Self-esteem in special education children with ADHD: relationship to disorder characteristics and medication use

OBJECTIVES

To describe the level of self-esteem among the study population, to examine how self-esteem ratings may vary by disorder characteristics and medication use, and to identify predictors of low self-esteem while adjusting for sociodemographic factors.

METHOD

In a school district-wide sample of children in special education programs, the authors assessed self-esteem with the Piers-Harris Self-Concept Scale among 143 students at high risk for attention-deficit/hyperactivity disorder (ADHD) in the school year 1995, with an interview participation rate of 73%. Disorder characteristics and medication use were assessed using multiple informants and standardized measures.

RESULTS

Self-esteem scores, on average, were in the normal range. However, across ADHD comorbidity profiles, children with ADHD and internalizing symptoms had significantly lower self-esteem scores, especially in the areas of anxiety and popularity, than children with ADHD alone or those with comorbid disruptive behavior disorders. Independent predictors of lower self-esteem were being while, high functional impairment, and comorbid internalizing conditions, but not medication use.

CONCLUSIONS

Findings suggest that interventions for ADHD should be culturally sensitive as well as aimed at improving a child's functional level and associated internalizing symptoms. Medication use among this younger patient group was not related to self-esteem scores.

Blood glucose monitoring skills in children with Type I diabetes

While blood glucose monitoring has become increasingly important in diabetes care, studies have yet to address the accuracy of youngsters' performance of blood glucose testing with current reflectance meters. The present study examined testing skills and predictors of accurate testing skills in a sample of 7-14-year-old children attending a summer camp for youth with diabetes (n=266). A 15-item behavior observational skill test was used to assess accuracy of blood glucose monitoring skills with reflectance meters. Accurate performance of individual skills ranged between 14.6% and 99.6% for the sample. However, a number of children made critical errors (errors that were likely to lead to inaccurate blood glucose testing results). When duration of diabetes and metabolic control were controlled, female gender, older age, experience with a particular meter, and absence of hypoglycemia at the time of testing were positively associated with accurate skill performance. Findings suggest that younger children, children using a new blood glucose testing meter, and children suspected of having hypoglycemia should be supervised and observed when testing. Although all young children should be supervised when blood glucose testing, boys may need closer supervision until an older age than girls. This study underscores the need for health care providers to periodically observe children's blood glucose monitoring techniques to assure accurate testing habits and to correct problematic testing behaviors.

Response to hypo- and hyperglycemia in adolescents with type I diabetes

OBJECTIVE

To assess the appropriateness of adolescents' responses to hypo- and hyperglycemia and to examine the relationship of patient age, gender, diabetes duration, diabetes knowledge, parental supervision, and glycemic control to response appropriateness.

METHODS

We assessed 125 adolescents' responses to daily episodes of hypo- and hyperglycemia by 24-hour recall interviews; responses were coded for type and appropriateness.

RESULTS

Adolescents responded inappropriately to 38% of hypoglycemic and 29% of hyperglycemic episodes. Parental supervision of blood glucose testing did not increase the likelihood of an appropriate response; in the case of hyperglycemic episodes, it appeared to be counterproductive. Adolescents who responded inappropriately to hyperglycemia were also older but not different from those who responded appropriately by gender, disease duration, diabetes knowledge, or glycemic control.

CONCLUSIONS

Health providers and family members may underestimate adolescents' difficulty managing hypo- and hyperglycemia appropriately. The presence of parental supervision does not ensure an appropriate response; parents may be particularly misinformed about the management of hyperglycemia.

Imipramine plus cognitive-behavioral therapy in the treatment of school refusal

OBJECTIVE

To investigate the efficacy of 8 weeks of imipramine versus placebo in combination with cognitive-behavioral therapy (CBT) for the treatment of school-refusing adolescents with comorbid anxiety and major depressive disorders.

METHOD

This was a randomized, double-blind trial with 63 subjects entering the study and 47 completing. Outcome measures were weekly school attendance rates based on percentage of hours attended and anxiety and depression rating scales.

RESULTS

Over the course of treatment, school attendance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendance of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatment, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the placebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with only 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depression on the Children's Depression Rating Scale-Revised decreasing at a significantly faster rate in the imipramine group compared with the placebo group (z = 2.08, p = .037).

CONCLUSIONS

Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comorbid anxiety and depression.

Caffeine withdrawal in normal school-age children

OBJECTIVE

Caffeine is widely consumed by children around the world. The purpose of this study was to determine whether children manifest withdrawal effects after cessation of caffeine intake.

