Further validation of social impairment as a predictor of substance use disorders: findings from a sample of siblings of boys with and without ADHD

Environmental enrichment promotes adaptive responding during tests of behavioral regulation in male heterogeneous stock rats

Organisms must regulate their behavior flexibly in the face of environmental challenges. Failure can lead to a host of maladaptive behavioral traits associated with a range of neuropsychiatric disorders, including attention deficit hyperactivity disorder, autism, and substance use disorders. This maladaptive dysregulation of behavior is influenced by genetic and environmental factors. For example, environmental enrichment produces beneficial neurobehavioral effects in animal models of such disorders. The present study determined the effects of environmental enrichment on a range of measures related to behavioral regulation using a large cohort of male, outbred heterogeneous stock (HS) rats as subjects. Subjects were reared from late adolescence onwards either in pairs in standard housing with minimal enrichment (n = 200) or in groups of 16 in a highly enriched environment consisting of a large multi-level cage filled with toys, running wheels, and shelters (n = 64). Rats were subjected to a battery of tests, including: (i) locomotor response to novelty, (ii) light reinforcement, (iii) social reinforcement, (iv) reaction time, (v) a patch-depletion foraging test, (vi) Pavlovian conditioned approach, (vii) conditioned reinforcement, and (viii) cocaine conditioned cue preference. Results indicated that rats housed in the enriched environment were able to filter out irrelevant stimuli more effectively and thereby regulate their behavior more efficiently than standard-housing rats. The dramatic impact of environmental enrichment suggests that behavioral studies using standard housing conditions may not generalize to more complex environments that may be more ethologically relevant.

Negative Parenting Moderates the Prospective Association of ADHD Symptoms and Youth Social Problems

Although ADHD and negative parenting are established predictors of youth outcomes, their independent and interactive effects on youth social functioning remain unclear. We tested childhood ADHD symptoms and negative parenting as independent and interactive predictors of prospective change in social problems across a four-year follow-up. At baseline, families of 221 (33% female) children with (n = 94) and without ADHD were rigorously assessed including observed positive and negative parenting behavior, youth ADHD symptoms, as well as multi-informant ratings of youth social problems at multiple occasions. Based on multiple regression with robust standard errors and full-information maximum likelihood procedures to address missing data, ADHD symptoms positively predicted social problems, even with control of observed parenting behavior, child age and sex, oppositional defiant disorder symptoms, and baseline social problems. Additionally, a child ADHD symptoms x negative parenting interaction uniquely predicted separate parent- and teacher-rated social problems where ADHD symptoms positively predicted social problems exclusively in the context of high (+1SD) and very high (+2 SD) negative parenting, respectively. When ADHD was separated into distinct dimensions (i.e., inattention, hyperactivity), an interaction between inattention symptoms and negative parenting approached significance such that inattention symptoms positively predicted parent-rated social problems in the context of high negative parenting. We discuss the interaction between parenting and ADHD symptoms in predictions of youth social problems and implications for intervention.

A preliminary investigation of reaction time variability in relation to social functioning in children evaluated for ADHD

Reaction time variability (RTV) is a ubiquitous phenomenon in Attention-Deficit/Hyperactivity Disorder (ADHD). Few studies have examined RTV in relation to functional outcomes such as social impairment in children with ADHD. In this exploratory study, we investigated whether RTV is associated with social functioning in children at risk for ADHD. Specifically, we explored the association between RTV (tau derived from correct go trials of a Stop-Signal task) and social functioning in 198 children ages 7-12 years referred for an ADHD evaluation. Social functioning measures included child and/or parent ratings of social competence, aggression, social problems, and impairment in relationships. In regression analyses that also included Oppositional Defiant Disorder symptoms and sex, higher RTV was significantly associated with lower ratings of social competence, and higher proactive/reactive aggression ratings on the child self-report measures. RTV was not significantly associated with parent report of social functioning or relationship impairment. This study provides preliminary evidence that RTV may be associated with social functioning in children at risk for ADHD. We propose that lapses of attention affecting cognitive control may also negatively impact social information processing thereby affecting social functioning. Replication is warranted and longitudinal studies are needed to investigate whether RTV predicts social dysfunction in ADHD.

