Yale Children's Inventory (YCI): an instrument to assess children with attentional deficits and learning disabilities. I. Scale development and psychometric properties

Behavioral and Socio-Emotional Disorders in Intellectual Giftedness: A Systematic Review

This work systematically reviewed past literature to investigate the association between intellectual giftedness and socio-emotional and/or behavioral disorders. Nineteen studies met the inclusion criteria, 17 of which have children and/or adolescents as participants, and 12 have a non-gifted control group. Socio-emotional problems, such as withdrawal, were found in 3 out of 8 studies; internalizing disorders, such as anxiety, were found in 5 out of 9; externalizing disorders, such as hyperactivity, were found in 3 out of 5. The most investigated comorbidity was attention-deficit/hyperactivity disorder. A univocal conclusion on the relationship between intellectual giftedness and socio-emotional/behavioral problems cannot be drawn, principally because of the heterogeneity of participants' age, informants, and instruments. The review highlights the need for future studies to use multi-informant and comprehensive assessments, to reach more robust findings, and suggests that age and discrepancy between verbal and non-verbal intellectual abilities should be considered critical factors.

Family History Is Not Useful in Screening Children for Dyslexia

Accurate and efficient early screening is important for providing effective early intervention for dyslexic readers. While family history is often considered a contributing risk factor for dyslexia, some have suggested that it could serve as a proxy for identification of dyslexia. We examined the classification accuracy of family history as a screening measure for dyslexia using an epidemiologic sample of 398 children followed from age 5 through adulthood. Sensitivity of family history for predicting dyslexia was unacceptably low for all family member groups. Moreover, results from receiver operating characteristic curves indicate that predicting dyslexia using family history does not improve the value of using an evidence-based early screening measure alone. Together, these analyses indicate that family history is inadequate as a screening measure for dyslexia; and thus, the use of positive family history as a proxy for dyslexia is unwarranted.

Students Who Seem to be Unmotivated May have Attention Deficits

A child or adolescent with school problems whose parents have concerns about motivation, such as, “seems lazy,” or, “could do better if he/she tried,” may have an attention deficit. This paper presents the results of analyses of a brief questionnaire constructed for parents to detect such a behavioral pattern. A 12-item scale, which we called the “Seems Unmotivated” scale, had an alpha of 0.88. Crosstabulations and analyses of variance demonstrated the power of this scale to identify children with attention deficits. In a child with perceived motivational difficulties, the possibility of an attention deficit should be considered.

A Preliminary Study of Motor Problems in Children with Attention-Deficit/Hyperactivity Disorder

Although many children with Attention-Deficit/Hyperactivity Disorder (ADHD) are described as “clumsy,” there is relatively little research on problems in motor development in this population. We used a survey method to assess retrospectively developmental histories of 25 children with ADHD and 27 control children (ages 8–15 years). Children with ADHD reportedly had more difficulty than control children with both learning and performing a variety of motor skills, e.g., tying shoes, printing letters, playing sports. In contrast, parents reported few problems in their children's language development. Severity of motor problems was related to performance on specific IQ indices and reading and spelling tests. Given previous research on adverse consequences of clumsiness in children with attention deficits, results of this preliminary study indicate that further research on motor development can shed light on the developmental psychopathology of ADHD.

Review of Clinical Validation of ADHD Behavior Rating Scales

The purpose of this review is to assess the range of overall accuracies for Attention Deficit/Hyperactivity Disorder (ADHD) behavior rating scales evaluated in clinical validation studies. Studies were characterized according to the evidence standards of the American Academy of Neurology (AAN). Studies were excluded due to major design problems such as overfitting by discriminant analysis. The 13 included evaluations of rating scales revealed overall accuracy in the range of 59%–79% with a pooled mean of 69% (±7%, standard deviation) and a pooled sample size of 2,228 subjects from nine studies. While some of the excluded studies demonstrated higher overall accuracies (>79%), these studies were observed to have factors in experimental design and statistics that are known to unduly inflate accuracy. We recommend further research following the full AAN standards, namely well-designed, blinded, prospective studies of rating scales applied to clinically representative samples evaluated with a clinical standard.

