The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Childhood conduct problems, attention deficit behaviors, and adolescent alcohol, tobacco, and illicit drug use

The relationships between conduct problems and attention deficit behaviors at age 8 years and the use of alcohol, tobacco, and illicit drugs at 15 years were studied in a birth cohort of over 900 New Zealand children. The analysis showed that while early conduct problems were significantly associated with later substance use there were no significant associations between early attention deficit behaviors and later substance use once the correlations between conduct problems and attention deficit behaviors were taken into account. These associations persisted after control for a range of potentially confounding covariates. Children who showed tendencies to conduct problems at age 8 consumed 1.5 to 1.9 times more alcohol and had rates of alcohol-related problems, daily cigarette smoking, and illicit drug use that were 1.9 to 2.0 times higher than children with low conduct problem scores. It is concluded that attention deficit behaviors, in the absence of conduct problems, are not associated with later substance use. However, even when due allowance is made for social and contextual factors associated with both early conduct problems and later substance use, early conduct problems are a risk factor for later substance use.

Is self-esteem an important outcome in hyperactive children?

Using a prospective design, this study examined (a) whether hyperactive children suffer from low self-esteem as adolescents; (b) whether low self-esteem is associated with poor functioning in adolescence; (c) whether hyperactive children exhibit a positive illusory bias, in which self-esteem is independent of level of functioning; and (d) whether self-esteem in adolescence is associated with poor functioning in adulthood. Subjects were 65 children diagnosed as hyperactive in childhood, and 62 matched controls sampled from a medical clinic. After controlling for current mental disorder, the hyperactive cohort reported lower self-esteem in adolescence, was judged by clinicians to have lower levels of overall adjustment in adolescence, and had lower educational achievement and occupational rank in adulthood, as compared to controls.

Continuity and change of self-reported problem behaviors from adolescence into young adulthood

OBJECTIVE

To investigate the 4-year course of behavioral and emotional problems from adolescence into young adulthood in a general population sample.

METHOD

The population consisted of 364 individuals, aged 15 to 18 years at the beginning of the study. Subjects filled out the Youth Self-Report at the first time of assessment. At follow-up, 2 and 4 years later, subjects aged 19 or older completed the Young Adult Self-Report, which was derived from the Youth Self-Report.

RESULTS

Almost 40% of the adolescents who were classified as deviant initially were still deviant 4 years later. There was no significant difference in the continuity of internalizing problems versus externalizing problems in this sample.

CONCLUSIONS

All types of problems tended to persist to a similar degree. This holds also for problems that are often regarded as typical childhood problems, such as attention problems and hyperactivity. Because adolescent problems are likely to continue, we need more knowledge on the efficacy of interventions.

Attention deficit disorder during adolescence: a review

Attention deficit disorder (ADD) in adolescents has received scant attention when compared with that given to children. With or without hyperactivity, ADD does not disappear at puberty and is an important factor in scholastic and social failure in adolescents. As a condition associated with decreased metabolism in the premotor and prefrontal superior cerebral cortex, ADD in adolescents responds well to treatment with stimulants, tricyclic antidepressants and monoamine oxidase inhibitors. Nonpharmacologic modalities such as behavior modification, individual and family therapy, and cognitive therapy are useful adjuncts to psychopharmacologic management. Without effective treatment, ADD often results in increased risk of trauma, substance abuse and conduct and affective disorders during adolescence, and marital disharmony, family dysfunction, divorce, and incarceration in adulthood. Properly treated with medication and counseling, adolescents with ADD succeed as well as their peers.

Presentation of unrecognized attention deficit hyperactivity disorder in college students

Mental health providers at university counseling and health centers should be alert to the possibility that college students with previously unrecognized attention deficit hyperactivity disorder (ADHD) may present for initial evaluation at their centers. This study was a systematic chart review of 42 students at an Upper Midwest university who were diagnosed with ADHD during calendar year 1993. Diagnoses were made by the treating psychiatrist, who reviewed records for presenting problems; recent associated problems; previous evaluations as a child, adolescent, or adult; and associated problems in childhood. Presenting problems included ADHD symptoms, mood symptoms, nonspecific learning disability, and academic underachievement. Associated problems were depressive disorders, anxiety disorders, drug and alcohol abuse or both, dependency, legal problems, learning disabilities, and eating disorders. Thirty-three percent had been evaluated for academic or behavior problems as children, and 36% had sought previous psychological care for non-ADHD symptoms as adults. Thirty-one percent were presenting at the university health center for their first evaluation. Childhood histories showed educational underachievement, learning disabilities, and behavior problems.