Reliability and Validity of the Before-School Functioning Scale in Children With ADHD

OBJECTIVE

Children with ADHD frequently manifest behavioral difficulties in the morning prior to school. We sought to assess the reliability and validity of the Before-School Functioning Questionnaire (BSFQ) as a measure of morning behaviors impaired by ADHD.

METHOD

We used pre-treatment data from a randomized crossover study of 6- to 12-year-old participants comparing the methylphenidate transdermal delivery system (MTS) with a placebo transdermal system (PTS) for a total of 4 weeks.

RESULTS

The BSFQ investigator-rated scale shows very good internal homogeneity (Cronbach's α = .91), good test-retest reliability ( r = .60), good concurrent validity ( r range = .42-.86), and a strong treatment effect (effect size = -.93). The self-rated BSFQ showed lower levels of reliability and validity.

CONCLUSION

The investigator-rated BSFQ should be used in future trials of ADHD medications aimed at assessing efficacy in the morning before school.

Higher Impulsivity As a Distinctive Trait of Severe Cocaine Addiction among Individuals Treated for Cocaine or Alcohol Use Disorders

AIMS

Despite alcohol being the most often used addictive substance among addicted patients, use of other substances such as cocaine has increased over recent years, and the combination of both drugs aggravates health impairment and complicates clinical assessment. The aim of this study is to identify and characterize heterogeneous subgroups of cocaine- and alcohol-addicted patients with common characteristics based on substance use disorders, psychiatric comorbidity and impulsivity.

METHODS

A total of 214 subjects with cocaine and/or alcohol use disorders were recruited from outpatient treatment programs and clinically assessed. A latent class analysis was used to establish phenotypic categories according to diagnosis of cocaine and alcohol use disorders, mental disorders, and impulsivity scores. Relevant variables were examined in the latent classes (LCs) using correlation and analyses of variance and covariance.

RESULTS

Four LCs of addicted patients were identified: Class 1 (45.3%) formed by alcohol-dependent patients exhibiting lifetime mood disorder diagnosis and mild impulsivity; Class 2 (14%) formed mainly by lifetime cocaine use disorder patients with low probability of comorbid mental disorders and mild impulsivity; Class 3 (10.7%) formed by cocaine use disorder patients with elevated probability to course with lifetime anxiety, early and personality disorders, and greater impulsivity scores; and Class 4 (29.9%) formed mainly by patients with alcohol and cocaine use disorders, with elevated probability in early and personality disorders and elevated impulsivity. Furthermore, there were significant differences among classes in terms of Diagnostic and Statistical Manual of Mental Disorders-4th Edition-Text Revision criteria for abuse and dependence: Class 3 showed more criteria for cocaine use disorders than other classes, while Class 1 and Class 4 showed more criteria for alcohol use disorders.

CONCLUSION

Cocaine- and alcohol-addicted patients who were grouped according to diagnosis of substance use disorders, psychiatric comorbidity, and impulsivity show different clinical and sociodemographic variables. Whereas mood and anxiety disorders are more prevalent in alcohol-addicted patients, personality disorders are associated with cocaine use disorders and diagnosis of comorbid substance use disorders. Notably, increased impulsivity is a distinctive characteristic of patients with severe cocaine use disorder and comorbid personality disorders. Psychiatric disorders and impulsivity should be considered for improving the stratification of addicted patients with shared clinical and sociodemographic characteristics to select more appropriate treatments.

Impaired Social Decision-Making Mediates the Association Between ADHD and Social Problems

Attention-deficit/hyperactivity disorder (ADHD) reliably predicts social dysfunction, ranging from poor social competence and elevated peer rejection to inadequate social skills. Yet, the factors mediating predictions of social problems from childhood ADHD are not well understood. In the present study, we investigated social functioning in 186 (69 % male) 6 to 10 year-old (M = 7.88, SD = 1.17) children with (n = 98) and without (n = 87) ADHD who were followed prospectively for two years. We implemented a well-validated measure of social problems as well as a novel social decision-making task assessing dynamic response to changing affective cues at the two-year follow-up. According to separate parent and teacher report, baseline ADHD symptoms positively predicted social problems at the two-year follow-up; individual differences on the social decision-making task mediated this association. This finding was replicated when ADHD dimensions (i.e., inattention and hyperactivity/impulsivity) were separately examined. These findings suggest that the deficient use of affective cues to effectively guide behavior may partially underlie poor social functioning among children with ADHD. If replicated, these preliminary findings suggest that social skills interventions that target interpretation of affective cues to aid in social decision-making behavior may improve social outcomes negatively affected by early ADHD symptoms.