Patterns of Sensory Processing in Children with Attention Deficit Hyperactivity Disorder

The researchers conducted this study to compare the sensory responses of children whose primary diagnosis was Attention Deficit Hyperactivity Disorder (ADHD) and children without disabilities on the Sensory Profile, a parent-reporting measure of children's sensory responses in daily life (Dunn, 1999). Parents of 70 children 3 to 15 years old with a primary diagnosis of ADHD and parents of children without disabilities matched by age and gender completed the Sensory Profile. Researchers completed a series of Multivariate Analyses of Variance (MANOVA) with post hoc testing to compare the performance of the two groups of children. Children with ADHD differed significantly from children without disabilities in their sensory responsiveness based on Sensory Profile results. The Sensory Profile can contribute to diagnostic and program planning processes and increase understanding of the nature of the disorder of ADHD.

Minor neurodevelopmental impairments are associated with increased occurrence of ADHD symptoms in children born extremely preterm

ADHD is more common in children born preterm than at term. The purpose of the study was to examine if, and to what extent, ADHD symptoms are associated with minor neurodevelopmental impairments (NDI) in extremely preterm children. In a national population-based cohort with gestational age 22-27 weeks or birth weight <1,000 g assessed at 5 years of age, scores on Yale Children's Inventory (YCI) scales (seven scales) were related to normal functions vs. NDI defined as mild impairments in cognitive function (IQ 70-84), motor function (Movement Assessment Battery for children score > the 95th percentile or freely ambulatory cerebral palsy), vision (correctable), and hearing (no hearing aid). YCI was completed for 213 of 258 eligible children (83%). Children with minor NDIs (n = 98) had significantly higher scores (more ADHD symptoms) than those without NDI (n = 115) on the YCI scales of Attention, Tractability, Adaptability and Total score. Increasing numbers of minor NDIs were associated with higher mean YCI scores. In multivariate analysis only decreased hearing, IQ, and male gender were significantly associated with scores on the Attention scale. Thirty-three children (16%) had scores >3 on the Attention scale (probably ADHD), and the proportion was significantly higher for those with mild NDIs compared to those without (Odds ratio = 2.7, 95% CI 1.3-6.0). Children born extremely preterm with minor NDIs were more likely to have ADHD symptoms than those with no NDI, and increasing number of minor NDIs were associated with more ADHD symptoms.

Shared and nonshared symptoms in youth-onset psychosis and ADHD

OBJECTIVE

We compared ratings of behavior and attention problems between youth-onset psychosis and ADHD, two disorders in which attentional impairments play a key role, and examined the effect of psychostimulant use on age of onset in psychosis.

METHOD

Parent and teacher ratings of behavioral problems and ADHD symptoms were collected using the Achenbach CBCL, TRF, and SNAP-IV Teacher Rating Scales on 42 participants with psychosis, 36 with ADHD and 57 controls (ages 8-19).

RESULTS AND CONCLUSIONS

Results suggested that academic, externalizing, and attention problems reflect symptoms shared between the disorders, whereas internalizing, social and thought problems reflect factors that differ between disorders. Furthermore, participants with psychosis who had been prescribed psychostimulants had a younger age of onset of psychotic symptoms than those who had not. This difference could reflect dissimilarities in symptom severity symptom between subgroups or potentially harmful effects of psychostimulants in individuals predisposed to develop psychosis.

Comorbidity/overlapping between ADHD and PTSD in relation to IQ among children of traumatized/non-traumatized parents

OBJECTIVE

This study explores the comorbidity between symptoms of ADHD and PTSD in relation to IQ among refugee children of traumatized parents (TP) and non-traumatized parents (NTP).

METHOD

The study compares 80 refugee children, 40 with TP with 40 with NTP. ADHD and PTSD are assessed using DICA. Children's cognitive functions are measured by WISC. Teacher ratings of YCI and SDQ are performed.

RESULTS

Overlapping between ADHD and PTSD symptoms are represented among children with TP. Cognitive functions, related to ADHD and PTSD, reveal associations between low IQ (<84) and having both ADHD and PTSD among children with TP.

CONCLUSIONS

Concerns are raised about how ADHD and PTSD symptoms in a child are to be interpreted. Some overlapping exists between the two syndromes, but further studies should determine whether true comorbidity exists between ADHD and PTSD symptoms to better understand how to correctly diagnose and treat refugee children with TP.

