sample of children and adolescents

OBJECTIVES

First, to investigate whether there is covariation between risk behaviors, including suicidality, in a community probability sample of children and adolescents; and second, to investigate whether risk behavior is associated with selected potential correlates.

METHOD

A sample of 9- to 17-year-old youths (N = 1,285) and their caretakers were interviewed in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The risk behaviors were marijuana smoking, alcohol use, intercourse, fighting, cigarette smoking, and suicidal ideation/attempts. Relationships between the risk behaviors were described using odds ratios. Linear regression analyses of an index of risk behavior on the selected potential correlates of risk behavior were conducted.

RESULTS

There were significant relationships between all pairs of risk behaviors. The score on the index of risk behavior was associated with stressors, lack of resources, family psychiatric disorder, psychopathology, and functional impairment.

CONCLUSIONS

Clinicians should be alerted to the possibility of risk behaviors, especially in children and adolescents engaging in other risk behaviors and those with inadequate resources, stressors, functional impairment, or psychopathology.

Major depression and dysthymia in children and adolescents: discriminant validity and differential consequences in a community sample

OBJECTIVES

To evaluate evidence, in a community sample, for discriminant validity between major depression (MDD) and dysthymia (Dy) in children and adolescents and to examine differential consequences of the 2 disorders for functioning.

METHOD

The National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study consists of probability samples of youths. Data for this study are derived from interviews with 1,285 complete parent-youth pairs aged 9 to 17 years from 4 geographic areas in the United States. Youths with MDD were contrasted with those with Dy and those with both (MDD-Dy) on the NIMH Diagnostic Interview Schedule for Children, Non-Clinician Children's Global Assessment Scale, Columbia Impairment Scale, and the Service Utilization and Risk Factors Module.

RESULTS

Groups with MDD, Dy, or MDD-Dy did not differ on sociodemographic, clinical, or family and life event variables. Youths with combined MDD-Dy were significantly less competent and more impaired than youths with either disorder alone.

CONCLUSIONS

The findings do not provide support for the differentiation of MDD and Dy but strongly suggest the importance of addressing the needs of youths who meet criteria for both MDD and Dy because this combination is likely to be both serious and disruptive of normal developmental processes.

Physical fighting in childhood as a risk factor for later mental health problems

OBJECTIVE

The prevalence, persistence, and desistance of boys' physical fighting was examined over a 7-year period. The importance of persistent physical fighting compared with other risk factors in the prediction of later mental health problems was explored.

METHOD

One hundred seventy-seven boys, aged 7 to 12 years, who had been referred to clinics for mental health problems were followed up annually for 7 years, with the boys, their parents, and teachers as informants.

RESULTS

Agreement among different informants about the boys' fighting tended to be low. The prevalence of fighting over time remained quite similar for different age cohorts. Almost 9 of 10 fighters in year 1 continued to fight in one or more successive years, and about one third of the boys could be classified as persistent fighters. Only 13.1% of the boys desisted in fighting. Boys who desisted, compared with those who persisted, had higher intelligence and their mothers scored lower on measures of antisocial personality disorder. At year 7, persistent fighting was significantly associated with impairment. The prevalence of psychiatric diagnoses in year 7 was 3 times higher for persistent fighters than for nonfighters. Using regression analyses with several control variables, conduct disorder was best predicted by earlier oppositional defiant disorder in year 1 and persistent fighting. Global impairment was best predicted by oppositional defiant disorder in year 1, persistent fighting, and low IQ. Finally, the number of diagnoses at year 7 was best predicted by persistent fighting.

CONCLUSION

Physical fighting constitutes a significant mental health risk in referred boys.