Cigarette smoking in adult patients diagnosed with attention deficit hyperactivity disorder

Previous work has shown that adolescent hyperactivity patients are significantly more likely to smoke than controls. To determine whether this pattern persists in adults, we studied a series of 71 patients (55 males, 16 females; mean age +/- SD: 33.9 +/- 11.4 years) diagnosed with ADHD. Of the males, 23 (42%) were current smokers, 7 (13%) were ex-smokers, and 25 (45%) were never smokers. Comparable figures for males in the general population in 1991, unselected for ADHD, were 28.1%, 29.1%, and 42.1%, respectively. Of the females, 6 (38%) were current smokers, 5 (31%) were ex-smokers, and 5 (31%) had never smoked, as compared with 23.5%, 19.0%, and 57.6%, respectively, in the general population. Quit ratio (percentage of ever-smokers who were ex-smokers) was 29% for ADHD patients, compared with 48.5% in the general population. The discrepancy was accounted for by the males, whose quit ratio was 23%, compared with 51.6% in the general population; the figure for ADHD females (45%) was similar to that in the general population (44.7%). Smokers recalled experiencing a significantly higher number of ADHD symptoms (11.5 +/- 1.7) as children than never smokers (9.9 +/- 2.3; p < .01) and scored significantly higher on several indices of childhood and adult comorbidity. Our findings suggest that ADHD patients overinclude smokers, and that these smokers find it extremely difficult to quit. For ADHD smokers, smoking may have begun as an attempt to manage deficits in attention and concentration, as suggested by greater childhood symptomatology in these patients.

Attention deficit disorder in college students: facts, fallacies, and treatment

Attention deficit disorder (ADD), with or without hyperactivity, is a common but highly misunderstood and frequently underdiagnosed condition in college students. It affects students' academic and social success and emotional development. ADD is an invisible impairment of cortical regulation of activity and impulse control that is often hereditary, is as common in women as in men, and does not subside or disappear at puberty. ADD increases the risk of drug abuse, delinquency, incarceration, job failure, marital discord, and divorce. In college students, ADD is amenable to treatment in a multimodal program combining medication; individual, family, and group psychotherapy; career counseling; and cognitive control, together with electronic prostheses and special accommodations in the college classroom.

Mathematical outcomes of attention-deficit hyperactivity disorder

We assessed the academic performance and behavior of 121 nondisabled elementary boys and 107 boys with attention-deficit hyperactivity disorder (ADHD), ages 7.4 through 14.5 years. Students completed computer-generated tasks of reading, computation, and math problem solving, and we recorded two performance measures (accuracy and speed) and three behavioral measures (vocalizations, head movements, and bottom movements). Our purpose was to determine the effects of ADHD on conceptual and computational math. For greater precision than has been available in past math research, we held reading and problem structure constant, while recording speed of processing, number recognition, and motor response. Our analysis yielded significantly lower problem-solving scores in specific math concepts and slower computational performance for the boys with ADHD. These findings demonstrated the educational implications of attention deficit disorders for mathematical skill and the need for interventions that are geared more specifically to these deficits, and that also provide accommodations for reading complexity and length, visual-motor skill, feedback, and self-pacing.

Prediction of response to methylphenidate among children with ADHD and mental retardation

OBJECTIVE

The primary purpose of this study was to predict stimulant medication response among children with attention-deficit hyperactivity disorder (ADHD) and mental retardation (MR).

METHOD

Forty-seven children with ADHD and MR (IQs of 48 to 77) served as subjects; ages ranged from 6.1 to 12.5 years. Subjects participated in a double-blind, placebo-controlled study of two doses of methylphenidate (0.3 and 0.6 mg/kg per dose) and a placebo. Data were collected in each child's weekday classroom and a Saturday laboratory classroom. Stepwise multiple regression analyses were used to predict drug responses in both settings.