A meta-analysis of quantitative EEG power associated with attention-deficit hyperactivity disorder

A meta-analysis was performed on quantitative EEG (QEEG) studies that evaluated attention-deficit hyperactivity disorder (ADHD) using the criteria of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition). The nine eligible studies (N = 1498) observed QEEG traits of a theta power increase and a beta power decrease, summarized in the theta/beta ratio with a pooled effect size of 3.08 (95% confidence interval, 2.90, 3.26) for ADHD versus controls (normal children, adolescents, and adults). By statistical extrapolation, an effect size of 3.08 predicts a sensitivity and specificity of 94%, which is similar to previous results 86% to 90% sensitivity and 94% to 98% specificity. It is important to note that the controlled group studies were often with retrospectively set limits, and that in practice the sensitivity and specificity results would likely be more modest. The literature search also uncovered 32 pre-DSM-IV studies of ADHD and EEG power, and 29 of the 32 studies demonstrated results consistent with the meta-analysis. The meta-analytic results are also supported by the observation that the theta/beta ratio trait follows age-related changes in ADHD symptom presentation (Pearson correlation coefficient, 0.996, P = 0.004). In conclusion, this meta-analysis supports that a theta/beta ratio increase is a commonly observed trait in ADHD relative to normal controls. Because it is known that the theta/beta ratio trait may arise with other conditions, a prospective study covering differential diagnosis would be required to determine generalizability to clinical applications. Standardization of the QEEG technique is also needed, specifically with control of mental state, drowsiness, and medication.

Behavioral Problems and the Effects of Early Intervention on Eight-Year-Old Children with Learning Disabilities

OBJECTIVES

1) To investigate the comorbidity of verbal and nonverbal learning disability subtypes with several domains of behavior problems among 8-year-old children. 2) To determine whether receipt of an early intervention modified the association between childhood behavior problems and learning disabilities (LD).

METHODS

This is a secondary data analysis of the Infant Health and Development Program (IHDP), a randomized clinical trial of an early intervention provided between ages 0 and 3 involving 985 children born low birthweight and premature. The findings are based on a prospective follow-up of these children at 8 years of age.

RESULTS

Compared to children without verbal LD (VLD), those with VLD were twice as likely to exhibit clinical levels of total behavior problems and 89% more likely to exhibit externalizing behavior problems. Analysis of specific subscales of behavior revealed significant associations with anxious/depressed and withdrawn behaviors, as well as an increased likelihood of attention problems among children with VLD. No significant association was found between nonverbal LD (NVLD) and any type of behavior problem. Furthermore, there was a significant interaction between VLD and the intervention, in which the odds of internalizing behavior problems were greater among children with VLD. No interaction effect of the intervention occurred for any type of behavior problem among children with NVLD.

CONCLUSIONS

These findings provide evidence that distinct differences exist for different learning disability subtypes with regards to behavioral outcomes and the effects of early intervention services among 8-year-old children.

Population based, controlled study of behavioural problems and psychiatric disorders in low birthweight children at 11 years of age

OBJECTIVE

To evaluate the risk of long term behavioural problems and psychiatric disorders associated with being born with low birth weight. DESIGN/STUDY GROUPS: A population based, controlled follow up study at 11 years of age of 130 low birthweight (LBW) children weighing less than 2000 g at birth who were without major handicaps, and a random sample of 131 normal birthweight (NBW) children born at term weighing over 3000 g.

MAIN OUTCOME MEASURES

Validated questionnaires addressing behaviour completed by mothers and teachers and child evaluation by child psychiatrist using a semistructured interview.

RESULTS

Behavioural problems, as defined by abnormal scores on more than four of 32 measures, were found in 40% of LBW children compared with 7% of NBW children (odds ratio (OR) 8.2, 95% confidence interval (CI) 3 to 25, p = 0001). A psychiatric disorder was diagnosed in 27% of the LBW children compared with 9% of the NBW children (OR 3.1, 95% CI 1.5 to 6.5, p = 0.001). The LBW children were more often inattentive, had social problems, and low self esteem. None of the pre-, neo-, or peri-natal variables in the LBW group were statistically significant predictors of behavioural outcomes or the presence of psychiatric disorders. Behavioural problems and psychiatric disorders were as common in those with birth weight less than 1500 g as those with birth weight 1500-2000 g.