Findings on disruptive behavior disorders from the first decade of the Developmental Trends Study

The paper summarizes the first decade of the Developmental Trends Study, a prospective longitudinal study of 177 boys. Initially, they were referred to mental health clinics in Pennsylvania (Pittsburgh), and Georgia (Athens and Atlanta). Since 1987, the boys, their parents, and their teachers have been followed up almost annually. The study is unique because the cooperation rate of participants has remained very high over the years, psychiatric diagnoses were derived from structured interviews (especially disruptive behavior disorders), and many risk factors were measured over the years. The present paper summarizes key findings on the development of disruptive behavior, especially Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficit-Hyperactivity Disorder. The paper also highlights results on risk factors and comorbid conditions of disruptive behaviors.

Low salivary cortisol and persistent aggression in boys referred for disruptive behavior

BACKGROUND

Persistent antisocial behavior in adulthood is often preceded by childhood-onset aggressive conduct disorder. Aggressive syndromes in both children and adults have previously been associated with abnormalities in peripheral responses to stress. One peripheral measure, salivary cortisol concentration, may reflect individual differences in the hypothalamic-pituitary-adrenal axis that underlie propensities for aggression, socialization, and adaptation to stress.

METHODS

The relationship between salivary cortisol levels and aggression was tested in 38 clinic-referred school-aged boys. Persistent aggression was measured by collecting disruptive behavior disorder symptoms in 4 annual clinical evaluations and peer nominations of aggression in the first 2 annual evaluations. Salivary cortisol levels were measured during years 2 and 4 of the study.

RESULTS

Low cortisol levels were associated with persistence and early onset of aggression, particularly when measures of cortisol concentrations were pooled. Boys with low cortisol concentrations at both time points exhibited triple the number of aggressive symptoms and were named as most aggressive by peers 3 times as often as boys who had higher cortisol concentrations at either sampling time.

CONCLUSIONS

This suggests that low hypothalamic-pituitary-adrenal axis activity is a correlate of severe and persistent aggression in male children and adolescents. A restricted (low) range of cortisol variability may be more indicative of persistent aggression than a low concentration of cortisol at any single point in time.

Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?

OBJECTIVE

To examine the unique cases contributed by parent and child informants to diagnostic classification, with the goal of identifying those diagnoses for which either or both informants are needed.

METHOD

The authors examined survey data from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a 4-community epidemiology survey of 9- to 17-year-old children and their parents. Parent-child dyads (1,285 pairs) were independently interviewed by lay persons with the Diagnostic Interview Schedule for Children; a subset of these pairs (n = 247) were also interviewed by clinicians. Agreement between parents and children was examined with respect to levels of impairment, need for/use of services, and clinicians' diagnoses.

RESULTS

Parents and children rarely agreed on the presence of diagnostic conditions, regardless of diagnostic type. Nonetheless, most child-only- and parent-only-identified diagnoses were similarly related to impairment and clinical validation, with 2 exceptions: child-only-identified attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).

CONCLUSIONS

Overall findings suggest that most "discrepant" diagnoses (those reported by one but not the other informant) reflect meaningful clinical conditions. In some instances, however, diagnoses reported by one but not the other informant should be treated with caution, as they may not reflect the full diagnostic condition (e.g., possibly child-only-identified ADHD or ODD). Further research is needed to determine the salience of child-only- or parent-only-reported cases.

Association of parental psychopathology to the comorbid disorders of boys with attention deficit-hyperactivity disorder

This study examined whether particular forms of parental psychopathology are related to similar forms of comorbid psychopathology in offspring with attention deficit-hyperactivity disorder (ADHD). Parental disorders were assessed using maternal interviews, and child disorders were assessed using multiple-informant interviews for 111 clinic-referred boys (aged 7-12) with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) ADHD. Associations between parental and child internalizing disorders and between parental and child externalizing disorders were found, but associations across categories of disorder (i.e., internalizing and externalizing) were not. Similar relationships were observed in 66 clinic-referred boys without ADHD. These findings support specific modes of familial transmission, in contrast to theories that comorbidity simply reflects more severe psychopathology in children with ADHD.

