Combining discrepant diagnostic information from multiple sources: are complex algorithms better than simple ones?

Developmental timing of exposure to elevated levels of phenylalanine is associated with ADHD symptom expression

This study addresses attention deficit hyperactivity disorder (ADHD), with a focus on how the timing of a known biological insult affects ADHD symptom expression. The sample consists of children exposed to elevated levels of phenylalanine, either postnatally as in Phenylketonuria (PKU; n = 46) or prenatally as in Maternal PKU (MPKU; n = 15). Non-hyperphenylalaninemic siblings of children with PKU (n = 18) serve as controls. Results indicate that elevated levels of phenylalanine are associated with ADHD symptoms. The manifestations of the symptom expression are dependent on exposure timing: prenatal exposure is associated with a higher likelihood of expressing hyperactive/impulsive symptoms and postnatal exposure is associated with a higher likelihood of expressing inattentive symptoms. This toxicity is dose-dependent and higher levels of phenylalanine appear more detrimental.

Child and parent attributions in chronic pediatric conditions: phenylketonuria (PKU) as an exemplar

BACKGROUND

Attribution theory, self-regulation, self-handicapping and sick role theories all suggest that children with chronic disease may be held to different standards. This study assesses child and parent attributions in pediatric chronic health conditions and addresses how attributional style may be related to treatment adherence.

METHODS

Four different vignettes were utilized to compare the attributional style of children with phenylketonuria (PKU) and parents of children with PKU to two comparison groups: children with other chronic medical conditions and medically healthy children. In addition, the relationship between metabolic control and attribution ratings was assessed in the PKU sample.

RESULTS

Parents of children with medical conditions provided attributions of less child control and more stability as well as more positive affective reactions when compared to parents of healthy children. Children without a medical condition viewed childhood problems as less controllable and more stable. Mothers were more disturbed affectively by behavioral dysregulation and fathers were more disturbed by academic difficulties. In the PKU sample, the higher the phenylalanine level in the child, the more likely the parent and child alike were to attribute childhood problems to external loci of control.

CONCLUSIONS

Attributional styles appear not to be diagnosis-specific in pediatric populations. Attributional style may be an important variable to consider when targeting treatment adherence.

Incremental validity in the psychological assessment of children and adolescents

Incremental validity in the process of psychological assessment of children and adolescents is explored. The authors highlight the dependence of the incremental validity of assessment information on factors such as goal of assessment, other information available, base rate of the problem or outcome, age or gender of the child, and type of problem being assessed. The authors discuss the incremental validity of assessment information from alternate sources, methods, and constructs. In view of the limited number of studies directly relevant to incremental validity in child clinical assessments, the authors call for more clinically relevant research. To have the greatest impact on child and adolescent services, this research must be readily generalized and immediately relevant to actual clinical practice.

Mediators of the relation between maternal depressive symptoms and child internalizing and disruptive behavior disorders

Drawing on a normative sample of 224 youth and their biological mothers, this study tested 4 family variables as potential mediators of the relationship between maternal depressive symptoms in early childhood and child psychological outcomes in preadolescence. The mediators examined included mother-child communication, the quality of the mother-child relationship, maternal social support, and stressful life events in the family. The most parsimonious structural equation model suggested that having a more problematic mother-child relationship mediated disruptive behavior-disordered outcomes for youths, whereas less maternal social support mediated the development of internalizing disorders. Gender and race were tested as moderators, but significant model differences did not emerge between boys and girls or between African American and Caucasian youths.

Strong genetic effects on cross-situational antisocial behaviour among 5-year-old children according to mothers, teachers, examiner-observers, and twins' self-reports

BACKGROUND

Early childhood antisocial behaviour is a strong prognostic indicator for poor adult mental health. Thus, information about its etiology is needed. Genetic etiology is unknown because most research with young children focuses on environmental risk factors, and the few existing studies of young twins used only mothers' reports of behaviour, which may be biased.

METHOD

We investigated genetic influences on antisocial behaviour in a representative-plus-high-risk sample of 1116 pairs of 5-year-old twins using data from four independent sources: mothers, teachers, examiner-observers previously unacquainted with the children, and the children themselves.

RESULTS

Children's antisocial behaviour was reliably measured by all four informants; no bias was detected in mothers', teachers', examiners', or children's reports. Variation in antisocial behaviour that was agreed upon by all informants, and thus was pervasive across settings, was influenced by genetic factors (82%) and experiences specific to each child (18%). Variation in antisocial behaviour that was specific to each informant was meaningful variation, as it was also influenced by genetic factors (from 33% for the children's report to 71% for the teachers' report).

CONCLUSIONS

This study and four others of very young twins show that genetic risks contribute strongly to population variation in antisocial behaviour that emerges in early childhood. In contrast, genetic risk is known to be relatively modest for adolescent antisocial behaviour, suggesting that the early-childhood form has a distinct etiology, particularly if it is pervasive across situations.