Theater-Based Community Engagement Project for Veterans Recovering From Substance Use Disorders

In this study, we examine the feasibility and acceptability of a 6-wk, interdisciplinary, occupation-based theater project for facilitating community engagement and substance use disorder (SUD) recovery in veterans. All data were collected at baseline, postintervention, and 6-wk and 6-mo follow-up intervals. Of the invited veterans, 24% consented to participate (n = 14), and 50% were retained (n = 7). Average attendance was 91%. Considerable improvements in social and occupational participation were noted at postintervention and at 6-wk follow-up but were not retained at 6 mo. No important change in self-efficacy was noted. Of the participants, 86% remained abstinent for 6 wk following the intervention. Theater provides a feasible and acceptable resource for potentially facilitating SUD recovery. Larger controlled effectiveness studies of theater are needed to examine whether robust and notable recovery outcomes in people with SUDs can be linked to participation in theater.

Attention-deficit/hyperactivity disorder symptoms mediate the association between deficits in executive functioning and social impairment in children

We investigated whether symptoms of attention-deficit/hyperactivity disorder (ADHD) are pathways through which deficits in inhibition and working memory are associated with teacher- and parent-rated social impairment in children. Participants were 64 children (55% males; 53% with ADHD) in grades 3-6. Consistent with our hypotheses, the association between inhibition and social impairment was mediated by hyperactivity/impulsivity and the association between working memory and social impairment was mediated by inattention. Support was not obtained for alternative models wherein the association between inhibition and social impairment was mediated by inattention, and the association between working memory and social impairment was mediated by hyperactivity/impulsivity. Further, tests of hierarchical models suggest that neither inhibition nor working memory is primary but, rather, that these cognitive processes are related to one another and that they collectively (but not uniquely) contribute to hyperactivity/impulsivity and inattention. These findings have implications for conceptual models of ADHD, for understanding factors that influence and sustain social impairment among youth with symptoms of the disorder, and for interventions aimed to addressing such impairment.

Substance use disorder in Asperger syndrome: An investigation into the development and maintenance of substance use disorder by individuals with a diagnosis of Asperger syndrome

BACKGROUND

Recent research has suggested that the prevalence of problematic substance use within the Asperger syndrome population has previously been underestimated. Furthermore, there is some indication that problematic substance use might take place to manage the traits of Asperger syndrome; however this possibility has yet to be examined in detail. This study aimed to address this omission by exploring individuals' perceptions of their substance use in relation to their diagnosis of Asperger syndrome.

METHODS

Eight participants were recruited from either a specialist Asperger syndrome service or a drug and alcohol service. Participants were interviewed regarding their views of which factors led to their development and maintenance of problematic substance use, specifically in relation to their experience of having been diagnosed with Asperger syndrome. Thematic analysis was conducted on the interview transcripts.

RESULTS

Six main themes were identified: self-medication; social facilitation; discrepancy between need and support; defining problematic substance use; substance use of peers, and recreational use of substances. The two themes of social facilitation and self-medication are focused on within this paper as they most closely reflect the more prominent bodies of literature in relation to the research aim.

CONCLUSIONS

Participants reported that substances were used to act as a social facilitator to compensate for social deficits by increasing confidence in social settings and increasing participants' ease with which they communicate. The self-medication of psychological distress was reported and was associated with depression, anxiety and sleep difficulties. The study ends with a reflection on the method of data collection, the implications for clinical practice and suggestions for future research.

Metacognition in persons with substance abuse: Findings and implications for occupational therapists

Background

Addiction is a massive public health problem in which a person’s occupational life is compromised and metacognition is impaired. Occupational therapists may play a critical role in addiction rehabilitation, but more information about patterns of metacognitive deficit co-occurring with addictive behaviour is needed to develop interventions that specifically target these impairments.

Purpose

This study examined whether persons with addiction(s) demonstrated specific patterns of metacognitive deficit on four subscales of metacognition measuring self-reflectivity, understanding others’ thoughts, decentration, and mastery.

Method

Using a mixed-methods design, qualitative data were obtained via the Indiana Psychiatric Illness Interview, which was then rated using a quantitative scale, the Metacognition Assessment Scale–Abbreviated.