RESULTS

Higher parent ratings of impulsivity and activity level at baseline were associated with greater gains in weekday classroom dependent measures. Similarly, higher weekday teacher measures of activity level, impulsivity, inattention, and conduct problems at baseline were related to improvement on Saturday laboratory classroom dependent measures. Finally, gender, race, and socioeconomic status (SES) were found to be important predictors, with males, Caucasian subjects, and subjects from families of higher SES more likely to evidence clinical gains on a number of variables than other subjects.

CONCLUSION

These results were generally consistent with research conducted among children with ADHD but without MR. However, factors such as race and conduct problems appear to have predictive utility specific to children with MR.

Children with deficits in attention, motor control and perception (DAMP) almost grown up: psychiatric and personality disorders at age 16 years

Fifty-six cases with childhood onset deficits in attention, motor control and perception (DAMP) were followed-up at age 16 years and compared with 45 children without DAMP. Both groups had originally been recruited from the general population at the age of 6 years. Psychiatric disorders (affective disorders in particular) were more common in the DAMP group. Personality disorders were common in both groups, but the DAMP group much more often had a combination of several different personality disorders. The reasons for the discrepancies between teenagers with and without a prior history of DAMP are discussed.

Comorbidity of empirically based syndromes in matched general population and clinical samples

Comorbidity of deviance on eight empirically based syndromes was compared in matched general population and clinical samples of 2,705 children aged 4-18, using a bidirectional formula to avoid confounding effects of differential base rates. Syndromes were assessed via parent ratings on the CBCL, teacher ratings on the TRF, and self ratings on the YSR. Significantly higher comorbidity rates were obtained for clinical than general population samples for all 28 pairings of CBCL syndromes, 15 pairings of TRF syndromes, and 22 pairings of YSR syndromes. Bidirectional comorbidity rates for empirically based syndromes were compared to pairings of comparable DSM-III diagnoses.

Future of child psychiatry. II: A personal perspective

This paper provides an overview of key future directions that child psychiatry may follow. It then focuses on the potential value of longitudinal studies in general and on those involving attention deficit hyperactive disorder in particular, with the aim of delineating how such studies may enable us to proceed toward some of the future directions outlined.

Mother-child interactions in ADHD and comparison boys: relationships with overt and covert externalizing behavior

Reciprocal relationships between child characteristics and such familial factors as parental psychopathology and interaction style with the child characterize the development and maintenance of attention-deficit hyperactivity disorder (ADHD) as well as its comorbidity with antisocial behavior. Our goal was to ascertain the ability of negative maternal behavior exhibited during mother-son interactions to predict independently observed overt and covert externalizing behavior in the child, controlling for current maternal symptomatology and the boy's acting out behavior during the interaction. Participants were 49 boys with ADHD and 37 comparison boys, aged 6 to 12 years. Hierarchical multiple-regression analyses revealed that, even with maternal psychopathology and child negativity with the mother partialed, maternal negative behaviors predicted both observed noncompliance exhibited in class and play settings and laboratory stealing. Stealing was predicted from maternal negativity even with child interactional compliance controlled. Differential predictions of noncompliance were revealed in ADHD versus comparison families, yet similar patterns emerged for stealing within each group. Results are discussed in light of the high risk for antisocial behavior in ADHD children.

Genetic factors in substance abuse based on studies of Tourette syndrome and ADHD probands and relatives. I. Drug abuse

There have been relatively few studies of genetic factors in drug abuse. Childhood Attention Deficit Hyperactivity Disorder (ADHD) has been implicated as a risk factor, and pedigree studies of Tourette Syndrome (TS), a hereditary impulse disorder closely related to ADHD, show an increased prevalence of substance abuse in relatives. These observations suggest the genes for TS and ADHD may play an important role in the development of drug abuse. To examine this hypothesis 217 TS probands and 328 of their relatives, 58 ADHD probands and 35 of their relatives, and 50 controls were prospectively studied using a structured questionnaire based on the Diagnostic Interview Schedule. All subjects were Caucasians 16 to 49 years of age. The responses concerning the use of 8 different drugs and 8 different symptoms of drug abuse were compared. The results showed a highly significant increase in positive responses with increased loading for the TS and ADHD genes for 6 of the 8 drugs and all of the drug abuse symptoms. The percentage of positive responses in TS probands was markedly influenced by the presence of comorbid ADHD, as well as discipline, obsessive-compulsive, or alcohol problems. These results suggest that the genes responsible for TS and ADHD play an important role in drug abuse/dependence. The dopamine D2 receptor gene (DRD2) appears to be one of these genes since variants at this locus are significantly increased in frequency in TS, ADHD, conduct disorder and drug abuse.