Intergenerational transmission of partner violence: a 20-year prospective study

An unselected sample of 543 children was followed over 20 years to test the independent effects of parenting, exposure to domestic violence between parents (ETDV), maltreatment, adolescent disruptive behavior disorders, and emerging adult substance abuse disorders (SUDs) on the risk of violence to and from an adult partner. Conduct disorder (CD) was the strongest risk for perpetrating partner violence for both sexes, followed by ETDV, and power assertive punishment. The effect of child abuse was attributable to these 3 risks. ETDV conferred the greatest risk of receiving partner violence; CD increased the odds of receiving partner violence but did not mediate this effect. Child physical abuse and CD in adolescence were strong independent risks for injury to a partner. SUD mediated the effect of adolescent CD on injury to a partner but not on injury by a partner. Prevention implications are highlighted.

Callous-unemotional traits and conduct problems in the prediction of conduct problem severity, aggression, and self-report of delinquency

The role of callous-unemotional (CU) traits and conduct problems in predicting conduct problem severity, severity and type of aggression, and self-reported delinquency at a 1-year follow-up was investigated in a sample of 98 children (mean age 12.43; SD = 1.72) recruited from a community-wide screening. Children with both CU traits and conduct problems had a greater number and variety of conduct problems at follow-up than children who at the screening had high levels of conduct problems alone. However, this poorer outcome for children with CU traits could largely be accounted for by differences in initial level of conduct problem severity. Children with CU traits and conduct problems were also at risk for showing higher levels of aggression, especially proactive aggression, and self-reported delinquency. Importantly, these outcomes could not be solely explained by initial level of conduct problem severity. Finally, CU traits predicted self-reported delinquency in some children who did not initially show high levels of conduct problems and this predictive relationship seemed to be strongest for girls in the sample who were high on CU traits but who did not show significant conduct problems.

Clinical implications of pervasive manic symptoms in children

BACKGROUND

Prior investigations of cross-informant agreement among parents, teachers, and clinicians about externalizing and internalizing problems have not directly addressed agreement about manic symptoms.

METHODS

We identified three groups from a large cohort of youths, aged 8-12 years, treated on an inpatient unit. All 108 participants met criteria for an externalizing disorder, based on a semi-structured diagnostic interview. Of these, 49 did not have manic symptoms endorsed by either the parent or a teacher; 34 had manic symptoms reported by the parent only, and 25 had pervasive manic symptoms (i.e., corroborated by both sources).

RESULTS

The "corroborated mania" group consistently showed the most disruptive behavior on the inpatient unit, the worst behavior problems on multiple scales, and the longest admission durations. The "parent-only" group scored in the midrange on all of these measures, with group differences typically representing small to medium effect sizes. The "externalizing only" group consistently scored lowest on all dependent measures, with the differences representing large to extremely large effects when compared with the corroborated mania group and medium effects as compared with the parent-only group.

CONCLUSIONS

Youths for whom multiple informants report manic symptoms appear likely to have more severe symptom presentation and more complicated, refractory courses than do youths without manic symptoms.

Who are the comorbid adolescents? Agreement between psychiatric diagnosis, youth, parent, and teacher report

The investigators examined the rates of psychiatric comorbidity for externalizing and internalizing behavior problems, using semistructured diagnostic interview and parent, teacher, and youth report on the Achenbach checklists. The study also evaluated the effects of conjunctive, compensatory, and disjunctive data combination strategies. Using the same data and identical diagnostic thresholds, between 5 and 74% of 189 youths presenting to an outpatient clinic were identified as having comorbid internalizing and externalizing problems. Parent report and semistructured interview indicated the highest comorbidity rates. Despite good cross-source agreement (rs .29-.58), there was very little agreement about which specific youths presented with comorbid internalizing and externalizing problems (kappas .14-.40). Results also indicate that single DSM-IV disorders, such as bipolar disorder, can manifest "comorbid" patterns of behavior problems on checklists.

Callous-unemotional traits and developmental pathways to severe conduct problems

One method for defining pathways through which children develop severe conduct problems is based on the presence or absence of callous-unemotional (CU) traits. This study investigated potential differences between nonreferred children (mean age = 12.36 years; SD = 1.73) with and without CU traits (n = 98). Children with conduct problems, irrespective of the presence of CU traits, tended to have significant problems in emotional and behavioral regulation. In contrast, CU traits, irespective of the presence of conduct problems, were associated with a lack of behavioral inhibition. Hostile attributional biases were associated with conduct problems but only in boys and in the absence of CU traits. These findings suggest that the processes underlying deficits in emotional and behavioral regulation in children with conduct problems may be different for children with CU traits.

