Child and adolescent psychopathology research: problems and prospects for the 1990s

The Validity of the ADHD Section of the Diagnostic Interview Schedule for Children

The purpose of this study was to assess the concurrent criterion validity of the attention-deficit/hyperactivity disorder (ADHD) portion of the National Institute of Mental Health Diagnostic Interview Schedule for Children–IV (NIMHDISC-IV). Fifty-seven adolescent participants were divided into three groups on the basis of whether participants met criteria for ADHD on caretaker and adolescent responses on the DISC: (a) 18 participants for whom both the caretakers and adolescents endorsed ADHD, (b) 17 participants for whom the caretakers but not the youth endorsed ADHD, and (c) a clinical control group with no ADHD diagnosis ( n = 22). These three groups were compared across parent, teacher, and adolescent checklists; clinician diagnosis; and three objective measures of behavior (continuous performance task, actigraphy monitoring, and a structured observation). Findings lend partial support to the concurrent criterion validity of the ADHD section of DISC.

Toward a conceptual framework of instrumental antisocial decision-making and behavior in youth

This paper reviews and organizes relevant theory and research toward a conceptual framework of instrumental antisocial decision-making and behavior in youth. To date, social cognitive study of the development of youth antisocial functioning has largely focused on response patterns (e.g., cognitive responses to aversive cues). Though instrumental decision making is paid significant attention in research on adult criminality, there exists no framework by which youths' goal-driven behavioral decisions that are made in pursuit of antisocial motives and interests may be understood. This is a problem in that lessons from research on children and adolescents suggest that there are meaningful differences in structure, phenomenology and function of subtypes of antisocial behavior (instrumental versus reactive). The absence of such a model may account, at least in part, for why the study of instrumental antisocial behavior in youth remains relatively limited.

The neurophysiology of attention-deficit/hyperactivity disorder

Recent reviews of the neurobiology of Attention-Deficit/Hyperactivity Disorder (AD/HD) have concluded that there is no single pathophysiological profile underlying this disorder. Certainly, dysfunctions in the frontal/subcortical pathways that control attention and motor behavior are implicated. However, no diagnostic criteria or behavioral/neuroimaging techniques allow a clear discrimination among subtypes within this disorder, especially when problems with learning are also considered. Two major Quantitative EEG (QEEG) subtypes have been found to characterize AD/HD. Here we review the major findings in the neurophysiology of AD/HD, focusing on QEEG, and briefly present our previous findings using a source localization technique called Variable Resolution Electromagnetic Tomography (VARETA). These two techniques represent a possible objective method to identify specific patterns corresponding to EEG-defined subtypes of AD/HD. We then propose a model representing the distribution of the neural generators in these two major AD/HD subtypes, localized within basal ganglia and right anterior cortical regions, and hippocampal, para-hippocampal and temporal cortical regions, respectively. A comprehensive review of neurochemical, genetic, neuroimaging, pharmacological and neuropsychological evidence in support of this model is then presented. These results indicate the value of the neurophysiological model of AD/HD and support the involvement of different neuroanatomical systems, particularly the dopaminergic pathways.

Calibration of ADHD Assessments Across Studies: A Meta-Analysis Tool

When analyzed separately, data from small studies provide only limited information with limited clinical generalizability, due to small sample size, differing assessments, and limited scope. In this methodological paper we outline a theoretical framework for performing meta-analysis of data obtained from disparate studies using disparate tests, based on calibration of the data from such studies and tests into a unified probability scale. We apply this method to combine the data from five studies examining the diagnostic abilities of different assessments of Attention Deficit/Hyperactivity Disorder (ADHD), including behavioral rating scales and EEG assessments. The studies enrolled a total of 111 subjects, 56 ADHD and 55 controls. Each individual study had a small sample focused on a specific age/gender group, for example 8 boys ages 6-10, and generally had insufficient power to detect statistically significant differences. No gender, or age comparisons were possible within any single study. However, when calibrated and combined, the data resulted in a clear separation between ADHD versus non-ADHD groups in males below the age of 16 (p < 0.001), males above the age of 16, (p = 0.015), females below the age of 16, (p = 0.0014), and females above the age of 16, (p = 0.0022). We conclude that if data from various studies using various tests are made comparable, the resulting combined sample size and the increased diversity of the combined sample lead to increased significance of the statistical tests and allow for cross-sectional comparisons, which are not possible within each individual study.

Family environment in attention deficit hyperactivity, oppositional defiant and conduct disorders

OBJECTIVE

This study aims to ascertain whether there were differences in family environment among patients with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder and conduct disorder.