CONCLUSION

An increased risk of behavioural problems and psychiatric disorders persists in LBW adolescents.

Altered cortical activity in children with attention-deficit/hyperactivity disorder during attentional load task

OBJECTIVE

To evaluate whether cortical activity recorded during attentional load in children with ADHD is different compared with controls.

METHOD

Quantitative electroencephalography (QEEG) was performed at open eyes and during performance of the Continuous Performance Task.

RESULTS

Children with ADHD showed an altered pattern of QEEG activity, especially during the attentional load task, with increased slow cortical activity (mainly over the frontal areas) and decreased fast cortical activity.

CONCLUSIONS

The findings indicate a different arousal level in children with ADHD, which could be due to a delay in functional cortical maturation. To evaluate the clinical importance of these findings, a longitudinal follow-up will be conducted.

Cord serum ferritin concentrations and mental and psychomotor development of children at five years of age

OBJECTIVE

Our purpose was to evaluate the association between fetal iron status and mental and psychomotor development at 5 years of age.

STUDY DESIGN

We evaluated the association of fetal iron status (umbilical cord serum ferritin concentrations) with test scores of mental and psychomotor development of 278 children. Six tests were given, including full-scale intelligence quotient (FSIQ), language ability, fine- and gross-motor skills, attention, and tractability.

RESULTS

Compared with children with cord ferritin in the 2 median quartiles, those in the lowest quartile scored lower on every test and had significantly worse language ability, fine-motor skills, and tractability. They were also 4.8-fold more likely to score poorly in fine-motor skills and 2.7-fold more likely to have poor tractability than children in the median quartiles. FSIQ in the highest quartile was slightly, but not significantly, lower than the median quartiles, but the odds ratio for having a FSIQ score of less than 70 for children in the highest quartile was 3.3 (95% CI 1.2-9.1).

CONCLUSION

Poor iron status (low ferritin) in utero appears to be associated with diminished performance in certain mental and psychomotor tests. The reason for the association between high ferritin concentrations and low FSIQ scores is unknown.

Behavior in term, small for gestational age preschoolers

AIMS

To evaluate whether being born small for gestational age (SGA) was associated with an increased frequency of preschool behavioral problems.

STUDY DESIGN

Follow-up study at 5 years of age.

SUBJECTS

A population based cohort of 318 term infants who were SGA, defined as having a birthweight less than the 15th percentile for gestational age, and without major handicap such as cerebral palsy or mental retardation, and a random control sample of 307 appropriate for gestational age (AGA) infants.

OUTCOME MEASURES

The Personality Inventory for Children and the Yale Children's Inventory (completed by the mothers), and child behavior during psychometric testing.

RESULTS

Behavior problems was not more common among the SGA children. The results were not confounded by a wide range of parental demographic and child rearing factors, including maternal non-verbal problem solving abilities, child rearing style, and maternal psychological distress. However, the parental factors explained 13% of the variance in a summary score of child behavior compared to 1% explained by SGA vs. AGA status. The SGA children were not more sensitive to the negative impacts of parental risk factors than AGA controls. The study does not address the outcome of severely growth-retarded SGA infants.

CONCLUSION

Being born moderately SGA is not a significant risk factor for preschool behavior problems.