The relation of narcissism and self-esteem to conduct problems in children: a preliminary investigation

Investigated several possible models to explain the seemingly discrepant relations between self-esteem and conduct problems, as both low self-esteem and exaggerated levels of self-esteem, thought to be captured by narcissism, have been associated with aggressive and antisocial behavior. Our sample consisted of 98 nonreferred children (mean age = 11.9 years; SD = 1.68 years) recruited from public schools to oversample children at risk for severe aggressive and antisocial behavior. Results indicated that certain aspects of narcissism (i.e., those indicating a need to be evaluated well by, and obtain status over, others) were particularly predictive of maladaptive characteristics and outcomes such as low self-esteem, callous-unemotional (CU) traits, and conduct problems. In addition, the relation between narcissism and conduct problems was moderated by self-esteem level, such that children with relatively high levels of narcissism and low self-esteem showed the highest rates of conduct-problem symptoms.

Life with (or without) father: the benefits of living with two biological parents depend on the father's antisocial behavior

The salutary effects of being raised by two married, biological parents depend on the quality of care parents can provide. Using data from an epidemiological sample of 1,116 5-year-old twin pairs and their parents, this study found that the less time fathers lived with their children, the more conduct problems their children had, but only if the fathers engaged in low levels of antisocial behavior. In contrast, when fathers engaged in high levels of antisocial behavior, the more time they lived with their children, the more conduct problems their children had. Behavioral genetic analyses showed that children who resided with antisocial fathers received a "double whammy" of genetic and environmental risk for conduct problems. Marriage may not be the answer to the problems faced by some children living in single-parent families unless their fathers can become reliable sources of emotional and economic support.

What proportion of failure to complete secondary school in the US population is attributable to adolescent psychiatric disorder?

Using information available from the longitudinal Children in Community Study, population-attributable risk percentage was calculated to estimate the amount of failure to complete secondary school in the United States that is associated with adolescent psychiatric disorder. Over half the adolescents in the United States who fail to complete their secondary education have a diagnosable psychiatric disorder. The proportion of failure to complete school that is attributable to psychiatric disorder is estimated to be 46%. School failure among young persons with psychiatric disorder exacts a large toll from individuals and society.

Sex differences in young children who meet criteria for attention deficit hyperactivity disorder

Examined sex differences in a mostly clinic-referred sample of 127 children (22 girls, 105 boys) who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; [DSM-IV], American Psychiatric Association, 1994) criteria for attention deficit hyperactivity disorder (ADHD) and 125 comparison children (24 girls, 101 boys) matched on age, sex, and race-ethnicity. Children in both groups ranged in age from 3 years, 10 months to 7 years, 0 months. Both girls and boys who met criteria for ADHD were more impaired than same-sex controls on a variety of measures when intelligence and other types of psychopathology were controlled. Teachers reported that boys with ADHD were more inattentive and more hyperactive/impulsive than girls with ADHD. These findings suggest that the diagnosis of ADHD is valid for both girls and boys in this young age range. Young girls and boys who meet DSM-IV criteria for ADHD are more similar than different, but boys tend to display more symptoms of ADHD, particularly in school.

Waxing and waning in concert: dynamic comorbidity of conduct disorder with other disruptive and emotional problems over 7 years among clinic-referred boys

Six waves of structured diagnostic assessments were conducted of 168 clinic-referred 7- to 12-year-olds, over 7 years. Wave-to-wave changes in the number of conduct disorder (CD) behaviors were paralleled by correlated changes in the numbers of symptoms of oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. In addition, CD in Wave 1 predicted levels of ODD, ADHD, depression, and anxiety in later waves when initial levels of those symptoms were controlled, but only ODD in Wave 1 predicted CD in later waves when initial CD levels were controlled. These findings indicate a striking degree of dynamic comorbidity between CD and other types of psychopathology and provide an initial empirical framework for needed developmental models of comorbidity.

Psychiatric disorders associated with risk for the development of eating disorders during adolescence and early adulthood

Longitudinal data were used to investigate whether anxiety, depressive, disruptive, personality, or substance use disorders are associated with risk for the development of eating disorders during adolescence or early adulthood. Psychiatric disorders were assessed among 726 youths from a random community sample during adolescence and early adulthood. Depressive disorders during early adolescence were associated with elevated risk for the onset of eating disorders, dietary restriction, purging behavior, and recurrent weight fluctuations after preexisting eating problems and other psychiatric disorders were controlled statistically. Disruptive and personality disorders were independently associated with elevated risk for specific eating or weight problems. The present findings suggest that depressive disorders during early adolescence may contribute to the development of eating disorders during middle adolescence or early adulthood.

Influence of adult domestic violence on children's internalizing and externalizing problems: an environmentally informative twin study

OBJECTIVE

Externalizing and internalizing problems may aggregate in families because (1) siblings share genetic risks for problem behaviors or (2) siblings are exposed to similar environmental risks. A genetically sensitive design was used to determine whether domestic violence accounted significantly for the variation and covariation of externalizing and internalizing problems, independent of additive genetic effects on these behavior problems.