Genetic factors in substance abuse based on studies of Tourette syndrome and ADHD probands and relatives. II. Alcohol abuse

Prior studies have suggested childhood attention deficit hyperactivity disorder (ADHD) as a risk factor for alcohol abuse in adults. Gilles de la Tourette Syndrome, a hereditary tic and impulse disorder, is clinically and genetically similar to ADHD. To examine the hypothesis that individuals carrying the Gts gene are at increased risk to develop alcohol use problems, the same TS (Tourette Syndrome) and ADHD probands, relatives and controls used in the prior study of drug abuse were also studied using a structured questionnaire based on the Diagnostic Interview Schedule and the MAST test. The frequency of a positive response to any of 16 different questions concerning alcohol abuse showed a highly significant increase with increased genetic loading for Gts and ADHD genes. The percentage of more than one positive response in TS probands was markedly influenced by the presence of comorbid ADHD, discipline, obsessive-compulsive or drug abuse problems. Comorbid drug abuse problems were the best predictor of alcohol abuse problems. These results suggest that the genes responsible for TS and ADHD play an important role in alcohol abuse/dependence as well as drug abuse/dependence. One of the elements common to all of these disorders may be mutant genes affecting serotonin metabolism.

Attention deficits: current concepts, controversies, management, and approaches to classroom instruction

This article reviews the current criteria for diagnosis of Attention-Deficit Hyperactivity Disorder and Undifferentiated Attention-Deficit Disorder, according to the American Psychiatric Association, and describes other typical presenting features of children with attentional disorders. The current theories of the biological basis of attentional disorders are reviewed. Treatments of attentional disorders are discussed, including medical treatments with stimulants and tricyclic antidepressants, and non-medical treatments, such as behavior modification, psychotherapy, diets, and specific educational modifications that are felt to be helpful. Finally, our current thinking about the long-term outlook for children with attentional disorders is summarized.

Children with deficits in attention, motor control and perception (DAMP) almost grown up: general health at 16 years

One hundred and one children (56 with and 45 without deficits in attention, motor control and perception (DAMP)), originally diagnosed at six or seven years of age and belonging to a representative cohort of children from the general population were followed up at 16 and 17 years of age. There was a significant excess of substance abuse, fractures and other accidents in the DAMP group than among controls, in addition to more motor co-ordination problems, clumsiness, and height and weight problems. Mean complex visual reaction time was significantly longer in the DAMP group, accounted for by the number of boys in the group. It appears that 10-year outcome for children who had attention problems and clumsiness during the preschool period is considerably poorer than for those who did not have such problems.

The stability of dimensions of behavior in ADHD and normal children over an 8-year followup

The present study reports on standardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria (n = 108) and a community control sample of normal children (n = 61) who were followed prospectively over 8 years into adolescence. On some parent-report measures both groups declined in the severity of their behavior problems across time, while on other measures only the hyperactive group declined, but the hyperactives always remained more deviant than the controls at followup. The hyperactives and controls also differed on most teacher and self-report ratings at followup. The greatest degree of agreement between raters at adolescence was between parent and youth ratings. These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup. They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology.

Effects of emotion on perceptual asymmetry in adolescent inpatients with attention-deficit hyperactivity disorder

OBJECTIVE

The authors studied the hemispheric functioning of adolescents with attention-deficit hyperactivity disorder (ADHD) in relation to this group's response to positively toned emotional stimuli.

METHOD

Dichotic word tests were used to measure perceptual asymmetry in 21 adolescent inpatients and 24 control subjects. Ten patients had ADHD; 11 did not. Subjects were tested under four emotional conditions by using combinations of neutral, positive, and negative words.

RESULTS

the ADHD group had lower right ear advantage (REA) scores when presented with stimulus pairs containing positive words than when presented with pairs not containing positive words. By comparison, the non-ADHD patient group and the control group had higher REA scores under positive emotional conditions than under non-positive conditions.