METHOD

The records of 233 patients, selected for high or low scores on a scale that taps ADHD symptoms, were reviewed by three clinicians who made DSM-IV diagnoses and rated the family environment with the Global Family Environment Scale (GFES). Self-report data obtained from the parent and child versions of the Child Behaviour Checklist were also used. The quality of the family environment was then compared between the various diagnostic groups.

RESULTS

A poorer family environment was associated with conduct disorder and oppositional defiant disorder and predicted a worse outcome (e.g. admission to a non-psychiatric institution, drug and alcohol abuse). Quality of the family environment did not vary according to ADHD diagnosis or gender.

CONCLUSIONS

There seems to be no association between the quality of the family environment and a diagnosis of ADHD among referred adolescents. However, there is an association with conduct disorder. Interventions that improve family environment in the early years of life may prevent the development of conduct problems.

Complementary development of prevention and mental health promotion programs for Canadian children based on contemporary scientific paradigms

Confusion regarding definitions and standards of prevention and promotion programs is pervasive, as revealed by a review of such programs in Canada. This paper examines how a discussion of scientific paradigms can help clarify models of prevention and mental health promotion and proposes the complementary development of prevention and promotion programs. A paradigm shift in science contributed to the emergence of the transactional model, advocating multiple causes and dynamic transactions between the individual and the environment. Consequently, the view of prevention applying over a linear continuum and of single stressful events causing mental disorders may no longer be appropriate. It is the author's belief that the new science of chaos theory, which addresses processes involved in the development of systems, can be applied to child development and thus to the heart of prevention and promotion programs. Critical moments followed by transitions or near-chaotic behaviours lead to stable states better adapted to the environment. Prevention programs would focus on the critical moments and target groups at risk to reduce risk factors. Promotion programs would focus on stable states and target the general population to develop age-appropriate life skills. The concept of sensitive dependence on initial conditions and certain empirical studies suggest that the programs would have the greatest impact at the beginning of life. It is hoped that this effort to organize knowledge about conceptual models of prevention and mental health promotion programs will foster the development of these programs to meet the urgent needs of Canadian children.

Stealth virus epidemic in the Mohave Valley: severe vacuolating encephalopathy in a child presenting with a behavioral disorder

An infectious illness, attributed to atypically structured cytopathic "stealth" viruses, occurred in 1996 in the Mohave Valley region of the United States. A stealth virus-infected child from this region has developed a severe noninflammatory, vacuolating (spongiform) en cephalopathy. The illness initially presented as a behavioral problem without overt neurological signs. Extensive investigations, including repeated magnetic resonance imaging, two brain biopsies, and stealth virus cultures, have helped define the disease process occurring in this child. Significant clinical benefit with apparent retardation of disease progression occurred during a 6-week course of ganciclovir therapy. The potential contributing role of stealth virus infections in children presenting with behavioral problems needs to be addressed.

Psychiatric disorders with onset in the preschool years: I. Stability of diagnoses

OBJECTIVE

To examine the stability of psychiatric disorders with onset in preschool years.

METHOD

Five hundred ten children aged 2 through 5 years enrolled initially, with 344 participating in a third wave of data collection 42 through 48 months later. The test batteries used for diagnoses varied by child's age, but they included the Child Behavior Checklist, developmental evaluation, Rochester Adaptive Behavior Inventory and a play session (under age 7 years), and a structured interview (Diagnostic Interview for Children and Adolescents, for parent and child) (ages 7 and older). Consensus DSM-III-R diagnoses were assigned using best-estimate procedures.

RESULTS

Intraclass correlations were 0.497 for emotional disorders, 0.718 for disruptive disorders, 0.457 for other diagnoses, and 0.544 for disruptive disorders comorbid with another disorder, indicating moderate stability for all groups of disorders. More than 50% of the children who were aged 2 through 3 years at wave 1 continued to have some psychiatric disorder at wave 2 or 3. Rates were higher for children aged 4 through 5 initially; approximately two thirds were cases subsequently. Odds ratios indicate that having an emotional or disruptive disorder is a strong risk factor for later diagnoses.

CONCLUSIONS

While some preschool children in primary care "grow out of" their disorder, an equally large number do not; this finding supports the need for early detection and intervention.

Psychopathology and health care use among preschool children: a retrospective analysis

OBJECTIVE

To examine the relationship between psychopathology and health care utilization beginning in the preschool (ages 2 to 5) years.

METHOD

Five hundred ten preschool children were enrolled through 68 primary care physicians. The test battery used for diagnoses included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Behavior Inventory, and a videotaped play session. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. Frequency of primary care visits was established through 1-year retrospective record review; mothers estimated total visits and emergency department (ED) use.

RESULTS

Logistic regression models showed that a DSM-III-R diagnosis was related to increased ED use but not primary care or total visits. Greater functional impairment was associated with fewer primary care visits and more ED visits. Total, internalizing, and externalizing behavior problem scores were associated with increased primary care and total visits; ED visits were associated with increased total and internalizing problems. Child's health status consistently correlated with utilization.

