Identification of elementary school children at risk for disruptive behavioral disturbance: validation of a combined screening method

Gender Effects in the Efficacy of Racemic Amphetamine Sulfate in Children with Attention-Deficit/Hyperactivity Disorder

Introduction

A laboratory classroom study in children aged 6–12 years with attention-deficit/hyperactivity disorder (ADHD) found that racemic amphetamine sulfate (RA-AMPH) significantly improved performance versus placebo from 45 min through 10 h post-dose (NCT01986062). A secondary analysis assessed gender as a potential moderator of response to treatment comparing the ADHD Rating Scale-IV (ADHD-RS-IV) and Swanson, Kotkin, Agler, M-Flynn and Pelham (SKAMP) rating scales.

Methods

After 8 weeks of open-label RA-AMPH dose optimization using improvement in ADHD-RS-IV symptoms as a guide, 97 subjects (38 females and 59 males) were randomized to the sequence of 2 weeks of double-blind treatment with the optimized dose of RA-AMPH followed by placebo or vice versa during a laboratory classroom day. Efficacy measures included the SKAMP and the Permanent Product Measure of Performance (PERMP). The average difference for RA-AMPH versus placebo was estimated using least-square (LS) means. Treatment interaction by gender was analyzed using a cross-sectional fixed-effects model.

Results

ADHD-RS-IV scores were comparable for males and females at study entry and at the end of open-label treatment. During double-blind treatment, LS mean scores significantly improved for both genders versus placebo on the SKAMP scale and the PERMP (average p < 0.0001 for all post-dose time points). Beginning at baseline, males had significantly higher (worse) SKAMP scores than females but not worse ADHD-RS-IV or PERMP scores.

Conclusion

Both genders responded well to treatment with RA-AMPH, with comparable onset and duration of effect. The ADHD-RS-IV and SKAMP scales both measure changes in attention and hyperactive-impulsive behavior, but the SKAMP scale also measures associated disruptive behaviors, such as frustration, lying, and interpersonal conflict, that are more characteristic of oppositional and conduct disorders and more prevalent in boys with ADHD. Therefore, the SKAMP may be more sensitive for measuring the range of symptoms of boys with ADHD than the ADHD-RS-IV.

Funding

Arbor Pharmaceuticals, LLC.

Associations between Peer Nominations, Teacher Ratings, Self-Reports, and Observations of Malicious and Disruptive Behavior

This study evaluates the validity of two aggression scales for predicting observations of malicious or disruptive behavior at school. Subgroups of a sample of 1,560 children (age 8.6 ± 1.5 years) were assessed using (a) peer nominations of aggression, (b) teacher reports on the Teacher Report Form (TRF) of the Child Behavior Checklist (CBCL) Aggression scale and the peer nomination items, or (c) self-reports on the peer nomination items. Criteria were observations of physical, verbal, initiated, retaliatory, malicious, and disruptive behaviors. Teacher report peer nominations predicted observed physical, verbal, initiated, and retaliatory aggression and disruptive behavior. Peer nominations predicted physical aggression, verbal aggression, initiation and disruptive behavior, and TRFs predicted verbal, initiated, and disruptive behavior. Self-reports did not significantly predict any behavior. Implications for assessment of aggression are discussed.

Individual Characteristics, Family Factors, and Classroom Experiences as Predictors of Low-Income Kindergarteners' Social Skills

There has been increasing awareness of the need for research and theory to take into account the intersection of individual characteristics and environmental contexts when examining predictors of child outcomes. The present longitudinal, multi-informant study examined the cumulative and interacting contributions of child characteristics (language skills, inattention/hyperactivity, and aggression) and preschool and family contextual factors in predicting kindergarten social skills in 389 low-income preschool children. Child characteristics and classroom factors, but not family factors, predicted teacher-rated kindergarten social skills, while child characteristics alone predicted change in teacher-rated social skills from preschool to kindergarten. Child characteristics and family factors, but not classroom factors, predicted parent-rated kindergarten social skills. Family factors alone predicted change in parent-rated social skills from preschool to kindergarten. Individual child characteristics did not interact with family or classroom factors in predicting parent- or teacher-rated social skills, and support was therefore found for an incremental, rather than an interactive, predictive model of social skills. The findings underscore the importance of assessing outcomes in more than one context, and of considering the impact of both individual and environmental contextual factors on children's developing social skills when designing targeted intervention programs to prepare children for kindergarten.