CONCLUSIONS

The abnormal response to positive emotional tone supports the reward system dysfunction hypothesis of ADHD and may also have implications for learning problems, behavioral difficulties, and disturbed interpersonal relationships in this population.

The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment

OBJECTIVE

To investigate predictors of adolescent outcome in a large sample of hyperactive children.

METHOD

123 hyperactive children were followed prospectively over an 8-year period. Multiple linear and logistical regression equations were used to relate childhood predictor variables to adolescent academic, psychiatric, social, and emotional adjustment.

RESULTS

Adolescent academic skills were related to childhood cognitive and academic competence while school conduct was predicted by other variables including early family stress. Duration of mental health treatment received often was negatively related to outcome, apparently serving as a marker variable for severity of disturbance in the child. Childhood impulsivity-hyperactivity and paternal antisocial acts were associated with later oppositional-defiant behaviors. Only child defiance and not hyperactivity predicted later arrests, however. Emotional problems in adolescence were predicted by more special education enrollment. Adolescent social competence was associated with parental personal competence, whereas maternal mental health status at outcome was related to variables unassociated with child adjustment.

CONCLUSIONS

Various outcome domains had different sets of predictors; no single predictor cut across all domains. Although a limited amount of variance in outcome was explained, findings suggest that promoting family and parental competence as well as assessing and treating defiance and aggression very early may improve outcome.

Assessing parents' willingness to pursue treatment for children with attention-deficit hyperactivity disorder

OBJECTIVE

This study investigated parents' willingness to pursue treatment for attention-deficit-hyperactivity-disorder (ADHD).

METHOD

A self-administered questionnaire (the ADHD Knowledge and Opinion Scale--AKOS) was developed and administered to a sample of 116 families attending an outpatient ADHD clinic. Socioeconomic status, parenting stress, family adaptability and cohesion, degree of child's externalizing behavior, and treatment history were obtained for each family.

RESULTS

Parents' willingness to use medication or to pursue counseling were not related to family factors. History of the child receiving medication was mildly correlated with willingness to use medication. History of counseling was mildly correlated with willingness to use medication and to pursue counseling. Mothers who viewed their family as "enmeshed" reported significantly higher sense of competence than those viewing the family as "connected" or "disengaged."

CONCLUSION

The AKOS is an instrument that may help clinicians identify and address parents' concerns about treatment for ADHD as well as parents' perceptions about their parenting skills.

Adolescent resilience: the potential impact of personal development in schools

The challenges and stresses faced by adolescents include entry into secondary school, the development of adolescent sexuality, family conflicts, parental mental illness, socio-cultural factors, substance use and abuse, work and career abuse, social and antisocial behaviour, and the carry-over of problems from childhood. The ways in which programmes through schools can address these issues, enhance resilience and promote adolescent mental health are discussed. The potential of personal development programmes could be utilized to this end, with targeted educational and group initiatives and evaluation of outcomes.

Does methylphenidate normalize the classroom performance of children with attention deficit disorder?

The present study examined the degree to which methylphenidate (MPH) normalized the classroom behavior and academic functioning of 31 children with attention deficit disorder (ADD). Subjects with ADD participated in a double-blind, placebo-controlled trial in which children received each of four doses (5, 10, 15, and 20 mg) of MPH and a placebo following baseline measures. Children with ADD were compared with a group of 25 normal control children on teacher ratings of social conduct, direct observations of on-task behavior, and academic efficiency. At a group level of analysis, MPH exerted a significant effect on classroom measures of attention and academic efficiency to a point where they were no longer statistically deviant from scores obtained by normal control children. Nevertheless, when examined at the individual level, 25% of the sample failed to show normalized levels of classroom performance, thus implying the need for ancillary school-based interventions.