METHOD

Using the Achenbach family of instruments, mothers and teachers reported internalizing and externalizing problems for 1,116 monozygotic and dizygotic 5-year-old twin pairs in the United Kingdom (93% response rate). Mothers reported their experiences of domestic violence in the previous 5 years. Structural equation models were tested to determine the effect of mothers' experiences of domestic violence on children's emotional and conduct problems, controlling for latent genetic and environmental effects on these behaviors.

RESULTS

A multivariate model showed that adult domestic violence accounted for 2% and 5% of the variation in children's internalizing and externalizing problems, respectively, independent of genetic effects. The co-occurrence of externalizing and internalizing scores was accounted for by genetic (62.6%) and shared environmental (29.2%) factors and by domestic violence (8%).

CONCLUSIONS

Because domestic violence affects children's behavior problems beyond genetic influences, programs that successfully reduce domestic violence should also prevent children's psychopathology.

Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions

Evaluated the concurrent validity of the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994): Child and Parents Versions (ADIS for DSM-IV-C/P; Silverman & Albano, 1996) social phobia, separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder diagnoses. Children referred to an outpatient anxiety disorder clinic (N = 186; ages 8 to 17), and their parents completed the Multidimensional Anxiety Scale for Children (MASC; March, 1998) and the ADIS-C/P interview. There was no convergence between MASC scores and ADIS-C/P GAD diagnoses. However, there was strong correspondence between ADIS-C/P social phobia, SAD, and panic disorder diagnoses and the empirically derived MASC factor scores corresponding to these disorders. These results provide support for the concurrent validity of the anxiety disorders section of the ADIS-C/P.

Adolescent outcomes of childhood conduct disorder among clinic-referred boys: predictors of improvement

Much remains to be learned about the adolescent outcomes of clinic-referred boys whose childhood conduct problems are serious enough to meet diagnostic criteria for conduct disorder (CD). Six structured diagnostic assessments were conducted over 7 years of 73 clinic-referred 7-12-year-old boys who met criteria for CD in Wave 1. There were substantial individual differences in the adolescent outcomes of CD, ranging from worsening to sustained recovery, with most boys showing persistent, but fluctuating levels of CD. Improvement in CD was not accounted for by treatment or incarceration, but more positive outcomes over Waves 2-7 were predicted prospectively with substantial accuracy, using a combination of baseline predictors: less initial severity of CD, fewer symptoms of attention-deficit hyperactivity disorder, higher child verbal intelligence, greater family socioeconomic advantage, and not having antisocial biological parents.

A DSM-IV-referenced screening instrument for preschool children: the Early Childhood Inventory-4

OBJECTIVE

To examine the validity of the Early Childhood Inventory-4 (ECI-4), a parent and teacher rating scale designed to screen for DSM-IV emotional and behavioral disorders.

METHOD

The convergent, divergent, and discriminant validity and clinical utility of the ECI-4 was studied in a sample of 224 consecutive referrals (3-6-year-old children) to a child psychiatric outpatient clinic.

RESULTS

The ECI-4 demonstrated adequate criterion validity for the most common disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, pervasive developmental disorder) when compared with data-based psychiatric diagnoses and correlated well with relevant scales of the Child Behavior Checklist, Teacher's Report Form, and Inattention/Overactivity With Aggression (IOWA) Conners.

CONCLUSION

The ECI-4 appears to be a useful screening measure for certain disorders in clinically referred children, but continued research is needed to determine its value in other settings (e.g., school and community), and its validity with other measurement methodologies.

Prevalence and correlates of antisocial behaviors among three ethnic groups

Using data from the MECA Study, this report examines the prevalence of Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), and various levels of antisocial behavior and their correlates among three ethnic groups: Hispanics, subdivided into Island Puerto Ricans and Mainland Hispanics; African Americans; and Mainland Non-Hispanic, Non-African Americans. Correlates considered include stressful life events, birth defects, low birth weight, learning difficulties, teen mothers, family environment, marital adjustment, social competence, parental monitoring, and family relationships. Logistic regression was used to determine the association of outcomes with individual correlates and of interaction terms with ethnicity. Differences between adjusted rates and observed rates of disorders and levels of antisocial behaviors are compared to estimate the extent to which each correlate explains the group differences in rates. Island Puerto Ricans had a lower prevalence of CD, ODD, and various levels of antisocial behavior than mainland Hispanics, African Americans, and non-Hispanic Whites. The lower prevalence appears to be associated with differences in the extent to which a number of these correlates are found on the island, the most salient being better family relations between the target children and their parents and siblings.