Teacher (Mis)Perceptions of Preschoolers' Academic Skills: Predictors and Associations With Longitudinal Outcomes

Preschool teachers have important impacts on children's academic outcomes, and teachers' misperceptions of children's academic skills could have negative consequences, particularly for low-income preschoolers. This study utilized data gathered from 123 preschool teachers and their 760 preschoolers from 70 low-income, racially diverse centers. Hierarchical linear modeling was utilized to account for the nested data structure. Even after controlling for children's actual academic skill, older children, children with stronger social skills, and children with fewer inattentive symptoms were perceived to have stronger academic abilities. Contrary to hypotheses, preschoolers with more behavior problems were perceived by teachers to have significantly better pre-academic abilities than they actually had. Teachers' perceptions were not associated with child gender or child race/ethnicity. Although considerable variability was due to teacher-level characteristics, child characteristics explained 42% of the variability in teachers' perceptions about children's language and pre-literacy ability and 41% of the variability in teachers' perceptions about mathability. Notably, these perceptions appear to have important impacts over time. Controlling for child baseline academic skill and child characteristics, teacher perceptions early in the preschool year were significantly associated with child academic outcomes during the spring for both language and pre-literacy and math. Study implications with regard to the achievement gap are discussed.

Social cognitions, distress, and leadership self-efficacy: associations with aggression for high-risk minority youth

Urban ethnic minority youth are often exposed to high levels of aggression and violence. As such, many aggression intervention programs that have been designed with suburban nonethnic minority youth have been used or slightly adapted in order to try and meet the needs of high-risk urban youth. The current study contributes to the literature base by examining how well a range of social-cognitive, emotional distress and victimization, and prosocial factors are related to youth aggression in a sample of urban youth. This study utilized data gathered from 109 9- to 15-year-old youth (36.7% male; 84.4% African American) and their parents or caregivers. A series of hierarchical multiple regressions were fit predicting youth aggression from social-cognitive variables, victimization and distress, and prosocial variables, controlling for youth gender and age. Each set of variables explained a significant and unique amount of the variance in youth aggressive behavior. The full model including all predictors accounted for 41% of the variance in aggression. Models suggest that youth with stronger beliefs supportive of violence, youth who experience more overt victimization, and youth who experience greater distress in overtly aggressive situations are likely to be more aggressive. In contrast, youth with higher self-esteem and youth who endorse greater leadership efficacy are likely to be less aggressive. Contrary to hypotheses, hostile attributional bias and knowledge of social information processing, experience of relational victimization, distress in relationally aggressive situations, and community engagement were not associated with aggression. Our study is one of the first to address these important questions for low-income, predominately ethnic minority urban youth, and it has clear implications for adapting aggression prevention programs to be culturally sensitive for urban African American youth.

Neurobehavioral functioning in adolescents with and without obesity and obstructive sleep apnea

STUDY OBJECTIVES

Children and adults with obstructive sleep apnea syndrome (OSAS) exhibit neurobehavioral abnormalities, but few studies have evaluated the transitional stage of adolescence. Obesity is also associated with neurobehavioral abnormalities, and many patients with OSAS are obese. However, the confounding effect of obesity on neurobehavioral abnormalities in adolescents with OSAS has not been evaluated. We hypothesized that obese adolescents with OSAS would exhibit more neurobehavioral abnormalities than obese and lean adolescents without OSAS.

DESIGN

Cross-sectional, case control.

SETTING

Sleep Center and community.

PARTICIPANTS

Obese adolescents with OSAS compared to (1) nonsnoring, obese controls without OSAS, and (2) nonobese, nonsnoring controls.

INTERVENTIONS

Neurobehavioral evaluation.