Findings

Persons with addiction(s) demonstrated significant impairments in metacognitive mastery but not other areas of metacognition.

Implications

Occupational therapy interventions for addiction should focus on improving metacognitive mastery. Future efficacy studies of interventions to improve mastery and overall outcomes are warranted.

Social functioning in youth with anxiety disorders: association with anxiety severity and outcomes from cognitive-behavioral therapy

Social functioning was assessed using the Child Behavior Checklist and Teacher Report Form for children with anxiety disorders who participated in a randomized clinical trial (N = 161, aged 7-14). Significant relationships were found between severity of children's principal anxiety disorder and most measures of social functioning, such that poorer social functioning was associated with more severe anxiety. Among youth who received cognitive-behavioral therapy (n = 111), significant associations were found between parent-reported social competence and both absence of principal anxiety disorder and lower anxiety severity at posttreatment and 1-year follow-up, controlling for the severity of the child's principal anxiety disorder at pretreatment. Findings support a relationship between anxiety severity and social difficulties, and suggest the importance of social competence for a favorable treatment response.

Treatment effects of combining social skill training and parent training in Taiwanese children with attention deficit hyperactivity disorder

BACKGROUND/PURPOSE

Children with attention-deficit/hyperactivity disorder (ADHD) often have problems in social interactions. We investigated the social and behavioral effects of providing both social skill training and parent training to school-aged children with ADHD in Taiwan.

METHODS

Seven consecutive 8-week behavioral-based social skill training (SST) group sessions were held for 48 children with ADHD; parallel 8-week parent group sessions were provided simultaneously. Fifty-five children with ADHD were recruited as a control group. All children took medication as prescribed by their doctors. The effects were assessed using the teacher and parent version of the Chinese version of Swanson, Nolan, and Pelham, version IV scale (SNAP-IV), the Chinese version of the Child Behavior Check List (CBCL-C), child and teacher version of the modified Social Skill Rating System (SSRS-C and SSRS-T), at baseline, post-treatment, and 4 months from baseline. The doses of methylphenidate and drug compliance were controlled during the analysis.

RESULTS

The mixed-effects model demonstrated the main effect of group sessions on the Oppositional subscale of SNAP-P, the Anxious/Depressed subscale of CBCL-C, the Self Control subscale of SSRS-C, and the Active Participation subscale of SSRS-T, all in favor of the experimental group. However, the improvement on the Oppositional subscale of SNAP-P and the Self Control subscale of SSRS-C were noted only between baseline and post-treatment period and were not sustained at the end of the follow-up period.

CONCLUSION

Our study demonstrated that children with ADHD could benefit from this low intensity psychosocial program, although some improvements were not maintained at follow-up assessment.

Factor structure of the Matson Evaluation of Social Skills with Youngsters-II (MESSY-II)

The importance of social skills in development is a well studied area of research, and deficits in these skills can have implications long into adulthood. Therefore, assessment tools must be able to aid clinicians in identifying areas of weaknesses to target in treatment. The purpose of the current paper was to investigate the factor structure of a well researched measure of social skills, the Matson Evaluation of Social Skills with Youngsters (MESSY), which has recently been re-normed to update its psychometric properties. As such, this measure has now been dubbed the MESSY-II. This new norm sample was utilized in the current study to determine whether the original two factor structure for the MESSY would remain for the MESSY-II. Based on factor analysis, a three factor model was found to be ideal. Implications of these findings are discussed.

A systematic review of global publication trends regarding long-term outcomes of ADHD