Attention Deficit Hyperactivity Disorder

Management of attention deficit hyperactivity disorder (ADHD) encompasses two general domains: pharmacologic therapies and nonpharmacologic therapies, including educational, cognitive-behavioral, and other psychological and psychiatric approaches. Within the past year there have been two seminal developments in treatment. The first is that the Evidence-based Practice Center at McMaster University, under contract with the Agency for Health Care Policy and Research, produced an evidence based report on the treatment of ADHD. The topic was proposed to the AHCPR by the American Academy of Pediatrics and American Psychiatric Association, who served as partners to the center. The second is the completion of the Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA) study by the National Institutes of Mental Health, a 14-month double-blind placebo trial of medication and behavioral therapy in ADHD. In general, the result of the evidence-based review and the MTA study is that stimulants are the most effective agents for the treatment of ADHD. Results from the MTA study indicate that methylphenidate (MPH) and MPH combined with behavioral therapy are superior to behavioral therapy alone and that all three are superior to community therapy. The evidence-based review indicates that each of the stimulants is superior to placebo and the stimulants (regular and sustained-release MPH as well as d and l isomers of the stimulants) are comparable. As for other agents, tricyclic antidepressants, specifically desipramine, are superior to placebo. Only a few studies compared stimulants directly with tricyclic antidepressants, and these were technically inadequate, leading to the conclusion that more rigorous studies are required. Only five studies were found that examined nonpharmacologic treatment, and all contained major limitations in methodology. Despite the limitations, all showed that stimulants were more effective than the nonpharmacologic therapies, consonant with the results of the MTA study. There was lack of evidence to support the superiority of combination multimodal treatment over stimulant therapy alone, again consonant with the MTA study. Both the evidence-based review and the MTA study examined ADHD in middle childhood. Finally, most studies are relatively short-term, including the MTA study (at 14 months). Some evidence suggests that MPH reduces behavioral disturbance as long as it is taken.

Norms for parental ratings on Conners' Abbreviated Parent-Teacher Questionnaire: implications for the design of behavioral rating inventories and analyses of data derived from them

Despite the wide usage of Conners' 10-item Abbreviated Parent-Teacher Questionnaire (APTQ), normative data for parental ratings on the APTQ are rare. Moreover, its psychometric properties as a "stand alone" behavioral rating instrument have yet to be examined in detail. Using data from parental ratings for 6,841 children aged 5 to 14 years, this paper reports the psychometric properties of the APTQ and provides normative and prevalence estimates for four age cohorts (5 to 6, 7 to 8, 9 to 11, and 12 to 14 years) by gender. In presenting the findings, the paper highlights key methodological issues endemic to the design of behavioral rating inventories like the APTQ and the analysis of data derived from them. These issues are illustrated and discussed in terms of their implications for the measurement and determination of prevalence estimates of problem behaviors in child psychology and child psychiatry. The need to revise the design, content, and response formats of child behavior rating inventories is stressed.

Learning disorders with a special emphasis on reading disorders: a review of the past 10 years

OBJECTIVE

To review the past 10 years of clinical and research reports on learning disorders.

METHOD

The most common and best-researched type of learning disorder is reading disability, which is the focus of this review. A selective review of the literature from Psychological Abstracts and Index Medicus from 1985 to the present was conducted. This review focused on conceptual and methodological issues, current assessment practices, epidemiology, correlates of brain function, biological factors, predictors of reading achievement, core deficits, comorbidity reading development and instructional approaches, treatment, and outcome.

RESULTS

Definitional issues, still unresolved, bedevil the field with the debate between those for and those against discrepancy definitions of reading disabilities. Nevertheless considerable progress has been made. Phonological processing problems are now considered the main core deficit responsible for reading disabilities. Correlates of brain function and possible genetic factors are noted. Comorbidity with externalizing and internalizing disorders is described, and some theories for the overlap are identified. Studies on the comorbidity with internalizing disorders are lacking. Good assessment practice and promising approaches to remediation are identified. Unless a concurrent disorder is present, the use of medication for the treatment of reading disabilities should be considered experimental. Favorable outcomes are dependent on initial severity and a supportive home and school environment.

CONCLUSIONS

Much progress has been made in our understanding of learning disabilities, especially in reading disabilities. Resolution of definitional and conceptual issues will greatly assist research into assessment, treatment, and long-term outcome of learning disabilities with and without concurrent psychiatric disorders. Further research into the nature, extent, and correlates of comorbid learning disabilities and their treatment is much needed.

Transient dystonia in non-handicapped low-birthweight infants and later neurodevelopment

The aim of the present study was to evaluate the long-term prognostic significance of transient increase in muscle tone during infancy (dystonia) in very low-birthweight (VLBW) infants without cerebral palsy. Motor (Peabody Developmental Motor Scales), cognitive (Wechsler Preschool and Primary scale of Intelligence) and behavioural (Personality Inventory for Children, Yale Children's Inventory) development was assessed at 5 years of age. In a population-based sample of 50 VLBW children, transient dystonia was present in 14. In explorative analyses, transient dystonia was associated with low 1 min Apgar scores, neonatal bacterial infection, and lack of breast-milk in the neonatal period. Cognitive, neuromotor and behavioural development at 5 years of age was comparable in those with and without transient dystonia, although there was a statistically non-significant tendency towards more neuromotor problems in the dystonic children.