Heightened motor activity level in male offspring of substance abusing fathers

Heightened activity level has been implicated in the liability for substance abuse, but no prior research has directly examined motor activity in a sample of prepubertal boys at high-risk for substance abuse. The magnitude of behavioral activity of 10-12 year-old sons of substance abusing fathers (SA +) (n = 42) and controls (SA -) (n = 60) was assessed using a microprocessor-based activity monitor during tasks that demanded significant concentration, effort, and constraint on motor activity, and when no such demands were present. Psychiatric status, measures of temperament traits, and measures of internalizing and externalizing behaviors were also obtained on the boys. Although the groups did not differ during the lower demand task, SA + boys showed significantly greater motor activity than SA - boys during the tasks that required concerted effort, attention, and behavioral suppression. Multiple regression analysis indicated that under the low-demand condition, the presence of an anxiety disorder in the boy was the only significant predictor of activity level. However, under the conditions that demanded effort, concerted attention and behavioral suppression, SA + group membership, and having low rhythmicity (as a temperament trait) predicted heightened activity. Statistically controlling for rhythmicity, the SA + boys were estimated to have about 24% higher activity than control boys. The results suggest that heightened motor activity may be associated with susceptibility to substance abuse.

Attention deficit disorder and age of onset of problem behaviors

In the course of a prospective longitudinal study, we examined age of onset of behavior problems in a group of boys and girls identified with attention deficit disorder (ADD) at age 11. Onset occurred during the preschool years, by the first year of schooling, or by the end of the second year of school. Onset was strongly related to informant source at age 11, pattern of comorbidity of disorder at age 11, and developmental language, perceptual motor, and IQ measures. Onset by the first year of schooling was particularly related to poor reading skills. By age 15, nearly three-quarters of those with onset of problems before age 6 had one or more DSM-III disorders.

Parenting stress among families of children with attention deficit hyperactivity disorder

Prior research has shown that parenting stress levels can be quite high among families of children with attention deficit hyperactivity disorder (ADHD). This study investigated the degree to which such stress was related not only to the child's ADHD, but also to various other child, parent, and family-environment circumstances. Multimethod assessments were conducted on 104 clinic-referred children with ADHD. Data collected from these subjects were entered into hierarchical multiple-regression analyses, utilizing the Parenting Stress Index as the criterion. The results showed that the child and parent characteristics accounted for a substantial portion of the variance in overall parenting stress. The child's oppositional-defiant behavior and maternal psychopathology were especially potent predictors. The severity of the child's ADHD, the child's health status, and maternal health status also emerged as significant predictors. These findings are discussed in terms of their impact upon the clinical management of children with ADHD.

Recurrent hypersomnia in two adolescent males with Asperger's syndrome

Two individuals with Asperger's syndrome, a rare pervasive developmental disorder, developed recurrent episodes of hypersomnia and abnormal behavior (Kleine-Levin syndrome) during adolescence. The possible etiological role of developmental structural brain anomalies and the differential diagnosis of recurrent hypersomnia and abnormal behavior in patients with pervasive developmental disorders are discussed.

Adolescents with attention deficit hyperactivity disorder: mother-adolescent interactions, family beliefs and conflicts, and maternal psychopathology

A group of 83 adolescents with attention deficit hyperactivity disorder (ADHD) were subdivided into those with ADHD alone (n = 27) and those with ADHD and oppositional defiant disorder (ADHD/ODD, n = 56). They were compared to each other and a community control group (n = 77) on measures of family conflicts, family beliefs, maternal adjustment, and observations of mother-adolescent interactions during both a neutral and conflict discussion. Both ADHD groups had more topics on which there was conflict and more angry conflicts at home than control adolescents on parent reports. Only the ADHD/ODD adolescents reported more such conflicts, endorsed more extreme and unreasonable beliefs about their parent-teen relations, and demonstrated greater negative interactions during a neutral discussion than the control teenagers. Similarly, only mothers of the ADHD/ODD teens displayed greater negative interactions during a neutral discussion, more extreme and unreasonable beliefs about their parent-teen relations, greater personal distress, and less satisfaction in their marriages than the mothers in the control group. Most findings for the ADHD only group were between the control group and the group with mixed ADHD/ODD but did not differ from either group. Results imply that it is the combination of ODD symptoms with those of ADHD that is associated with the greater-than-normal conflicts, anger, poor communications, unreasonable beliefs, and negative interactive styles seen in ADHD adolescents. These same characteristics typify their mothers' interactions as well such that both the adolescents' ODD symptoms and maternal psychological distress (hostility) make unique contributions to the degree of conflict and anger in the parent-teen relations of ADHD adolescents.