There is increased global recognition of attention deficit hyperactivity disorder (ADHD) as a serious medical condition with long-term consequences. Although originally conceived of as a childhood disorder, ADHD is being increasingly recognized in adults. Individual geographic regions may have specific interests and objectives for the study of ADHD. A systematic review of long-term outcomes (LTOs) in ADHD was conducted to evaluate research on ADHD LTOs on a global scale. Studies that were at least 2 years in duration were examined. A total of 351 studies were identified in the final analysis. We identified nine outcomes of interest and classified studies by specific geographical regions, age groups studied and study design by region and over time. Published studies of LTOs in ADHD have increased in all geographical regions over the past three decades, with a peak number of 42 publications in 2008. This rise in publications on ADHD LTOs may reflect a rise in global interest and recognition of consequences and impairment associated with ADHD. Although many world regions have published on ADHD LTOs, the majority of studies have emerged from the US and Canada, followed by Europe. While investigators in the US and Canada were predominantly interested in drug addiction as a LTO, European researchers were more interested in antisocial behavior, and Eastern Asian investigators focused on both of these LTOs as well as self-esteem. Geographical differences in the focus of ADHD LTO studies may reflect regional variations in cultural values. Proportionally fewer prospective longitudinal studies and proportionally more retrospective and cross-sectional studies have been published in more recent decades. Finally, more studies focusing on ADHD in adolescents and adults have been conducted in recent years, and particularly adolescents in Eastern Asia. These changes in basic study design may reflect an increase in the recognition that ADHD is a lifetime chronic disorder. This systematic review analysis of publication trends in ADHD LTOs reflects geographically based interests that change over time.

Reliability and validity of the Matson Evaluation of Social Skills with Youngsters

Social skills are an important part of development, and deficits in this area have long-term impacts on a child. As a result, clinicians should include a measure of social skills as part of a comprehensive assessment. There are a few well-researched measures of social skills that are currently used, including the Matson Evaluation of Social Skills with Youngsters (MESSY). The MESSY has been translated and studied internationally in more than nine countries; however, updated norms for the United States have not been conducted since the inception of the measure. The purpose of this article is to examine the psychometric properties of the MESSY using an updated norm sample and age cohorts. Overall results indicated strong internal consistency and good to strong convergent and divergent validity. Psychometric properties for the older age cohorts were stronger and more consistent than those for the 2- to 5-year-olds. This reflects the variability of development and difficulty of assessing social skills at this young age.

The association between psychopathology and substance use in young people: a review of the literature

This article reviews the recent literature on the association between psychopathology and substance use in young people. An electronic literature search, using PSYCINFO/PSYCLIT and PUBMED/MEDLINE, yielded 93 English-language articles for the period 1990-2008. Of these articles, 89 (95.7%) reported studies conducted in developed countries, 57 (61.3%) had community or population samples, 38 (40.9%) had sample sizes ranging from 500 to 2000 subjects, and 33 (36.7%) had sample sizes of between 50 and 500. The most commonly-used assessment tool (n = 29, 31.2%) was the Diagnostic Interview Schedule. Evidence exists for associations between depression and cigarette smoking, between anxiety and cigarette smoking, and between anxiety and alcohol use. The strength of the associations is increased with greater frequency and quantity of substance use, and is influenced by the nature of the psychopathology, the specific substances of use, and demographic factors such as gender, age or developmental stage. The need for more longitudinal studies on community populations, and increased access to funds and resources for researchers in developing countries is highlighted.

Impact of a classroom behavior management intervention on teacher risk ratings for student behavior

Classroom behavior management interventions have been used successfully with drug prevention programs to prevent subsequent antisocial behavior and substance use among youth. This article presents results from implementation of the All Stars Challenge, a classroom-based behavior management component to a drug prevention program for fifth graders. Risk ratings for shyness and lack of awareness of social norms among high-risk students who received the All Stars Challenge were reduced compared with fifth graders who did not receive the intervention. In contrast, physical and social aggressivity among low-risk students who received the program increased when compared to similar control students.

Social functioning in predominantly inattentive and combined subtypes of children with ADHD

OBJECTIVE

The objective of this study was to compare the social functioning of children with the Combined (CB) and Predominantly Inattentive (PI) subtypes of Attention Deficit/Hyperactivity Disorder (ADHD), controlling for comorbidity and medication-status, which may have confounded the results of previous research.

METHOD

Parents and teachers of rigorously diagnosed unmedicated children with PI or CB subtypes of ADHD, and typical comparison children, rated them on the multidimensional Social Skills Rating Scale (SSRS).

RESULTS

After co-varying for oppositionality and anxiety, social impairment was substantial and equivalent in both ADHD groups whether rated by parent or teacher. In addition, when rated by teacher, the nature of the deficits varied by subtype: Children with PI were impaired in assertiveness, whereas children with CB were deficient in self-control. These findings indicate that AD/HD subtypes differ in the nature of their social dysfunction independent of comorbidity and highlight the need for interventions to target their divergent needs.