Behavioral problems in low-birthweight preschoolers

Preschool behavior of a population-based sample of 144 5-year-old children with birthweights less than 2000g (LBW) was compared with a random sample of 163 normal-birthweight term controls. The Personality Inventory for Children and the Yale Children's Inventory were completed by the mothers, and child behavior during psychometric testing was assessed. Nineteen per cent of the LBW children compared to 4% of controls had behavioral problems as defined by abnormal scores on more than three behavioral measures. The LBW children were more often socially insecure, anxious and difficult to manage, but inattention and hyperactivity were not prominent. The LBW children were not more sensitive to the negative impact of parental risk factors than normal-birthweight children.

Whole blood serotonin and disruptive behaviors in juvenile obsessive-compulsive disorder

OBJECTIVE

The study was conducted with children and adolescents with obsessive-compulsive disorder (OCD) to assess the relationship of whole blood serotonin (5-HT) content to a concurrent diagnosis of a disruptive behavior disorder (DBD) and to severity ratings of aggressive behavior.

METHOD

Eighteen children and adolescents who met DSM-III-R criteria for OCD were evaluated with a structured interview, clinician rating scales, and the Child Behavior Checklist (CBCL). Blood 5-HT concentration was assayed with a fluorometric procedure. Relationships among categorical diagnoses, dimensional ratings, and blood 5-HT content were analyzed with bivariate and multivariate techniques.

RESULTS

OCD subjects with a DBD (n = 6) had significantly higher scores than those without a DBD (n = 12) on the Total Problem scale, the Externalizing Problem scale, and several of the behavioral syndrome scales of the CBCL. Blood 5-HT concentrations were significantly lower in those with a DBD than in those without a DBD, and blood 5-HT concentrations had significant negative correlations with the Total score, the Externalizing score, and the Aggressive Behavior score of the CBCL.

CONCLUSIONS

The results provide further evidence of a significant relationship between aggressive behavior and serotonergic functioning.

A review of neuromotor tests and the construction of a scored neuromotor examination for four-year-olds

We have reviewed the methodologies in construction of some widely used tests and constructed a computer-compatible scored method for the neuromotor evaluation of four year olds. Using the data from 333 neurological assessments, factor analysis indicated five subscales. Alpha coefficients show high reliability for both subscales and total scores. Using data from a second sample, we describe predictive validity for the five subscales and total score.

Language, learning, and behavioral disturbances in childhood: a longitudinal perspective

OBJECTIVE

Investigate longitudinally the course of development of preschool learning impaired (LI) children to better understand the interaction between neurodevelopmental delay, behavioral/emotional disorders, and language development and disorders.

METHOD

Relationships between developmental language disorders and emotional problems were investigated in 99 8-year-old specifically language impaired and control children originally assessed at age 4 years using the Achenbach Child Behavior Checklist and the Conners' Parents Questionnaire.

RESULTS

LI children received higher behavior problem scores and were more likely to score in the clinical range than were control children. Neither degree of early language impairment nor amount of language improvement predicted 8-year behavioral/emotional status. LI children with the largest drop in IQ between ages 4 and 8 received the highest behavior problem scores. No significant comorbid relationship was seen between LI and attention-deficit hyperactivity disorder.

CONCLUSIONS

The enhanced incidence of behavior problems reported heretofore may be related more to lower IQ than to linguistic deficit per se. Care must be taken to differentiate the symptoms of neurodevelopmental delay and emotional disturbance, however, preschool children with scores in the clinical range on such measures should be referred for additional evaluation.

Diagnostic specificity of a brief measure of expressed emotion: a community study of children

The association between expressed emotion (EE) and psychiatric disorders was investigated in a community survey of 108 preadolescent children. Results indicated that the two components of EE, critical comments and emotional overinvolvement, identified non-overlapping subsets of families and displayed diagnostic specificity. Significantly higher rates of disruptive behavior diagnoses were observed in children of parents who expressed high levels of criticism, while children of parents who expressed high levels of emotional overinvolvement were significantly more likely to have an anxiety disorder when compared to the remaining sample. Findings support the utility of this brief measure of EE in epidemiologic samples.