MEASUREMENTS AND RESULTS

Obese adolescents with OSAS had significantly worse executive function and attention compared to both obese (P < 0.001) and lean (P < 0.001) controls, and more depression (P = 0.004) and externalizing symptoms than lean controls (P = 0.008). A higher percentage of participants in the OSAS group scored in the clinically abnormal range on executive functioning, attention, sleepiness, and behavioral functioning than lean controls. Mediation analyses indicated that level of sleep apnea significantly mediated the effect of body mass on executive functioning, attention, and behavior.

CONCLUSIONS

Obese adolescents with OSAS show impaired executive and behavioral function compared to obese and lean controls, and are more likely to score in the clinically abnormal range on measures of neurobehavioral functioning. These results are especially concerning given that the frontal lobe is still developing during this critical age period. We speculate that untreated OSAS during adolescence may lead to significant neurobehavioral deficits in adulthood.

Pilot study of nasal expiratory positive airway pressure devices for the treatment of childhood obstructive sleep apnea syndrome

STUDY OBJECTIVES

Alternative therapies for childhood obstructive sleep apnea syndrome (OSAS) are needed as OSAS may persist despite adenotonsillectomy, and continuous positive airway pressure (CPAP) adherence is low. Nasal expiratory positive airway pressure (NEPAP) devices have not been studied in children. We hypothesized that NEPAP would result in polysomnographic improvement. Further, we aimed to determine NEPAP adherence, effects on sleepiness, behavior, and quality of life.

METHODS

A randomized, double-blind, placebo-controlled, crossover pilot study was performed. CPAP candidates, 8-16 years old, underwent NEPAP and placebo polysomnograms. Subjects with ≥ 50% reduction in the apnea hypopnea index (AHI) from placebo to NEPAP night or AHI < 5/h on NEPAP night wore NEPAP at home for 30 days. Adherence was assessed by daily phone calls/emails and collecting used devices.

RESULTS

Fourteen subjects (age 13.4 ± 1.9 years, BMI z-scores 2.2 ± 1 [mean ± SD]) were studied. There was significant improvement in the obstructive apnea index with NEPAP vs. placebo: 0.6 (0-21.1)/h vs. 4.2 (0-41.9)/h (median [range], p = 0.010) and trends for improvement in other polysomnographic parameters. However, responses were variable, with 3 subjects not improving and 2 worsening. Older children and those with less hypercapnia had a better response. Eight subjects were sent home with devices; one was lost to follow-up, and adherence in the remainder was 83% of nights; these subjects had a significant improvement in sleepiness and quality of life.

CONCLUSIONS

NEPAP devices are a potential alternative therapy for OSAS in a small subset of children. Due to variability in individual responses, efficacy of NEPAP should be evaluated with polysomnography.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, identifier: NCT01768065.

Effects of positive airway pressure therapy on neurobehavioral outcomes in children with obstructive sleep apnea

RATIONALE

Positive airway pressure therapy is frequently used to treat obstructive sleep apnea in children. However, it is not known whether positive airway pressure therapy results in improvements in the neurobehavioral abnormalities associated with childhood sleep apnea.

OBJECTIVES

We hypothesized that positive airway pressure therapy would be associated with improvements in attention, sleepiness, behavior, and quality of life, and that changes would be associated with therapy adherence.

METHODS

Neurobehavioral assessments were performed at baseline and after 3 months of positive airway pressure therapy in a heterogeneous group of 52 children and adolescents.

MEASUREMENTS AND MAIN RESULTS

Adherence varied widely (mean use, 170 ± 145 [SD] minutes per night). Positive airway pressure therapy was associated with significant improvements in attention deficits (P < 0.001); sleepiness on the Epworth Sleepiness Scale (P < 0.001); behavior (P < 0.001); and caregiver- (P = 0.005) and child- (P < 0.001) reported quality of life. There was a significant correlation between the decrease in Epworth Sleepiness Scale at 3 months and adherence (r = 0.411; P = 0.006), but not between other behavioral outcomes and adherence. Behavioral factors also improved in the subset of children with developmental delays.

CONCLUSIONS

These results indicate that, despite suboptimal adherence use, there was significant improvement in neurobehavioral function in children after 3 months of positive airway pressure therapy, even in developmentally delayed children. The implications for improved family, social, and school function are substantial. Clinical trial registered with www.clinicaltrials.gov (NCT 00458406).