Behavioural problems among preschool age children in Shanghai: analysis of 3,000 cases

This paper reports the preliminary findings of an epidemiological study of 3,000 children ages four and five in the Shanghai area. Associations were investigated between problems in the narrow band syndromes of the Achenbach Child Behavior Checklist and certain sociodemographic variables (a one-child family, other social circumstances related to the family). No strong evidence emerged of a distinct psychopathology associated with children from single-child families, although there was a significant correlation between being an only child and having social withdrawal problems. Delinquent behaviour and hyperactivity were more frequent among boys, while somatic complaints, schizoid or anxious, and depression were more frequent among girls. A four year follow-up study of 433 children from the original group who continued to have problems showed a marked increase in hyperactive syndrome problems; this suggests the existence of a clinically identifiable group of behaviourally disturbed children. Early identification allows for early treatment and comparison of the relative efficacy of early and late treatment approaches.

Child psychiatry and early intervention: IV. The externalizing disorders

This paper is the last in a series of four using the concept of the aggregate burden of suffering to review the major psychiatric disorders of childhood. This paper reviews the externalizing disorders of childhood to prioritize early intervention programs. The paper discusses the prevalence, course, risk and early indicators, associated impairments, and responses to intervention. The externalizing disorders affect the individual, family and community and are thought to result in the greatest aggregate burden of suffering of all the childhood mental disorders. Early intervention is advocated and will likely need to be intense and long term for this group of children. The need for research into efficient and effective programs is emphasized.

Self-management therapies and attention-deficit hyperactivity disorder. Reinforced self-evaluation and anger control interventions

The lack of sufficiency of the primary treatment modalities for children with Attention-Deficit Hyperactivity Disorder (ADHD)-operant behaviormodification procedures and psychostimulant medications-have prompted exploration of cognitive-behavioral self-management treatments as altematives or adjuncts. Although self-instructional treatments are not adequate interventions for such children, reinforcement-and rehearsal-based behavioral interventions can be combined with self-management approaches to supplement and extend the gains induced by behavioral procedures. After presenting background material regarding cognitive-behavioral treatments for ADHD, we present case material related to multimodality treatment, with focus on training in anger management and self-evaluation skills. We argue against unsubstantiated claims for the efficacy of cognitive-behavioral interventions but contend that, when combined with pharnacologic and behavioral approaches, self-management procedures deserve consideration for the difficult social and behavioral problems of ADHD children.

Co-morbid symptoms of depression and conduct disorder in First Nations children: some findings from the Flower of Two Soils Project

The prominence of co-morbidity in children and adolescents has increased over the past decade as new empirical research data has accumulated. Yet little epidemiological data of any kind exists for First Nations Children. Following a brief literature review on co-morbidity in children and adolescents, the authors analyzed data from the Flower of Two Soils Project (M. Beiser, principal investigator) to examine more closely the relationship between self-reported depressive symptoms and parent/teacher reported conduct symptoms. Such a relationship has been consistently found in a number of studies. Children aged 7 to 10 were found to show more academic and social problems when rated as having high conduct symptoms. Children in the co-morbid group were found to have the highest rates of family stress and help-seeking behavior. Suicidal ideation was as high in the conduct and co-morbid groups as it was in the high depression group. More First Nations children were found in the high conduct-low depression group. The significance of these findings is discussed.

Psychostimulant effects on academic and behavioral measures for ADHD junior high school students in a lecture format classroom

This study evaluated the effects of two doses of psychostimulants on nine ADHD students' performance in a classroom designed to be analogous to a junior high school American history class conducted during a summer treatment program. Double-blind, placebo-controlled assessment revealed significant and clinically important effects of psychostimulants on quiz and test performance, observations of attention and behavior during lectures, and teacher ratings, as well as accuracy on assignments completed during study hall. Analysis of individual differences revealed a 66% positive response rate. The implications for use of psychostimulants with ADHD young adolescents are discussed.