Utility of behavior ratings by examiners during assessments of preschool children with attention-deficit/hyperactivity disorder

This study examines the clinical utility of behavior ratings made by nonclinician examiners during assessments of preschool children with Attention-Deficit/Hyperactivity Disorder (AD/HD). Matched samples of children with (n = 127) and without (n = 125) AD/HD were utilized to test the internal, convergent, concurrent, and incremental validity of ratings completed by examiners on the Hillside Behavior Rating Scale (HBRS). Results indicated that HBRS ratings were internally consistent, possessed sufficient interrater reliability, and were significantly associated with parent and teacher reports of AD/HD when controlling for age, gender, intelligence, and symptoms of other psychopathology. HBRS ratings also were significantly associated with other measures of functioning, and provided a significant increment in the prediction of impairment over parent and teacher report alone. These findings suggest that behavioral ratings during testing provide a unique source of clinical information that may be useful as a supplement to parent and teacher reports.

Boys who join gangs: a prospective study of predictors of first gang entry

In a representative sample of boys who were in the 7th grade of an urban public school system at the start of a 6-year longitudinal study, more African American boys (23.8%) than non-Hispanic White boys (3.9%) had entered an antisocial gang by age 19. There were too few White gang members to study, but among African American boys, first gang entry was predicted prospectively by both baseline conduct disorder (CD) behaviors and increasing levels of CD behaviors prior to gang entry. This suggests that gang entry may be a further developmental step for some boys who are already on a trajectory of worsening antisocial behavior. Having friends prior to gang entry who engaged in aggressive delinquency increased the risk of gang entry further, but only during early adolescence. Family income and parental supervision also independently predicted gang entry, but the direction of their influences depended on the youth's age.

Relation of age of onset to the type and severity of child and adolescent conduct problems

In a cross-sectional household sample of 9-through 17-year-old youths from 4 U.S. communities, youths with earlier ages of onset of conduct problems engaged in more conduct problems than youths with later ages of onset when current age and gender were controlled. Specifically, youths with earlier ages of onset were more likely to engage in several types of physical aggression, frequent lying, theft, and vandalism and were less likely to engage in only truancy. There also was an inverse relation between age of onset and level of functional impairment, mental health service use, and meeting diagnostic criteria for conduct disorder, attention-deficit hyperactivity disorder, and oppositional defiant disorder. Within the limits of cross-sectional data, these results support the hypothesis that key aspects of the heterogeneity of conduct problems among youths are related to the age of onset of conduct problems.

Annotation: the development of antisocial behavior: an integrative causal model

In this paper we have described an integrative causal model of the development of antisocial behavior in children and adolescents. The present model primarily integrates several previous models, but offers some new testable hypotheses. We believe that stable individual differences in propensity to antisocial behavior reflect variations in a number of dimensions of predisposing temperament and cognitive ability, each with its own genetic and environmental influences. The dimensions of predisposing temperament include oppositionality, harm avoidance, and callousness. Genetic influences are predicted to have only indirect effects on antisocial behavior via their influence on predisposition and on the youth's social environment. Environmental influences are expected to be important contributors to antisocial propensity, but these environmental influences reflect, in part, the genetic influences on the dimensions of predisposition (i.e. genotype-environment covariance). We also hypothesize that the levels of influence of the factors that determine individual differences in antisocial propensity change with development, such that genetic influences are of greater magnitude in early childhood and social influences contribute more strongly during later childhood and adolescence (both through independent effects and genotype-environment covariance). However, low levels of heritable predisposing child characteristics may protect against peer influences at all ages.

Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study

OBJECTIVE

To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders.

METHOD

Diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

RESULTS

The rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults.

CONCLUSIONS

The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.

Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children

OBJECTIVE

Little is known about the validity of the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children. Moreover, the results of the DSM-IV field trials raised concerns that inclusion of the new predominantly hyperactive-impulsive type of ADHD in DSM-IV might increase the likelihood of the diagnosis being given to active but unimpaired preschool and primary school children.

METHOD

The validity of DSM-IV criteria for each subtype of ADHD was evaluated in 126 children, aged 4 through 6 years, and 126 matched comparison children. Probands and controls were classified by using structured diagnostic interviews of the parent and a DSM-IV checklist completed by the teacher.