The Association between Preschool Children's Social Functioning and Their Emergent Academic Skills

This study examined the relationship between social functioning and emergent academic development in a sample of 467 preschool children (M = 55.9 months old, SD = 3.8). Teachers reported on children's aggression, attention problems, and prosocial skills. Preliteracy, language, and early mathematics skills were assessed with standardized tests. Better social functioning was associated with stronger academic development. Attention problems were related to poorer academic development controlling for aggression and social skills, pointing to the importance of attention in these relations. Children's social skills were related to academic development controlling for attention and aggression problems, consistent with models suggesting that children's social strengths and difficulties are independently related to their academic development. Support was not found for the hypothesis that these relationships would be stronger in boys than in girls. Some relationships were stronger in African American than Caucasian children. Children's self-reported feelings about school moderated several relationships, consistent with the idea that positive feelings about school may be a protective factor against co-occurring academic and social problems.

Clinical effectiveness of quetiapine in children and adolescents with Tourette's syndrome : a retrospective case-note survey

BACKGROUND AND OBJECTIVE

Tourette's syndrome is a relatively common biological genetic disorder with a broad spectrum of neurobehavioural manifestations. Unfortunately, treatment of the condition is often unsatisfactory and all available drugs are associated with potential adverse effects. We therefore aimed to investigate the efficacy of quetiapine, a newer atypical antipsychotic, in the treatment of children and adolescents with Tourette's syndrome.

METHODS

This was a retrospective study carried out in outpatient clinics. Twelve patients aged 8-18 years with Tourette's syndrome (diagnosed according to Diagnostic and Statistical Manual IV criteria) who were receiving quetiapine therapy and had no diagnosis of epilepsy, major depression or psychotic disorder, were included in the study. The main outcome measure was the Yale Global Tic Severity Scale (YGTSS) score.

RESULTS

The initial dose of quetiapine was 25 mg/day, but the mean dose was increased to 114.6 +/- 51.6 mg/day and 175.0 +/- 116.8 mg/day at the fourth and eighth weeks of treatment, respectively. The YGTSS score, which was 21.6 +/- 4.0 at baseline, showed significant decreases at 4 and 8 weeks (reducing to 7.5 +/- 7.4 and 5.6 +/- 8.1, respectively; p < 0.003). Routine laboratory parameters and serum prolactin level were all normal and did not change throughout treatment. Mild but significant increases in both bodyweight and body mass index at 4 and 8 weeks compared with baseline were observed.

CONCLUSION

Other than causing mild weight gain, quetiapine appears to be an effective, safe and well tolerated drug in children and adolescents with Tourette's syndrome.

Validity of teacher ratings in selecting influential aggressive adolescents for a targeted preventive intervention

This study describes a method for using teacher nominations and ratings to identify socially influential, aggressive middle school students for participation in a targeted violence prevention intervention. The teacher nomination method is compared with peer nominations of aggression and influence to obtain validity evidence. Participants were urban, predominantly African American and Latino sixth-grade students who were involved in a pilot study for a large multi-site violence prevention project. Convergent validity was suggested by the high correlation of teacher ratings of peer influence and peer nominations of social influence. The teacher ratings of influence demonstrated acceptable sensitivity and specificity when predicting peer nominations of influence among the most aggressive children. Results are discussed in terms of the application of teacher nominations and ratings in large trials and full implementation of targeted prevention programs.

Evaluation and assessment issues in the diagnosis of attention deficit hyperactivity disorder

This article discusses the availability and appropriateness of various assessment techniques for diagnosing ADHD. In terms of the interview/history, the necessity and viability of using formal structured, semi structured, computerized and informal interviews for making an ADHD diagnosis are critiqued. The pros and cons of the various questionnaires frequently used to diagnose ADHD are addressed. The conundrum raised by multiple informants who often disagree is discussed, as are the effects of age and gender. The contributions of the medical and neurological examinations to the diagnosis of ADHD are considered. The utility of a neuropsychological assessment and of continuous performance testing to diagnosis is critiqued. Finally the lack of need for laboratory tests and the lack of necessity of neurological workup, specifically EEG and imaging, are argued.