Adolescents with ADHD: patterns of behavioral adjustment, academic functioning, and treatment utilization

Adolescents with attention deficit hyperactivity disorder (ADHD) were compared with a control group on a comprehensive assessment battery. More ADHD teenagers had oppositional defiant disorder (68%) and conduct disorder (39%) and were rated as more impaired in social competence, behavioral and emotional adjustment, and school performance by parents and teachers than control teens. The ADHD youths, however, rated themselves as better adjusted than did their parents and teachers, differing only from controls in depressive symptoms and antisocial acts. Poorer performances in verbal learning and vigilance and greater ADHD behaviors during a math task also distinguished the ADHD from control teenagers.

Long-term outcome of hyperactive children: a review

Reports of adolescent outcome in attention deficit hyperactivity disorder have uniformly indicated high rates of behavioral problems including cognitive impairment. Dysfunction is markedly reduced in adulthood, but the pattern of outcome remains unchanged except for failure to document cognitive deficits. In adulthood, dysfunction is characterized by antisocial personality and substance (nonalcohol) use disorders. These are in turn associated with criminality. The little existing information on girls with attention deficit hyperactivity disorder does not suggest a worse outcome than for boys. Attempts to identify the children most likely to have a poor outcome have been largely unsuccessful.

A twelve-year follow-up of preschool hyperactive children

Two percent (N = 21) of a large sample of preschool children were identified as "pervasively hyperactive." Compared with nonhyperactive preschoolers, these children more often came from families with high levels of adversity, and they showed poorer language skills. Over a 12-year follow-up period, the hyperactive preschoolers continued to show poorer cognitive skills, lower levels of reading ability, disruptive and inattentive behaviors at home and at school, and higher rates of DSM-III disorder in preadolescence and adolescence. By age 15, only one-quarter of this group were identified as having met "recovery" criteria. The findings point to the long-term adverse consequences of preschool hyperactivity and indicate the need for intervention with this type of disorder.

The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology

The present study reports the results of a prospective, 8-year follow-up study of 100 hyperactive and 60 normal children followed from childhood into adolescence. Ratings of child behavior problems and family conflicts as well as direct observations of mother-child interactions were taken in childhood and again at adolescent follow-up. At outcome, hyperactives continued to have more conduct and learning problems and to be more hyperactive, inattentive, and impulsive than controls. Hyperactives were also rated by their mothers as having more numerous and intense family conflicts than the normal controls, although the adolescents in both groups did not differ in their own ratings of these conflicts. Observations of mother-adolescent interactions at outcome found the hyperactive dyads displaying more negative and controlling behaviors and less positive and facilitating behaviors towards each other than in the normal dyads. These interaction patterns were significantly related to similar patterns in mother-child interactions observed 8 years earlier. Mothers of hyperactives also reported more personal psychological distress than normal mothers at outcome. Further analyses of subgroups of hyperactives at outcome, formed on the presence or absence of ADHD and oppositional defiant disorder (ODD), indicated that the presence of ODD accounted for most of the differences between hyperactives and normals on the interaction measures, ratings of home conflicts, and ratings of maternal psychological distress. Results suggest that the development and maintenance of ODD into adolescence in hyperactive children is strongly associated with aggression and negative parent-child interactions in childhood.

Attention deficit hyperactivity disorder: the differential diagnosis

Children and adolescents doing poorly in school or at home or both are often labelled as suffering from attention deficit hyperactivity disorder (ADHD). Frequently the referred child is not examined systematically for the presence of other disorders. This paper presents the diagnostic criteria and management of disorders that may be wrongly identified as ADHD or may coexist with ADHD, thus complicating identification and treatment. The disorders discussed are depression, mania, primary disorder of vigilance, narcolepsy, developmental specific learning disorders, conduct disorders, and acquired neurologic deficits.

The DSM-III-R field trial of disruptive behavior disorders

The members of the DSM-III-R Advisory Committee responsible for the diagnostic criteria for the disruptive behavior disorders (attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder) were able to reach agreement on potential items to be included in the final diagnostic criteria. However, there was considerable disagreement about the relative utility of different items for the three disorders and no agreement on how many items should be required from a final list of discriminating items to establish each of the diagnoses. This article describes the method and results of a national field trial of the proposed criteria. Using as a standard the diagnosis of these disorders made by expert clinicians with experience with these disorders, the diagnostic criteria that were finally included in DSM-III-R demonstrated high sensitivity, specificity, and internal consistency.