A comparison of the neuropsychological profiles of the DSM-IV subtypes of ADHD

Recent research on the DSM-IV subtypes of attention-deficit/hyperactivity disorder (ADHD) has demonstrated that the subtypes differ in demographic characteristics, types of functional impairment, and profiles of comorbidity with other childhood disorders. However, little research has tested whether the subtypes differ in underlying neuropsychological deficits. This study compared the neuropsychological profiles of children without ADHD (n = 82) and children who met symptom criteria for DSM-IV Predominantly Inattentive subtype (ADHD-IA; n = 67), Predominantly Hyperactive Impulsive subtype (ADHD-HI; n = 14), and Combined subtype (ADHD-C; n = 33) in the areas of processing speed, vigilance, and inhibition. We hypothesized that children with elevations of inattention symptoms (ADHD-IA and ADHD-C) would be impaired on measures of vigilance and processing speed, whereas children with significant hyperactivity/impulsivity (ADHD-HI and ADHD-C) would be impaired on measures of inhibition. Contrary to prediction, symptoms of inattention best predicted performance on all dependent measures, and ADHD-IA and ADHD-C children had similar profiles of impairment. In contrast, children with ADHD-HI were not significantly impaired on any dependent measures once subclinical symptoms of inattention were controlled. Our results do not support distinct neuropsychological deficits in ADHD-IA and ADHD-C children, and suggest that symptoms of inattention, rather than symptoms of hyperactivity/impulsivity, are associated with neuropsychological impairment.

Dramatic-erratic personality disorder symptoms: I. Continuity from early adolescence into adulthood

This longitudinal study examined dramatic-erratic personality disorder symptoms (histrionic, borderline, and narcissistic symptoms) in a community sample of 407 adolescents to assess whether this diagnostic construct is meaningful in young people. Based on latent variable models and dimensional symptom scales, these so-called Cluster B symptoms were highly stable across an eight-year interval from early adolescence to early adulthood. Furthermore, when compared with internalizing and externalizing symptoms, dramatic-erratic symptoms were more stable over time than these well-established Axis I symptom clusters. Based on high correlations with co-occurring internalizing and externalizing symptoms, Cluster B symptoms clearly reflect emotional distress during adolescence. These analyses reinforce recent efforts to establish personality disorders as a clinically significant and valid diagnostic construct in young people.

Relationship between specific adverse life events and psychiatric disorders

This study examines whether certain psychiatric disorders are associated more closely with adverse life events than other disorders are, and whether some adverse life events are associated with a specific group of disorders (e.g., depressive disorders), but not with other disorders (e.g., anxiety disorders). A probability sample of youth aged 9-17 at 4 sites is used (N = 1,285). Univariate and multivariate logistic regressions identify specific relationships between 25 adverse life events and 9 common child and adolescent psychiatric disorders, measured by the Diagnostic Interview Schedule for Children. Conduct Disorder, Oppositional Defiant Disorder, Major Depressive Disorder, and Dysthymia are significantly associated with many of the adverse life events examined, whereas Attention Deficit/Hyperactivity Disorder, Agoraphobia, and Social Phobia are related to very few. This study suggests that certain psychiatric disorders may be more closely associated with adverse life events than other psychiatric disorders are, and that some adverse life events seem to be related to specific types of disorders.

The 18-month impact of an emergency room intervention for adolescent female suicide attempters

Following a suicide attempt by female adolescents, the impact of a specialized emergency room (ER) care intervention was evaluated over the subsequent 18 months. Using a quasi-experimental design, this study assigned 140 female adolescent suicide attempters (SA), ages 12-18 years, and their mothers (88% Hispanic) to receive during their ER visit either: (a) specialized ER care aimed at enhancing adherence to outpatient therapy by providing a soap opera video regarding suicidality, a family therapy session, and staff training; or (b) standard ER care. The adjustment of the SA and their mothers was evaluated over 18 months (follow-up, 92%) using linear mixed model regression analyses. SA's adjustment improved over time on most mental health indices. Rates of suicide reattempts (12.4%) and suicidal reideation (29.8%) were lower than anticipated and similar across ER conditions. The specialized ER care condition was associated with significantly lower depression scores by the SA and lower maternal ratings on family cohesion. Significant interactions of intervention condition with the SA's initial level of psychiatric symptomatology indicated that the intervention's impact was greatest on maternal emotional distress and family cohesion among SA who were highly symptomatic. SA's attendance at therapy sessions following the ER visit was significantly associated with only one outcome--family adaptability. Specialized ER interventions may have substantial and sustained impact over time, particularly for the parents of youth with high psychiatric symptomatology.

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.

Aggression, antisocial behavior, and substance abuse in survivors of pediatric cancer: possible protective effects of cancer and its treatment

OBJECTIVE

To examine aggression, antisocial behavior, and substance abuse in young adult survivors of pediatric cancer (PCS) relative to case control peers (CC).

METHODS

We obtained self-reports of current aggression, antisocial behavior, and lifetime substance use from 26 PCS (time off-treatment, M: = 56 months) and 26 CC using the Antisocial Behavior Checklist and the Drinking and Drug History. A report of current aggression and antisocial behavior also was obtained from primary caregivers using the Child Behavior Checklist.