Practice parameter for psychiatric consultation to schools

This practice parameter reviews the topic of psychiatric consultation to schools. The review covers the history of school consultation and current consultative models; the process of developing a consultative relationship; school administrative procedures, personnel, and milieu; legal protections for students with mental disabilities; and issues typically arising in consultative situations. The objective of the parameter is to provide an introduction to the special vocabulary, knowledge, and skills that are important prerequisites for successful consultation in school settings.

Validation of three dimensions of childhood psychopathology in young clinic-referred boys

Short measures of child inattention-overactivity (IO), aggression-defiance (AG), and anxiety-depression or emotionality (EM) derived through a double validation procedure are administered to mothers of 243 clinic-referred suburban New York boys between 6 and 10 years of age. Mother-rated IO is uniquely related to poor performance on cognitive and achievement tests; observed inattentive, hyperactive, and impulsive behaviors in a restricted academic setting; less father education and lower family income; and most mother-reported impairments and treatment use. Mothers of high-IO boys describe themselves and their sons as having similar childhood symptoms. AG is uniquely related to child-reported disruptive behavior and sensation seeking, many measures of family conflict and negative parenting styles, and mother-reported symptom pervasiveness and number of treatments. EM is uniquely related only to poorer cognitive and achievement test performance, living with one parent, parents who considered themselves too busy, and fewer friends. Each dimension also is associated with parallel teacher-rated factors.

Ten-year review of rating scales, VII: scales assessing functional impairment

OBJECTIVE

This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement.

METHOD

The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche.

RESULTS

These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need.

CONCLUSIONS

Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

A rating scale for disruptive behavior disorders, based on the DSM-IV item pool

DSM IV includes three clusters of items that are used to establish diagnoses for the Disruptive Behavior Disorders: Attention Deficit, Conduct, and Oppositional Defiant. In this report, we examine the feasibility of using the items in each cluster to form a rating scale. We studied eighty-four consecutive school-aged referrals to an inner-city child and adolescent Psychiatry clinic. Case diagnosis was established with a clinician's KID-SCID assessment. Parents and teachers rated the 41 DSM items on four-point scales, and completed the Conners' Rating Scales, in English or Spanish. In this paper we report psychometrics of the new scale, the Rating Scale for Disruptive Behavior Disorders (RS-DBD), along with the agreement among parents and teachers, and concurrence between the new scales and the relevant Conners' scales. While, the parent and teacher ratings may provide a useful index for severity of behavioral disturbance in the home and school environments, it will not establish a diagnosis. There was a great deal of comorbidity among diagnostic groups.

Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing

OBJECTIVES

Excessive daytime sleepiness (EDS) is seen less frequently as a presenting complaint in children with sleep-disordered breathing than in adults. Instead, symptoms of hyperactivity are often described. We hypothesized that children with suspected sleep-disordered breathing (S-SDB) were both sleepier and more hyperactive than control subjects. Furthermore, we hypothesized that overnight polysomnographic parameters correlated with sleepiness and hyperactivity.

METHODS

A cross-sectional study was conducted at a university-affiliated hospital and a community-based pediatric clinic. A total of 108 patients with S-SDB (mean [standard deviation] age: 7 +/- 4 years) and 72 control subjects (8 +/- 4 years) were recruited. A modified Epworth Sleepiness Scale (ESS) and the Conners Abbreviated Symptom Questionnaire were administered. Polysomnography was performed in patients with S-SDB.

RESULTS

Patients with S-SDB had a higher ESS (8.1 +/- 4.9 vs 5.3 +/- 3.9) and a higher Conners score (12.8 +/- 7.6 vs 9.0 +/- 6.2) than control subjects. On the basis of adult criteria, 28% of patients had EDS. There was no difference in the ESS and Conners scores of patients with primary snoring and patients with obstructive sleep apnea. The ESS had weak correlations with polysomnographic parameters.

CONCLUSIONS

Although the ESS score of children with S-SDB was within the normal range for adults, these children were sleepier and more hyperactive than control subjects. However, these data should be confirmed by a population-based study.