RESULTS

Children who met DSM-IV criteria for each subtype of ADHD according to parent and teacher reports differed consistently from controls on a wide range of measures of social and academic impairment, even when other types of psychopathology and other potential confounds were controlled.

CONCLUSIONS

When diagnosed by means of a structured diagnostic protocol, all three DSM-IV subtypes of ADHD are valid for 4- through 6-year-old children in the sense of identifying children with lower mean scores on measures of adaptive functioning that are independently associated with ADHD.

Validity of DSM-IV subtypes of conduct disorder based on age of onset

OBJECTIVE

To present data from the DSM-IV field trials that led to the distinction between subtypes of conduct disorder (CD) that emerge in childhood or adolescence. In addition, data from a household sample were used to attempt to cross-validate these findings.

METHOD

Differences between youths who met criteria for the two subtypes of CD were examined in the field trials sample of 440 youths aged 4 through 17 years and in a household sample of 1,285 youths aged 9 through 17 years.

RESULTS

In both samples, there was a steep decline in aggression occurring around an age of onset of 10 years, but the number of nonaggressive behaviors was unrelated to the age of onset of CD. In the field trials sample, youths who met criteria for the adolescent-onset type were more likely to be girls, less likely to meet criteria for oppositional defiant disorder, and less likely to have a family history of antisocial behavior than the childhood-onset type, but these latter findings were not confirmed in the household sample.

CONCLUSIONS

The DSM-IV approach to subtyping CD distinguishes subgroups that differ markedly in level of physical aggression. The advantages of a developmental approach to subtyping are discussed.

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

OBJECTIVE

To examine the validity of the DSM-IV requirement of an age of onset of impairment due to symptoms before 7 years of age for the diagnosis of attention-deficit/hyperactivity disorder (ADHD).

METHOD

The validity of this criterion was examined in a clinic sample of 380 youths aged 4 through 17 years by comparing youths who met symptom criteria for ADHD and either did or did not display impairment before age 7 years.

RESULTS

Nearly all youths who met symptom criteria for the predominantly hyperactive-impulsive subtype also met the age of onset of impairment criterion, but 18% of youths who met symptom criteria for the combined type, and 43% of youths who met symptom criteria for the predominantly inattentive type, did not manifest impairment before 7 years. For the latter two subtypes, requiring impairment before age 7 years reduced the accuracy of identification of currently impaired cases of ADHD and reduced agreement with clinicians' judgments.

CONCLUSIONS

These findings raise questions about the validity of the DSM-IV definition of age of onset of ADHD. Marked differences in the ages of onset of both symptoms and impairment for the three subtypes of ADHD support the validity of distinguishing among these subtypes in DSM-IV.

Maternal smoking during pregnancy and the risk of conduct disorder in boys

BACKGROUND

Previous animal and human studies have indicated that prenatal exposure to nicotine is associated with adverse reproductive outcomes, including altered neural structure and functioning, cognitive deficits, and behavior problems in the offspring. Our study extends previous research on humans by controlling a broad range of correlates of maternal smoking during pregnancy to determine if smoking is associated with behavior problems in the offspring severe enough to qualify for DSM-III-R diagnosis.

METHODS

Subjects were 177 clinic-referred boys, ages 7 to 12 years at the time of the first assessment, who underwent longitudinal assessment for 6 years using annual structured diagnostic interviews. Correlates of maternal smoking during pregnancy and previously identified demographic, parental, perinatal, and family risk factors for the disruptive behavior disorders were controlled in logistic regression analyses.

RESULTS

Mothers who smoked more than half a pack of cigarettes daily during pregnancy were significantly more likely to have a child with conduct disorder (odds ratio, 4.4; P = .001) than mothers who did not smoke during pregnancy. This association was statistically significant when controlling for socioeconomic status, maternal age, parental antisocial personality, substance abuse during pregnancy, and maladaptive parenting.