CONCLUSION

There is a consistent relationship between health care use and child psychopathology beginning in the preschool years.

A typology of teacher-rated child behavior for a national U.S. sample

The purpose of the current study was to build on the emerging effort to produce a meaningful typology of classroom behavior for elementary school age children. The Behavior Assessment System for Children (BASC) Teacher Rating Scales for Children (TRS-C) norming data were collected for 1,227 six- to eleven-year-old children at 116 sites representing various regions of the United States. The TRS-C has 148 items that are rated by the teacher on a 4-point scale of frequency, ranging from Never to Almost always. The Ward method of cluster analysis was used to identify the initial centroids or cluster seeds. An iterative clustering method, a K-means procedure, was used to refine the Ward cluster solution. A seven-cluster solution was selected based on both rational and empirical considerations. The resulting clusters were named well-adapted, average, learning disorder, disruptive behavior disorder, physical complaints and worry, severe psychopathology, and mildly disruptive. The seven-cluster solution resembles those of Achenbach (1991), Curry and Thompson (1985), and other researchers. The resulting typology points the way toward future cluster studies of child psychopathology by delineating additional research and theoretical questions.

Quantitative EEG differences in a nonclinical sample of children with ADHD and undifferentiated ADD

OBJECTIVE

To use quantitative electroencephalographic (EEG) techniques to identify electrophysiological differences between children with distinct disorders of attention and/or hyperactivity.

METHOD

Forty children from a prescreened community sample were evaluated by means of both spectral EEG and evoked response potential (ERP) techniques. The children were 7 to 13 years of age and were selected on the basis of membership in one of the following DSM-III-R categories: attention-deficit hyperactivity disorder (ADHD) (n = 16), undifferentiated attention deficit disorder (UADD) (n = 12), or no disruptive disorder diagnosis (n = 12).

RESULTS

Spectral EEG revealed that UADD subjects had less delta band relative percent power (RPP) (p < .01), more beta band RPP (p < .01), and ERP findings of a decreased rare tone P300 amplitude (p < .02) compared with the control group. ADHD subjects had spectral EEG findings of increased beta band RPP (p < .05) and ERP findings of an increased common tone N100 latency (p < .02) and a decreased rare tone P300 amplitude (p < .02). Interhemispheric asymmetries appeared to distinguish the groups: the UADD group had spectral EEG asymmetries; the ADHD group had only ERP asymmetries; and the control group had no asymmetries.

CONCLUSION

Quantitative EEG techniques may prove useful in differentiating specific subtypes of ADHD.

Presentation and course of major depressive disorder during childhood and later years of the life span

OBJECTIVE

To examine whether major depressive disorder (MDD) in childhood, adolescence, and adulthood represents essentially the same diagnostic entity.

METHOD

Recent publications on clinically referred patients with MDD that met certain selection criteria were examined to abstract information on six phenomenological features of the disorder: episode number, symptom presentation, psychiatric comorbidity, recovery from the index episode, recurrence of MDD, and switch to bipolar illness. The studies included both inpatients and outpatients with an age range of 6 to 80+ years.

RESULTS

Synthesizing the information across broad age groups revealed that clinically referred depressed youths, compared with adults and the elderly, are almost exclusively first-episode probands, evidence comparable symptom pictures, have similar rates of psychiatric comorbidity, recover somewhat faster from their index episode of MDD, have a similar recurrence rate, and are at greater risk for bipolar switch.

CONCLUSIONS

MDD in clinically referred youths is similar in many regards to MDD in adults and the elderly. However, the findings that the risk of recurrent MDD among children approximates the rate among adults but, on average, about 20 years earlier in their lives, and that youths with unipolar depression convert to bipolar illness more frequently than do adults, suggest that very early onset MDD is a particularly serious form of affective illness.

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.

Contributing factors in the manifestation of aggression in preschoolers with hyperactivity

This study examined family characteristics of preschoolers with hyperactivity. We assessed child-rearing practices, maternal depression, marital conflict, and social support. Sixty-three preschool boys were placed in a hyperactivity-aggressive, hyperactive, aggressive or comparison group based on behavioral ratings. Parents were given questionnaires, mothers were interviewed, and children were administered the Woodcock-Johnson Psycho-Educational Battery and were observed playing. Compared to preschoolers with hyperactivity, preschoolers with hyperactivity plus aggression had families with (a) more restrictive fathers, (b) siblings who retaliated aggressively, and (c) mothers who reported more physical aggression directed to their partners and more verbal aggression received. Follow-forward aggression ratings were predicted by initial child manageability and maternal depression, perceived support, and low income.