Ten-year review of rating scales. V: scales assessing attention-deficit/hyperactivity disorder

OBJECTIVE

This article summarizes information on scales assessing attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

METHOD

The authors sampled articles on ADHD over the past decade. Several popular older ADHD measures have recently been revised, and new ADHD scales have been developed. The authors selected primarily ADHD scales based on the DSM-IV construct of ADHD that also have multiple literature citations. They then reviewed their psychometric properties. Those with adequate psychometric functioning plus considerable literature citations, known wide usage in clinical practice, or a current niche are presented here.

RESULTS

Several rating scales consistent with the DSM-IV conceptualization of ADHD are now available for use in both home and school settings. Many of the instruments demonstrate solid psychometric properties and a strong normative base. However, some popular scales have not been adequately investigated. Some measures are restricted to the comprehensive assessment of ADHD, whereas others also include symptoms of other disorders. The potential applications for these scales with youths diagnosed with ADHD are broad.

CONCLUSIONS

Rating scales can reliably, validly, and efficiently measure DSM-IV-based ADHD symptoms in youths. They have great utility in research and clinical work, assist treatment planning, and help to ensure accountability in practice.

Überblicksarbeit

Zusammenfassung. Präventionen für Hoch-Risiko-Gruppen (“targeted interventions“) erweisen sich nur dann als wirksam, wenn mit ihrer Hilfe die anvisierten Risikobedingungen in einer Population angesprochen werden. Ein Erfolg hängt somit von der Genauigkeit und Stärke der Methoden zur Identifikation der Hoch-Risiko-Kinder ab. Der effektive Einsatz von Präventionen setzt unter anderem voraus, dass ein Verständnis dafür besteht, welche Risikobedingungen zu welchem Entwicklungszeitpunkt vorliegen und wie stark die Beziehung zwischen Risikobedingung und einem Outcome (z.B. aggressives Verhalten) ist. Im vorliegenden Review wird zunächst ein Überblick zu den etablierten Entwicklungsmodellen und bekannten Risikobedingungen aggressiv/dissozialen Verhaltens gegeben und diese vor dem Hintergrund aktueller empirischer Befunde diskutiert. Metaanalytische Befunde und unterschiedliche methodische Ansätze verdeutlichen, dass für die Vorhersage eines späteren aggressiv/dissozialen Verhaltens nicht nur Verhaltensmerkmale (z.B. frühes externalisierendes Verhalten), sondern auch psychosoziale Risikobedingungen bedeutsam sind. Abschließend wird der Nutzen dieser Befunde für die Vorhersage eines aggressiv/dissozialen Verhaltens und die Durchführung von Multiple-Gating-Screeningprozeduren zur Identifikation von Hoch-Risiko-Kindern erörtert und das Problem von Fehlklassifizierungen in Vorhersagen vor dem Hintergrund von Befunden aus der Entwicklungspsychopathologie diskutiert.

Screening for conduct problems: does the predictive accuracy of conduct disorder symptoms improve with age?

OBJECTIVES

To investigate the influence of age on the predictive accuracy of conduct disorder (CD) symptoms for future CD and to evaluate the usefulness of CD symptoms as a screening tool in normal populations.

METHOD

Two cohorts were derived from the Canadian National Longitudinal Survey of Children and Youth based on age at baseline (cohort 1: ages 5-6, n = 881; cohort 2: ages 8-9, n = 859). CD symptoms were assessed with behavior symptom checklists at baseline and the 2-year follow-up assessment. Predictive accuracy (PA) was evaluated with logistic regression and receiver operating characteristic curves.

RESULTS

The PA of teacher-identified CD symptoms, alone or in combination with other risk factors (gender, socioeconomic status, familial factors), was higher in the older cohort. PA increased when CD symptoms were combined with other risk factors. However, none of the predictors evaluated achieved minimum criteria for sensitivity and positive predictive value of at least 50%.

CONCLUSIONS

The PA of CD symptoms improves with age. However, the results show that the PA of CD symptoms assessed at a single point in time in children in normal populations is insufficient. Screening initiatives that use this approach to detect risk for CD should be abandoned.