Psychometric testing methods for children's social skills

Social skill excesses and deficits have garnered considerable attention from researchers and clinicians over the last three decades. This trend is undoubtedly due to the central role these problems play in psychopathology and the general adjustment of children of all ages. Not surprisingly, these concerns and attention to such problems have also fostered a substantial literature on scaling methods specifically designed to help define and identify social skill deficits as well as track treatment progress. In this paper, for example, we identified 48 scales and related testing methods specifically designed for this purpose. Our goal here was to critically review the psychometric properties and patterns of research with existing social skill tests for children. Current strengths and weaknesses along with future directions for research are considered for this highly researched topic.

Psychosocial interventions used to treat children with ADHD: safety and efficacy

Although stimulant therapy is the most common treatment for attention-deficit/hyperactivity disorder (ADHD) in children, it is not always effective in reducing behavioral symptoms. As a result, research on psychosocial interventions has progressed in recent years. This article provides a synopsis of psychosocial interventions for childhood ADHD, with an emphasis on basic behavior management principles, evidence-based interventions, and safety issues. Developmental issues that distinguish psychosocial interventions for children and adolescents are highlighted, and practical recommendations for collaborating with mental health professionals are provided.

Epidemiology of attention problems among Turkish children and adolescents: a national study

OBJECTIVE

To evaluate the epidemiology of attention problems using parent, teacher, and youth informants among a nationally representative Turkish sample.

METHOD

The children and adolescents, 4 to 18 years old, were selected from a random household survey. Attention problems derived from the Child Behavior Checklist (CBCL) (N = 4,488), Teacher Report Form (TRF) (N = 2,360), and the Youth Self Report (YSR) (N = 2,206) were examined.

RESULTS

The CBCL and TRF attention problems scores were higher among young male children, whereas the YSR reported scores were higher among older adolescents without a gender effect. The CBCL and YSR scores were also higher by urban residence.

CONCLUSION

Compared with other European samples, our national sample had higher mean attention problems scores than the Scandinavian but lower mean scores than the former Soviet Union samples. In addition to elucidating the profile of attention problems in Turkey, our results also contribute to understanding the comparative global epidemiology of attention problems.

Ein Entwicklungsmodell des Substanzmissbrauchs im frühen Erwachsenenalter

Zusammenfassung. Ziel ist die Erarbeitung eines Entstehungsmodells des Substanzmissbrauchs mit 25 Jahren unter besonderer Berücksichtigung vorangegangener psychischer Auffälligkeiten. Im Rahmen einer epidemiologischen Längsschnittuntersuchung (Untersuchungszeitpunkte im Alter von acht, 13, 18 und 25 Jahren; n = 321) wurden Substanzmissbrauch (Nikotin, Alkohol, illegale Drogen), Psychopathologie sowie psychosoziale und organische Risikofaktoren erfasst. Der Substanzmissbrauch im frühen Erwachsenenalter wird insbesondere durch eine bereits mit 18 Jahren bestehende Suchtsymptomatik bestimmt. Diese stellt sich als Folge psychosozialer Belastungen sowie insbesondere früher externalisierender Symptome dar, welche in enger Wechselwirkung zueinander stehen. Für den Nikotinmissbrauch der 25-Jährigen liefern die hyperkinetischen Symptome zu allen Messzeitpunkten auch nach Kontrolle dissozialer Auffälligkeiten einen eigenständigen Vorhersagebeitrag. Gleiches gilt für die hyperkinetischen Symptome der 13-Jährigen und den späteren Missbrauch von Alkohol. Von den übrigen Einzelsymptomen erwies sich die Fettsucht mit acht, 13 und 18 Jahren als herausragender Prädiktor für den Substanzmissbrauch der 25-Jährigen. Die frühzeitige Erkennung und effektive Behandlung externalisierender Störungen ist gleichzeitig Prävention für Substanzmissbrauch im jungen Erwachsenenalter. Eine Adipositas im Kindes- und Jugendalter ist ebenfalls als Risikofaktor für späteren Substanzmissbrauch in Erwägung zu ziehen.