CONCLUSIONS

Maternal smoking during pregnancy appears to be a robust independent risk factor for conduct disorder in male offspring. Maternal smoking during pregnancy may have direct adverse effects on the developing fetus or be a marker for a heretofore unmeasured characteristic of mothers that is of etiologic significance conduct disorder.

Psychiatric disorders associated with substance use among children and adolescents: findings from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study

The relationships between specific quantities and frequencies of alcohol, cigarette, and illicit substance use and substance use (SUD) and other psychiatric disorders were investigated among 1,285 randomly selected children and adolescents, aged 9 to 18, and their parents, from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Logistic regressions indicated that daily cigarette smoking, weekly alcohol consumption, and any illicit substance use in the past year were each independently associated with an elevated likelihood of diagnosis with SUD and other psychiatric disorders (anxiety, mood, or disruptive behavior disorders), controlling for sociodemographic characteristics (age, gender, ethnicity, family income). The associations between the use of specific substances and specific psychiatric disorders varied as a function of gender.

Representativeness of clinical samples of youths with mental disorders: a preliminary population-based study

In a household community sample of 1,285, 9-17 years-olds with mental disorders who had received outpatient specialty mental health services in the past year were compared with youths with mental disorders who had not received those services to determine if samples drawn from clinical settings are representative of youths with mental disorders in the general population. Those who had used services were more impaired, less competent, more likely to have comorbid disorders, more likely to belong to non-Hispanic White relative to other ethnic groups, and less likely to be prepubertal girls. Their parents were more educated, but less satisfied with family life, engaged in less monitoring of their children, and more likely to have used mental health services themselves. These findings suggest the hypothesis that samples of youths with mental disorders drawn from outpatient clinical settings are not representative of all youths with mental disorders. If confirmed, this would indicate the importance of population-based samples for the study of psychopathology in youths.

The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study

OBJECTIVE

To describe the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 and to provide data on its performance characteristics in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

METHOD

Data were collected on the DISC-2.3 at four sites on 1,285 randomly selected children, aged 9 through 17 years, and their parents. Two hundred forty-seven of these child-parent pairs were reassessed on the DISC-2.3 by a clinician interviewer, 1 to 3 weeks later.

RESULTS

Administration time was approximately 1 hour and the interview was acceptable to more than 90% of subjects. The reliability of questions to parents assessing impairment and age of onset was generally good to acceptable for most diagnoses but was less satisfactory for the child interview. Using information from parent and child, the prevalence for any diagnosis ranged from 50.6 if no impairment criteria were required to 5.4 if a Global Assessment Scale score of 50 or less was necessary. The prevalence of anxiety disorders and enuresis was markedly reduced by requiring attributable impairment.

CONCLUSIONS

The DISC-2 is a reliable and economical tool for assessing child psychopathology. Reliability of the DISC-P-2.3 is superior to that of the child DISC for most diagnoses but is least good for anxiety disorders. The 2.3 version of the instrument provides a significant improvement over earlier versions.

Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3)

OBJECTIVE

To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings.

METHOD

Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses.

RESULTS

In general, the DISC showed moderate to good validity across a number of diagnoses.

CONCLUSIONS

Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology

OBJECTIVE

A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents.

METHOD

Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization.

RESULTS

More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend.

CONCLUSIONS

These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Developmental change in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study

One hundred six clinic-referred boys meeting criteria for DSM-III-R attention-deficit hyperactivity disorder (ADHD) (mean age 9.4 years) were assessed annually for 4 years using structured interviews of multiple informants. Hyperactivity-impulsivity symptoms declined with increasing age, but inattention symptoms did not. Rather, inattention declined only from the first to the second assessment and remained stable thereafter in boys of all ages. The rate of decline in hyperactivity-impulsivity symptoms was independent of the amount and type of treatment received. Boys who still met criteria for ADHD in Years 3 and 4 were significantly younger, more hyperactive-impulsive, and more likely to exhibit conduct disorder in Year 1 than boys who no longer met criteria in Years 3 and 4.