METHOD

Thirty normal children completed the single-blind, within-subjects, repeated-measures study with weekly sessions. Subjects were tested four times: (1) baseline (on regular caffeine diet); (2) on caffeine (approximately 120 to 145 mg/day); (3) during withdrawal (24 hours after discontinuation of caffeine taken for 13 consecutive days); and (4) at return to baseline. Subjects were evaluated with self-report measures of symptoms and objective measures of attention, motor performance, processing speed, and memory.

RESULTS

During caffeine withdrawal, there was a significant deterioration on response time of a visual continuous performance test of attention. This finding is consistent with caffeine withdrawal. The deterioration in response time appeared to persist for 1 week.

CONCLUSIONS

Twenty-four hours after children discontinued caffeine, there was a decrease in performance on reaction time of a task requiring sustained attention. Further work is indicated to determine whether children manifest caffeine withdrawal effects after cessation of caffeine intake.

Children in special education programs: attention deficit hyperactivity disorder, use of services, and unmet needs

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD), a common psychiatric condition, may impair a child's ability to learn and to form social relationships, tasks critical to healthy development. This study describes the prevalence of the disorder among children in special education programs and identifies the extent and predictors of unmet service needs.

METHODS

A 2-stage screening protocol of a countywide population of second- through fourth-grade students in special education was conducted to (1) screen for ADHD, employing standardized parent and teacher questionnaires, and determine health services use (n = 499) and (2) perform diagnostic assessments of ADHD (n = 318).

RESULTS

Almost half of the children qualified for a diagnosis of ADHD, yet only half of those were reportedly receiving care for the condition, mainly in the general health care sector. Girls were more than 3 times as likely as boys to have unmet service needs; minority status, low income, and health maintenance organization coverage also emerged as possible risk factors for unmet service needs.

CONCLUSIONS

ADHD is a common yet often untreated condition among children in special education. Mental health services for children with this disorder should be integrated with general health care and special education programs.

Knowledge and information about ADHD: evidence of cultural differences among African-American and white parents

Attention deficit hyperactivity disorder (ADHD) is considered the most common child psychiatric disorder in the United States of America. Despite the high prevalence (estimated at 3-5%), little is known about the level and source of knowledge about ADHD among those affected by the disease, and about cultural and ethnic variations in knowledge levels and information sources. This represents a serious deficit, because health behavior, including demand for health services, is thought to be strongly influenced by knowledge or beliefs held by individuals and their networks. Furthermore, recent research suggested minority children may be less likely to receive services for ADHD. To examine possible differences in ADHD knowledge and information source, a sample of 486 African-American and white parents of children at high risk for ADHD were surveyed by telephone and subsequently participated in face-to-face interviews addressing their explanatory models of ADHD. Results revealed significant ethnic differences in knowledge and sources of information about ADHD. Fewer African-American parents than white parents indicated that they had ever heard of ADHD (69% compared to 95%, P < 0.001), or that they knew some or a lot about it (36% compared to 70%, P < 0.001) African-American parents were more likely to attribute ADHD to excessive sugar in the diet than whites (59% compared to 30.0%, P < 0.001). Finally, even though the physician was listed as the most preferred information source for both groups, only 17.5% of African-American parents reported they had received information about ADHD from the physician compared to 29% of whites (P < 0.01). African American parents reported less use of and less preference for written informational materials (newspapers, journals, library) than white parents. We conclude that substantially more research should be undertaken to examine the relationship between ethnicity and ADHD knowledge, to inform culturally appropriate education campaigns and to improve access to services for this important treatable child mental health condition.

Diagnostic utility of two commonly used ADHD screening measures among special education students

OBJECTIVE

To examine the diagnostic utility of two commonly used attention-deficit hyperactivity disorder (ADHD) screening measures in a population of special education students and address whether screener performance is affected by demographic characteristics.

METHOD

A school district population of special education students was screened for ADHD risk using two parent questionnaires, the 46-item Attention Deficit Disorders Evaluation Scale (ADDES) and the 10-item Conners Abbreviated Symptom Questionnaire (ASQ). All high-risk children and a random sample of low-risk children subsequently underwent DSM-IV-based diagnostic assessment through parental diagnostic interviews (Diagnostic Interview Schedule for Children Version 3.0). Diagnostic utility was summarized by sensitivity, specificity, predictive utilities of positive and negative tests, and efficiency, all of which were estimated using an approach that accounted for the sampling design.