A short-term longitudinal study of the early development of self-regulation

A short-term longitudinal study was conducted to determine whether self-regulation at 4 years could be predicted from child and maternal measures obtained when the children were age 24 months. The subjects were 69 children and their mothers drawn from the general community. Criterion behaviors assessed at 4 years were those suggestive of attention-deficit hyperactivity disorder. Of the 24-month child measures, maternal ratings of the child's impulsivity and attention span, plus an objective measure of delay ability, were the most effective predictors. Maternal negativity, as assessed in mother-child interaction, predicted the criterion behaviors, even after the child's behavior as an elicitor of maternal behavior was controlled. Maternal child-rearing attitudes on the dimensions of warmth and aggravation were also effective predictors, even after controlling for the child's emotionality as a possible determinant of maternal attitudes. It is argued that the results with the maternal attitude measures provide support for the hypothesis that maternal behavior is a contributor to the development of self-regulation.

Interpersonal disabilities: social skill deficits in older children and adolescents. Their description, assessment, and management

Good social skills are critical for peer acceptance and friendship formation, which are developmental missions for the older child and adolescent. Good social skills can be developed and can favorably influence other domains of function. A sensitive and comprehensive assessment and management plan is essential. Pediatricians have a unique vantage point because of their familiarity with a child, the family, the school and community, and their knowledge of child development and behavior. Pediatricians can therefore play a central role in the assessment, management, and follow-up of social skills problems.

Attention deficit

Attention deficit, among the most commonly diagnosed functional deficits in pediatric neurology, is, like epilepsy, most often idiopathic. It can also be a symptom of many neuropathologic states. Although a lifelong problem, attention deficit is most troublesome during school years, because, like asthma, it is highly sensitive to environmental influence. The neurologist can consider attention deficit in its own right, apart from hyperkinesis and other associated behavior disorders, as a cognitive limitation and handicap to academic progress.

Clinical management of attention deficit hyperactivity disorder

This article reviews current approaches to the diagnosis and management of children with attention deficit hyperactivity disorder in a multidisciplinary setting. The physician's role in terms of data collection, formulation of the diagnosis, and discussion of findings with the parents and child is reviewed. The use of psychostimulants in this condition is reviewed, and some case vignettes are presented.

Growth hormone and prolactin response to methylphenidate in children with attention deficit disorder

Utilizing a double-blind, drug-placebo design, we examined growth hormone (GH) and prolactin (Pro) response to oral administration of methylphenidate (MPH) in 14 boys (ages 7.0-12.4 years) with Attention Deficit Disorder (ADD). Four conditions representing three different MPH doses (0.3 mg/kg O.D., 0.3 mg/kg B.I.D., 0.6 mg/kg O.D.) and Placebo were compared in each subject, each condition lasting for a period of 3 weeks. GH and Pro response were measured both as maximum peak GH (DGH) or nadir of Pro (DPro) as well as area under the curve for the first four hours after MPH administration (AUCGH, AUCPro). Behavioral measures included parent ratings on the Yale Children's Inventory and teacher ratings on the Yale and Conners Behavior Rating Scales and Kagan's Matching Familiar Figures Test (MFFT). Prolactin response as measured by AUCPro was significantly increased after MPH compared to placebo (t = 2.04, p less than 0.05, placebo vs all doses MPH). This difference observed for AUCPro between placebo and MPH was evident as well when we considered the number of times AUCPro declined after MPH as compared to placebo (p = .018, Fisher's exact test). Within-subjects analysis of covariance demonstrated significant correlations between the improvement in reaction time on the MFFT and 1) GH response (AUCGH, r = .58, p less than .001) and 2) prolactin response (AUCPro, r = .40, p less than .05) and between improvement in attention as measured on the Yale BRS and GH response (AUCGH, r = .57, p less than .05). Our findings suggest that measures other than GH and prolactin may be more desirable measures of brain catecholaminergic functioning.