Which boys will fare worse? Early predictors of the onset of conduct disorder in a six-year longitudinal study

OBJECTIVE

This article addresses the following questions: What are the best demographic and psychiatric predictors of the onset of conduct disorder (CD)? Does physical fighting play a role in the transition from oppositional defiant disorder (ODD) to CD? And what are the predictors of an earlier compared with a later onset of CD?

METHOD

Data are presented on the follow-up of a clinic-referred sample of 177 preadolescent boys who were studied for a period of 6 years. Psychiatric assessments were based on information from the boys, their parent, and their teacher.

RESULTS

Of all CD symptoms, physical fighting best predicted the onset of CD in bivariate analyses. Logistic regression showed that low socioeconomic status of the parent, ODD, and parental substance abuse best predicted the onset of CD. In addition, attention-deficit hyperactivity disorder (ADHD) predicted an early onset of CD.

CONCLUSIONS

Parental substance abuse, low socioeconomic status, and oppositional behavior are key factors in boys' progression to CD. Physical fighting, although not a symptom of ODD, should be targeted in preventive interventions along with ODD symptoms. ADHD is implicated in the early onset of CD, but not in later-onset CD.

Four-year longitudinal study of conduct disorder in boys: patterns and predictors of persistence

A prospective study of conduct disorder (CD) was conducted using 4 annual structured diagnostic interviews of 171 clinic-referred boys, their parents, and their teachers. Only about half of the 65 boys who met criteria for CD in Year 1 met criteria again during the next year, but 88% met criteria for CD again at least once during the next 3 years. For most boys with CD, the number of symptoms fluctuated above and below the diagnostic threshold from year to year but remained relatively high. Lower socioeconomic status, parental antisocial personality disorder (APD), and attention-deficit hyperactivity disorder were significant correlates of CD in Year 1, but the interaction of parental APD and the boy's verbal intelligence predicted the persistence of CD symptoms over time (i.e., only boys without a parent with APD and with above-average verbal intelligence clearly improved).

DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents

OBJECTIVE

Optimal diagnostic thresholds were determined for DSM-IV attention deficit hyperactivity disorder, and the psychometric properties were compared to alternative definitions.

METHOD

Structured diagnostic interviews of multiple informants for 380 clinic-referred youths aged 4-17 years were conducted. In addition, standardized clinicians' validation diagnoses of attention deficit disorder were obtained to assess agreement with clinical judgment. Measures of impairment were obtained to assess the accuracy of identifying youth with an impairing condition.

RESULTS

Three subtypes of attention deficit hyperactivity disorder (predominantly inattentive, predominantly hyperactive-impulsive, and combined types) were distinguished on the basis of the degree of deviance on separate dimensions of inattention and hyperactivity-impulsivity. These three subtypes were found to differ in terms of types of impairment, age, and sex ratio, but not ethnicity. In terms of case identification of attention deficit hyperactivity disorder, DSM-IV was found to be very similar to DSM-III-R, except that DSM-IV identified more impaired girls and preschool children.

CONCLUSIONS

These results support the decision to subdivide the heterogeneous category of DSM-III-R attention deficit hyperactivity disorder into three subtypes. The resulting DSM-IV definition appears to be somewhat less biased toward the symptom pattern typical of elementary school boys.

DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents

OBJECTIVE

The purpose of the field trials for oppositional defiant disorder and conduct disorder was to select valid diagnostic thresholds for these disorders and to compare the psychometric properties of DSM-IV criteria for oppositional defiant disorder and conduct disorder with previous DSM diagnostic formulations.

METHOD

Structured diagnostic interviews, standardized clinician's validation diagnoses, and multiple measures of impairment were obtained for 440 clinic-referred children and adolescents aged 4-17 years.