RESULTS

PCS self-reported significantly less illegal drug use and experimentation than CC. No significant differences emerged between groups for use of alcohol and tobacco nor for aggression and antisocial behavior.

CONCLUSIONS

PCS are functioning as well as, or better than, CC in terms of aggression, antisocial behavior, and substance abuse. However, given the compromised health status of survivors, efforts should focus on further reduction of drug-related risk behaviors that may amplify organ damage or increase risk for further malignancies in this population.

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.

Mothers' mental illness and child behavior problems: cause-effect association or observation bias?

OBJECTIVE

A number of studies have consistently found that a mother's mental health (particularly her level of depression) is a strong predictor of mental health problems experienced by her child(ren). However, the validity of this finding is in doubt because the majority of these studies have relied on maternal reports as indicators of children's behavior.

METHOD

This prospective, longitudinal study examines data on the mental health of the mother from prior to the birth of her child to when the child reaches 14 years of age. Child behavior is measured at 14 years of age using reports from mother and child. Mother and child responses are compared to provide an indication of the possible magnitude of maternal observation bias in the reporting of child behavior problems.

RESULTS

Anxious and/or depressed mothers tend to report more cases of child behavior problems than do their mentally healthy counterparts or children themselves. Differences between mothers and youths in reporting behavior problems appear to be related to the mothers' mental health.

CONCLUSIONS

Current maternal mental health impairment appears to have a substantial effect on the reporting of child behavior problems by the mother, thereby raising questions about the validity of reports of child behavior by persons who are currently emotionally distressed.

The importance of callous-unemotional traits for extending the concept of psychopathy to children

This study focused on the use of callous-unemotional (CU) traits to identify a subgroup of children with both attention deficit/hyperactivity disorder (ADHD) and a conduct problem diagnosis (oppositional defiant disorder [ODD] or conduct disorder [CD] who show characteristics similar to adults with psychopathy. In a clinic-referred sample of children aged 6 to 13 years (N = 154), those with diagnoses of both ADHD and ODD/CD were divided on the basis of teacher ratings of CU traits. Children high on these traits showed features typically associated with psychopathy, such as a lack of fearfulness and a reward-dominant response style. Furthermore, children with CU traits seemed less distressed by their behavior problems. These findings are consistent with research on adults showing that impulsivity and antisocial behavior alone are insufficient to document persons who fit the construct of psychopathy.

Subject and interview characteristics affecting reliability of the Diagnostic Interview Schedule for Children

Despite the well-known difficulties in obtaining reliable and valid assessments of child psychopathology, investigators generally have not examined the influence of factors such as subject characteristics or the specific assessment procedures themselves on the validity of the information obtained. To address these issues, this special section presents four studies of the Diagnostic Interview Schedule for Children, in which investigators examined the impact of a range of variables on the reliability of its symptom and diagnostic information. Factors studied include interview structural characteristics; question length, complexity, and placement within the interview; and interview subject characteristics. Overall findings suggest that interview and subject characteristics exert important influences on the data obtained, and that novel approaches, such as allowing subjects a greater role in the ordering of questions to be answered, may improve the precision and accuracy of such measures of children's psychopathology.

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.

The association between anxiety and psychopathy dimensions in children

Although several theoretical models posit that low levels of anxiety are a risk factor for psychopathy and antisocial behavior, a number of studies have reported elevated levels of anxiety among antisocial individuals. Nevertheless, most investigators in this literature have not distinguished between fearfulness and trait anxiety or attempted to separate the antisocial lifestyle dimension from the callous and unemotional dimension of psychopathy. In a study of clinically referred children (N = 143), we found that (a) measures of trait anxiety and fearlessness (low fearfulness) exhibited low correlations; (b) conduct problems tended to be positively correlated with trait anxiety, whereas callous and unemotional traits tended to be negatively correlated with trait anxiety; and (c) controlling statistically for the effects of one dimension increased the divergent correlations of the other dimension with both trait anxiety and fearful inhibition. These findings bear potentially important implications for the diagnosis and etiology of psychopathy and antisocial behavior and suggest that distinctions between trait anxiety and fearful inhibition, as well as between the two dimensions of psychopathy, may help to clarify longstanding confusion in this literature.

Psychiatric disorders among Japanese children

OBJECTIVE

To generate current data on the prevalence of psychiatric disorders among Japanese children, using DSM-III-R criteria.

METHOD

As part of an ongoing longitudinal study in a Japanese community sample, 114 mother-child dyads were interviewed when the children were approximately 8 years old. DSM-III-R disorders of the children were diagnosed through the administration of a structured diagnostic instrument, the parent and child versions of the Child Assessment Schedule, to both the children and their mothers.

RESULTS

The prevalence rate for any diagnosis was 49.1%, which is similar to that of U.S. children and adolescents.

CONCLUSION

The Child Assessment Schedule is an appropriate scale for assessing the psychopathology of Japanese children, which is as prevalent as in a U.S. sample.