Epilepsy in children with attention deficit disorder: cognitive, behavioral, and neuroanatomic indices

Our study examined the hypothesis that if epilepsy adversely influences the cognitive and behavioral performance of children, then children with both attention deficit-hyperactivity disorder and epilepsy (ADHD-Sz) should exhibit more severe cognitive and behavioral difficulties and be more likely to demonstrate abnormalities on cranial computed tomography than ADHD children without epilepsy. We compared ADHD-Sz and ADHD patients using a variety of psychologic, behavioral, and educational measures, as well as cranial computed tomography. ADHD-Sz children scored significantly below the ADHD group on the Wechsler Intelligence Scale for Children-Revised (performance and full scale scores). In both ADHD-Sz and ADHD groups, the prevalence of learning disabilities (LD) and a variety of behavioral features were similar. Neither seizure disorder nor ADHD was associated with an increased incidence of structural abnormalities or asymmetries of the brain. These findings support the belief that epilepsy adversely affects IQ but does not appear to affect the prevalence of LD or behavioral abnormalities in ADHD children. They further support the accumulating body of data demonstrating normal brain anatomy in ADHD by computed tomography.

Behavioral and cognitive subtypes of ADHD

Attention-deficit hyperactivity symptoms are observed by teachers in 9.2% of a nonreferred elementary school population. Two subtypes of attention-deficit hyperactivity disorder (ADHD), a cognitive form and a behavioral form, are identified. The behavioral subtype includes about 80% of those identified and is characterized by distinct clinical phenomenology of inattention, impulsivity, and hyperactivity. These children can be described on a continuum of severity, with the most severe showing behavioral features indistinguishable from conduct disorder. Children with behavioral subtypes of ADHD do not exhibit the specific skill deficits on neuropsychological tests that are characteristic of reading disabled children. There is a second, less prevalent type of cognitive attention-deficit hyperactivity disorder constituting approximately 20% of ADHD children that includes severe academic underachievement along with inattention, impulsivity, and overactivity. Children with the cognitive subtype exhibit information processing deficits that involve inadequate encoding and retrieval of linguistic information, characteristic of reading disabilities.

Measures of attention deficit. Part I: Questionnaires

Despite much progress in the diagnosis and management of children with attentional problems, hyperactivity, and learning difficulties, current diagnostic techniques remain inadequate to readily distinguish a primary attentional disorder from a more complex secondary problem. Developmental and behavioral questionnaires to supplement office evaluation of hyperactivity, neuromaturation, and selected cognitive processes continue to be improved. These measures suffer from different biases, focus on different childhood characteristics and associated problems, and approach childhood interaction with the environment differently. Several are psychometrically more sound, and several provide the physician with developmental and social information that may help improve the habilitative prescription. The general pediatrician can use these questionnaires to complement his or her evaluation and follow-up of children who present with learning and behavioral problems. Prior to choosing an instrument, the clinician should review the advantages of each and choose the one most suited to his or her practice.

Attention deficit disorder: current perspectives

This review focuses on selected issues in the rapidly proliferating scientific literature on attention deficit disorder (ADD). It encompasses a brief overview of ADD, including a review of the historical trends, causation, and a description of the clinical characteristics. Critical issues fundamental to understanding of ADD are addressed next. Evidence is presented to suggest that there are several groups of children with ADD who are currently under-identified and therefore, underserved (girls with ADD; ADD without hyperactivity). The concept is introduced of uncomplicated ADD and ADD-Plus (ADD-P), a term used to designate ADD associated with other complicating features such as conduct disorder. Specific methodologic issues and their relationship to the under-identification of these groups of children follows. This discussion encompasses the reasons for diagnostic imprecision and inconsistency, emphasizing the problem of selective referral patterns and how it results in an inaccurate portrait of ADD. We then present new approaches to the definition and diagnosis of ADD based on empiric studies designed to circumvent some of these problems. We conclude with a summary of the implications of these findings, and recommendations for public policy in ADD, particularly the need to recognize that ADD may occur even in the most intellectually gifted individuals and even in students in select colleges. Often these children with the highest potential are penalized most, not because of conceptual limitations or because they do not understand, but because educators often fail to recognize the symptom complex. Many of these children are succeeding through intelligence and great effort, but many more could succeed with proper identification.