RESULTS

A diagnostic threshold of four symptoms of oppositional defiant disorder optimized identification of impaired children, improved agreement somewhat with the clinician's validation diagnosis, and had somewhat better test-retest agreement than DSM-III-R. In the case of conduct disorder, the optimal time window for ascertainment of symptoms was clarified. A diagnostic threshold of three symptoms of conduct disorder maximized accurate identification of impaired children and agreement with the clinician's validation diagnosis and resulted in slightly better test-retest agreement than DSM-III-R. Compared with the DSM-III-R definition, the DSM-IV definition of oppositional defiant disorder was somewhat more prevalent, but the prevalence of conduct disorder was essentially unchanged.

CONCLUSIONS

DSM-IV definitions of oppositional defiant disorder and conduct disorder are somewhat better than DSM-III-R definitions in terms of internal consistency and test-retest agreement, and the validity of the DSM-IV definition of oppositional defiant disorder is slightly better than that of DSM-III-R.

DSM-IV field trials for the disruptive behavior disorders: symptom utility estimates

OBJECTIVE

We tested the predictive utility of symptoms for proposed DSM-IV definitions of the disruptive behavior disorders using indices corrected for symptom and diagnosis base rates.

METHOD

The field trials sample consisted of 440 clinic-referred youths who were consecutive referrals to a heterogeneous group of mental health clinics. Multiple informants were interviewed to determine the presence of symptoms and diagnoses.

RESULTS

Some symptoms which were either not in DSM-III or DSM-III-R, or were modifications of DSM-III-R symptoms, had greater diagnostic efficiency than did several existing symptoms. Symptom utility estimates were generally similar for different ages and genders, although some interesting age and sex trends emerged for a few symptoms.

CONCLUSIONS

The results supported the inclusion of more restricted definitions of "lying" and "truancy" to increase their association with a conduct disorder diagnosis and they supported the elimination of "swearing" in the oppositional defiant disorder criteria. In addition to their relevance for developing optimal criteria for DSM-IV, these results can aid DSM-IV users by providing a useful guide to the relative efficiency of individual symptoms based on data from a large heterogeneous clinic population.

Criterion validity of informants in the diagnosis of disruptive behavior disorders in children: a preliminary study

The relative validity of the reports of parents, teachers, and children, and combinations of these informants was assessed using measures of concurrent impairment associated with disruptive behavior disorders as criterion variables in a clinic-referred sample of 177 boys ages 7-12 years. For oppositional defiant disorder (ODD) and conduct disorder (CD), the reports from teachers, alone and in combination with parents and children, showed the strongest relations to impairment criteria. The reports of parents and children, alone and in combination, were relatively less valid. For attention-deficit hyperactivity disorder, there were no significant correlations between the reports of any single informant or combination of informants and the impairment criteria. This study provides preliminary support for the validity of multi-informant diagnostic assessment of ODD and CD in children, especially when the teacher is one of the informants.

Evidence for developmentally based diagnoses of oppositional defiant disorder and conduct disorder

This paper compares the validity of DSM-III-R diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD) and an alternative option which is subdivided into three levels according to developmental sequence and severity: modified oppositional disorder (MODD), intermediate CD (ICD), and advanced CD (ACD). Using a sample of 177 boys followed over 3 years, both the DSM-III-R and the alternative diagnostic constructs are evaluated on three criteria: symptom discriminative validity, and diagnostic external and predictive validity. Most DSM-III-R ODD and CD symptoms discriminated between ODD and CD, but exceptions are noted. Additional analyses demonstrated considerable overlap among DSM-III-R oppositional symptoms. The majority of the symptoms proposed for the alternative option could be assigned to a specific level based on acceptable symptom discrimination. External validity lent support to the distinctions between DSM-III-R ODD and CD, and between MODD, ICD, and ACD. MODD was a better predictor than ODD of which MODD, ICD, and ACD. MODD was a better predictor than ODD of which boys received a later diagnosis of CD. Suggestions are made for the inclusion and exclusion of symptoms for developmentally based diagnoses of oppositional and conduct disorders.