RESULTS

Overall efficiency scores ranged between 70% and 74%. Sensitivity estimates were below 70% even at low screener cutoff scores. The ADDES did not perform significantly better than the ASQ. Significant gender and ethnicity effects emerged.

CONCLUSIONS

Overall, both the ASQ and the ADDES yielded substantial numbers of false positives and false negatives among this population of children, indicating that alternative approaches will be required to accurately and efficiently identify children in need of services for ADHD. Child psychiatrists can play a valuable consulting role as school districts and primary care settings struggle to implement appropriate identification procedures for ADHD.

Somatic symptoms in anxious-depressed school refusers

OBJECTIVE

To identify the most common physical complaints in a sample of adolescent school refusers with comorbid anxiety and depressive disorders. Whether somatic symptoms are more likely to be associated with high levels of anxiety or high levels of depression was also explored.

METHOD

Forty-four adolescents in a treatment study were evaluated at baseline with structured psychiatric interviews and measures of anxiety, depression, and somatization.

RESULTS

The most common somatic complaints were in the autonomic and gastrointestinal categories. In simple regression analyses, anxiety level as measured with the Revised Children's Manifest Anxiety Scale and depression level as measured with the Beck Depression Inventory each significantly predicted the severity of somatic symptoms. The correlation between percentage of days absent from school and severity of somatic symptoms approached significance (r = .27, p = .074).

CONCLUSIONS

Knowledge that somatic complaints are commonly an expression of underlying anxiety and depression may facilitate more rapid referral for psychiatric assessment and treatment and thereby help avoid unnecessary medical workups and sequelae from school refusal.

Anxiety disorders in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the research on anxiety disorders in children and adolescents, focusing on new developments in the past 10 years.

METHOD

This review includes recent articles which contribute to the conceptualization, assessment, and treatment of childhood anxiety disorders.

RESULTS

Information was organized into a developmental framework. Anxiety disorders research has shown steady progress.

CONCLUSIONS

More research is needed, particularly in the areas of neurobiological basis of anxiety disorders, longitudinal studies, and treatment.

Management of blood-drawing fears in adolescents with comorbid anxiety and depressive disorders

As more pharmacologic treatment and research on child and adolescent psychiatric patients are conducted, the common problem of blood-drawing fears will need to be addressed. Avoidance of blood-drawing could jeopardize an individual's physical and mental health, and inhibit the collection of data aimed at furthering the study of psychiatric disorders in youth. This report describes the naturalistic application of specific techniques for managing severe blood-drawing fears in adolescent subjects undergoing a clinical trial. The adolescents (ages 12-18) were 44 consecutive school refusers with comorbid anxiety and major depressive disorders. Of the school-refusing adolescents, 27% (12 of 44) were observed to have a severe fear of blood-drawing. A management strategy comprised of providing information, distraction, supportive reassurance, and exposure appeared successful in managing the fears of blood-drawing in all of the adolescents, except two. These 2 adolescents refused to enter the treatment study due to a marked fear of blood-drawing. All 10 subjects who exhibited a fear of blood-drawing and were able to complete the initial blood test, using the interventions noted, were able to obtain subsequent venipunctures with minimal or no avoidance behavior. These preliminary findings suggest that blood-drawing fears can be effectively managed in most cases, though controlled studies of these interventions are needed.

Caffeine effects on learning, performance, and anxiety in normal school-age children

OBJECTIVE

The purpose of this investigation was to study the acute effects of caffeine on learning, performance, and anxiety in normal prepubertal children.

METHOD

Twenty-one children were evaluated in a double-blind, placebo-controlled crossover design. Subjects were studied during four sessions, 1 week apart, under the following conditions: baseline, placebo, 2.5 mg/kg caffeine, and 5.0 mg/kg caffeine. Subjects were randomized to order of placebo and the two dosages of caffeine. Dependent measures included tests of attention, manual dexterity, short-term memory, and processing speed. Anxiety rating scales were also administered. Saliva samples were analyzed for caffeine levels.

RESULTS

Caffeine improved performance on two of four measures of the Test of Variables of Attention and on a test of manual dexterity in the dominant hand. There was a trend toward increased current level of self-reported anxiety after caffeine on a visual analogue measure of anxiety. Children reported feeling significantly less "sluggish" after caffeine ingestion than after placebo ingestion.

CONCLUSIONS

In a small sample size, there was indication that caffeine enhanced performance on a test of attention and on a motor task. Children also reported feeling less "sluggish" but somewhat more anxious. Because caffeine is so widely available and frequently consumed by children, these results are important and need replication.