Identification of childhood psychiatric disorder by informant: comparisons of clinic and community samples

OBJECTIVE

To compare the identification of psychiatric disorder as informed by parents versus teachers in children aged 6-11 years and parents versus adolescents in youth aged 12-16 years in clinic versus community samples.

METHOD

Study data come from parallel surveys in Hamilton, Ontario, of children aged 6-16 years. The surveys included consecutive referrals (N = 1150) between 1989 and 1991 to the region's 2 agencies providing outpatient child mental health services. Also, a simple random sample (N = 1689) was used, drawn in 1989 from students attending public schools. Conduct disorder, hyperactivity, emotional disorder, and somatization disorder were assessed by informants using the original Ontario Child Health Study scales.

RESULTS

The percentage of children identified with a disorder was markedly higher in the clinic sample, irrespective of the type of disorder, the age and sex of the child, and who provided the assessment. Also, there was a statistically significant differential shift between parents and teachers in the percentage of children identified with disorder. The ratio of children aged 6-11 years identified with conduct disorder or hyperactivity by parents versus teachers was higher in the clinic sample than in the community sample. Among youth aged 12-16 years, a similar pattern emerged for parents as informants versus the adolescents themselves, but it was statistically nonsignificant.

CONCLUSIONS

The data suggest that the relative contribution of informants to the identification of childhood psychiatric disorder varies by sample type: clinic and community. If risk factors for child disorder are influenced by contextually specific factors wedded to informants, then studies conducted in clinic versus community samples may lead to discrepant information about the determinants of psychopathology. The extent of this problem needs to be assessed by comparing the results of parallel studies conducted in clinic versus community samples.

Sherlock Holmes and child psychopathology assessment approaches: the case of the false-positive

OBJECTIVE

To explore the relative value of various methods of assessing childhood psychopathology, the authors compared 4 groups of children: those who met criteria for one or more DSM diagnoses and scored high on parent symptom checklists, those who met psychopathology criteria on either one of these two assessment approaches alone, and those who met no psychopathology assessment criterion.

METHOD

Parents of 201 children completed the Child Behavior Checklist (CBCL), after which children and parents were administered the Diagnostic Interview Schedule for Children (version 2.1). Children and parents also completed other survey measures and symptom report inventories. The 4 groups of children were compared against "external validators" to examine the merits of "false-positive" and "false-negative" cases.

RESULTS

True-positive cases (those that met DSM criteria and scored high on the CBCL) differed significantly from the true-negative cases on most external validators. "False-positive" and "false-negative" cases had intermediate levels of most risk factors and external validators. "False-positive" cases were not normal per se because they scored significantly above the true-negative group on a number of risk factors and external validators. A similar but less marked pattern was noted for "false-negatives."

CONCLUSIONS

Findings call into question whether cases with high symptom checklist scores despite no formal diagnoses should be considered "false-positive." Pending the availability of robust markers for mental illness, researchers and clinicians must resist the tendency to reify diagnostic categories or to engage in arcane debates about the superiority of one assessment approach over another.

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.

In the eye of the beholder? Parental ratings of externalizing and internalizing symptoms

Variations in ratings of externalizing and internalizing symptoms may contain a trait (i.e., shared view) component when behavioral symptoms that generalize across context are perceived and an individual view component when they are misperceived of when each informant has access to different symptoms. Using a LISREL model, we estimated that the trait and the important-specific, individual view components in parental ratings of externalizing and internalizing symptoms of adolescent siblings. This model demonstrated that mothers' and fathers' ratings contained a substantial individual view component (from 21% to 50% of total rating variance, depending on rater and trait). Except for fathers' ratings of internalizing symptoms (13%), parental ratings also contained a substantial trait component (42% to 58%). Mother's, fathers', and child's ratings may be averaged to estimate a trait of externalizing. To estimate an internalizing trait, it may be best to combine just the mother's rating with the child's self-rating.

Does psychiatric history bias mothers' reports? An application of a new analytic approach

OBJECTIVE

To evaluate whether mothers' psychiatric history biases reports of their children's behavior problems, mothers' and teachers' reports of children's behavior problems were compared using a recently developed statistical approach.

METHOD

Child Behavior Checklists and Teacher's Report Forms were completed by mothers and teachers, respectively, about 801 six-year-old children. Mother's history of major depression, anxiety disorders, and substance use disorder was assessed by using the National Institute of Mental Health Diagnostic Interview Schedule. Generalized estimating equations were used for data analysis.

RESULTS

According to both teachers and mothers, maternal history of major depression was associated with more internalizing problems; the association was significantly stronger when mothers were the informants. Mothers with history of any psychiatric disorder reported more externalizing problems in their children than expected, whereas teachers' reports of externalizing behaviors were unrelated to maternal psychiatric history. These findings could not be explained by variations in children's behaviors across settings.