Oppositional defiant and conduct disorders: issues to be resolved for DSM-IV

Oppositional defiant disorder (ODD) and conduct disorder (CD) are reasonably distinct both in terms of statistical covariation among symptoms and ages of onset. The two disorders are related in similar ways to impairment and family history of antisocial behavior, but the association is stronger for CD than ODD. Virtually all clinic-referred youths with prepubertal onset of CD have retained the symptoms of ODD that emerged at earlier ages. Furthermore, a set of serious antisocial behaviors characteristically emerges at later ages in some youths with CD, suggesting further developmental progression within CD. These findings are consistent with a conceptualization of ODD and CD as developmentally staged, hierarchically organized levels of severity of the same disorder, but two findings argue for distinguishing separate disorders in DSM-IV: (1) many youths with ODD never develop CD, and (2) CD that emerges for the first time in adolescence appears to be independent of ODD.

Familial risk factors to oppositional defiant disorder and conduct disorder: parental psychopathology and maternal parenting

In a sample of 177 clinic-referred children aged 7-13, an association was found between a diagnosis of conduct disorder (CD) and several aspects of family functioning: maternal parenting (supervision and persistence in discipline) and parental adjustment (paternal antisocial personality disorder and paternal substance abuse). Children with oppositional defiant disorder (ODD) were intermediate to families of children with CD and clinic control children on all variables, but differed from control children only in having a higher rate of paternal substance abuse and paternal antisocial personality disorder (APD). When both parental APD and deviant maternal parenting were entered into 2 x 2 logit-model analyses predicting CD, only parental APD was significantly associated with CD, and no interactions between parental adjustment and maternal parenting were found. The importance of these findings for understanding the etiology of CD and for disentangling correlated risk factors in future studies is discussed.

Familial risk factors to oppositional defiant disorder and conduct disorder: Parental psychopathology and maternal parenting

In a sample of 177 clinic-referred children aged 7-13, an association was found between a diagnosis of conduct disorder (CD) and several aspects of family functioning: maternal parenting (supervision and persistence in discipline) and parental adjustment (paternal antisocial personality disorder and paternal substance abuse). Children with oppositional defiant disorder (ODD) were intermediate to families of children with CD and clinic control children on all variables, but differed from control children only in having a higher rate of paternal substance abuse and paternal antisocial personality disorder (APD). When both parental APD and deviant maternal parenting were entered into 2 x 2 logit-model analyses predicting CD, only parental APD was significantly associated with CD, and no interactions between parental adjustment and maternal parenting were found. The importance of these findings for understanding the etiology of CD and for disentangling correlated risk factors in future studies is discussed.

Diagnostic conundrum of oppositional defiant disorder and conduct disorder

Evidence for a diagnostic distinction of oppositional defiant disorder (ODD) and conduct disorder (CD) is reviewed, and alternative conceptualizations and definitions for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders are considered. Studies suggest that CD and ODD are strongly and developmentally related but clearly different. Factor analyses indicate that distinct covarying groups of ODD and CD symptoms can be identified, but certain symptoms relate to both (particularly mild aggression and lying). Age of onset for ODD is earlier than for most CD symptoms. Nearly all youths with CD have a history of ODD, but not all ODD cases progress to CD. The disorders demonstrate the same forms of parental psychopathology and family adversity but to a greater degree for CD than for ODD. Alternative conceptualizations for the disorders are presented for further study before the introduction of the DSM-IV.

Academic underachievement and the disruptive behavior disorders

Academic underachievement (AU) was studied among 177 clinic-referred boys reliably diagnosed as having attention-deficit hyperactivity disorder (ADHD) or conduct disorder (CD). Unlike previous studies, the present study assessed AU using a formula that determined the discrepancy between a child's predicted level of achievement and actual level of achievement while controlling for regression and age effects. AU was associated with both ADHD and CD when the disorders were examined individually. However, when examined in multivariate logit model analyses, the apparent relation between CD and AU was found to be due to its comorbidity with ADHD. When boys with ADHD were divided into those with attention deficits only and those with co-occurring hyperactivity, findings did not support the hypothesis that the association with AU is stronger for attention deficits without co-occurring hyperactivity.