CONCLUSION

The generalized estimating equation models enabled simultaneous examination of whether children of depressed mothers have excess behavior problems and whether depressed mothers overreport behavior problems in their children. The results indicate that children of depressed mothers have more internalizing problems. In addition, depressed mothers overstate and overgeneralize their offspring's behavior problems. This study broadens the concerns with reporting bias beyond maternal depression to include other psychiatric problems. The results emphasize the potential for bias in family history studies that rely on informants.

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.

Abnormality of EEG alpha asymmetry in female adolescent suicide attempters

Abnormal electroencephalographic (EEG) activity has been associated with various psychiatric disorders and behaviors, including depression, suicide, and aggression. We examined quantitative resting EEG in Hispanic female adolescent suicide attempters and matched normal controls. Computerized EEG measures were recorded at 11 scalp sites during eyes open and eyes closed periods from 16 suicide attempters and 22 normal controls. Suicide attempters differed from normal controls in alpha asymmetry. Normal adolescents had greater alpha (less activation) over right than left hemisphere, whereas suicidal adolescents had a nonsignificant asymmetry in the opposite direction. Nondepressed attempters were distinguished from depressed attempters in that they accounted for the preponderance of abnormal asymmetry, particularly in posterior regions. Alpha asymmetry over posterior regions was related to ratings of suicidal intent, but not depression severity. The alpha asymmetry in suicidal adolescents resembled that seen for depressed adults in its abnormal direction, but not in its regional distribution. Findings for suicidal adolescents are discussed in terms of a hypothesis of reduced left posterior activation, which is not related to depression but to suicidal or aggressive behavior.

Integrating assessment data from multiple informants

OBJECTIVE

To examine the consequences for measurement of child psychiatric disorder (conduct and oppositional disorders) of not integrating the data on the same individual from different informants compared with integrating the information from parents and teachers, using three different strategies.

METHOD

Data for the study came from problem checklist assessments done by parents and teachers of children aged 6 to 16 years (N = 1,134) selected with known probability from a general population sample and from structured interviews obtained in a stratified random subsample (n = 251).

RESULTS

As expected, parent-teacher agreement was low. The pattern of associated features of disorder was found to vary markedly in parent-identified compared with teacher-identified disorder. Furthermore, combining informants had the disadvantage of masking the distinctive patterns of associated features noted in informant-specific disorders. Finally, by treating disorder as informant-specific, the internal properties of the measure are not generally inferior to those obtained by combining informants in various ways.

CONCLUSION

Child psychiatric disorders should be conceptualized as informant-specific phenomena.

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.

DSM-III-R and DSM-III criteria for conduct disorder in preadolescent girls: specific but insensitive

OBJECTIVE

To determine whether DSM-III and DSM-III-R criteria for conduct disorder identify girls in the general population with early-onset, persistent, and pervasive antisocial behavior.

METHOD

2,251 girls, representative of all girls entering kindergarten in Qúebec, were assessed using parent and teacher ratings of antisocial behavior; a subsample was then rated for the next 6 years (ages 7 to 12) by parent and teacher. At age 10 years, the girls who been rated as antisocial in kindergarten, along with a random sample of those not rated as antisocial, were assessed for DSM-III and DSM-III-R diagnoses of conduct and oppositional defiant disorder using a structured psychiatric interview (Diagnostic Interview Schedule for Children) administered to the parent, teacher, and/or child (n = 381).

RESULTS

Of the girls with early-onset, persistent, and pervasive antisocial behavior, 3% met DSM-III-R criteria and 22% met DSM-III criteria for conduct disorder. Conduct disorder was not diagnosed at all in girls who had not been initially rated as antisocial in kindergarten. Lowering the threshold for a DSM-III-R conduct disorder diagnosis to two symptoms and adding the criterion of violation of rules increased the rate of diagnosis to 35% in the pervasively antisocial girls but only to 1% in girls who did not have persistent antisocial behavior.

CONCLUSIONS

DSM-III-R criteria for conduct disorder do not identify most preadolescent girls with early-onset, pervasive, and persistent antisocial behavior. Modifications to the DSM-III-R criteria resulted in increased sensitivity without a loss of specificity.

A nationwide study of developmental and gender prevalence for psychopathology in childhood and adolescence

Psychopathology was assessed through standardized observations by teachers of 1,400 youths 5 through 17 years old comprising the national norm sample of the Adjustment Scales for Children and Adolescents. The sample was stratified according to the US. population by age, sex, ethnicity, parent education, family structure, national region, community size, and handicapping condition. The maladjusted portion of the sample for each of six specific syndromes was examined for departures from expected developmental and gender prevalence. Males outnumbered females for most types of maladjustment, including attention-deficit hyperactive, both provocative and impulsive forms of solitary aggressive, oppositional defiant, and avoidant disorders. Also revealed were general patterns of reduced behavior excess and increased avoidant behavior with advancing age.