Attention-deficit/hyperactivity disorder: a neuropsychological perspective towards DSM-V

Neuropsychological methods and techniques have much to offer in the evaluation of the individual suspected as having Attention-Deficit/Hyperactivity Disorder (ADHD). After a review of the historical evolution of the ADHD concept, incidence and prevalence, and DSM-IV criteria for diagnosis, especially as regards omission related to gender differences, and other associated cultural, familial, socioenvironmental, and subject influences, this paper describes a number of dilemmas and obstacles encountered in clinical practice. Included are the confounds associated with the wide range of possible comorbidities, the insufficiency of current DSM-IV criteria, the emergence of subtype differentiation and its impact on diagnosis and treatment. The complex relationship between neuropsychological constructs and ADHD, and obstacles to valid assessment are also addressed. The complexities associated with a thorough ADHD evaluation are viewed within an impressive and expansive existing scientific framework and recommendations are made for future directions.

Psychosocial treatments for children with attention deficit/hyperactivity disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.

Behavioral predictors of substance-use initiation in adolescents with and without attention-deficit/hyperactivity disorder

OBJECTIVE

Our goal was to examine substance-use initiation in healthy adolescents and in adolescents who have been diagnosed with attention-deficit/hyperactivity disorder.

METHODS

Seventy-eight adolescents (28 healthy and 50 with attention-deficit/hyperactivity disorder) participated in an ongoing longitudinal study of predictors of substance use. The substances most commonly reported were tobacco, alcohol, and marijuana. Aggression, conduct problems, hyperactivity, impulsivity, inattention, anxiety/depression, social difficulties, and somatic complaints were assessed at study entry and tested as predictors for later substance use.

RESULTS

With an average of 4 years into the study, 37 adolescents had not used any substances, 41 had experimented with at least 1 substance, and 29 experimented with >1 substance. Psychiatric diagnoses (attention-deficit/hyperactivity disorder, attention-deficit/hyperactivity disorder and conduct disorder, and attention-deficit/hyperactivity disorder and depression/anxiety) did not influence reports of substance use. Distinct behavioral measures collected at study entry predicted use of different substances. In a multivariate analysis, aggression had the greatest association with tobacco smoking and marijuana use. Impulsivity was associated with alcohol use. Severity of drug exposure, indexed by the number of substances used, was predicted by aggression.

CONCLUSIONS

This 4-year longitudinal study captured the onset of substance use, not abuse. Behavioral predictors differed with the type of substance used. These behavioral characteristics may raise suspicion among pediatricians for enhanced risk for substance-use initiation.

Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood, and primary care clinicians provide a major component of the care for children with ADHD. However, because of limited available evidence, the American Academy of Pediatrics guidelines did not include adolescents and young adults. Contrary to previous beliefs, it has become clear that, in most cases, ADHD does not resolve once children enter puberty. This article reviews the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and describes how the information informs practice. It describes some of the unique characteristics observed among adolescents, as well as how the core symptoms change with maturity. The diagnostic process is discussed, as well as approaches to the care of adolescents to improve adherences. Both psychosocial and pharmacologic interventions are reviewed, and there is a discussion of these patients' transition into young adulthood. The article also indicates that research is needed to identify the unique adolescent characteristics of ADHD and effective psychosocial and pharmacologic treatments.

Social rejection and ADHD in young adults: an analogue experiment

Poor outcomes in ADHD may be related to problematic social functioning and consequences of social rejection. This study examines how ADHD symptom expression affects mood and social rejection. Working from findings in depression that describe maintenance through negative interpersonal interactions, the authors seek to examine this theory's applicability to poor outcomes in ADHD. In a completely randomized design, 130 participants are exposed to one of several videotape segments that include displays of ADHD, depression, and social anxiety. A normal control is also used. All abnormal videotapes are met with greater rejection than the control. Displays of ADHD elicit similar levels of rejection to those elicited by displays of depression. Additionally, ADHD elicits greater levels of hostile mood, whereas depression elicits high levels of depression and fatigue. Implications for an interpersonal theory of vulnerability in ADHD are discussed along with implications for future research, prevention, and intervention.

Altering the course of neurodevelopment: a framework for understanding the enduring effects of psychotropic drugs

Childhood is a time filled with wondrous changes, as brain plasticity permits experiences to shape the immature brain to meet the demands of the environment. Change occurs at various levels--from neuroanatomy, including within a given region and its connectivity to other regions, to the function of neurotransmitter systems and their reactivity to pharmacological agents in the short- and long-term. The nature and degree to which drug exposure influences the final adult topography is influenced greatly by the maturational phase of these critical factors. Moreover, evidence is slowly emerging that suggests that the long-term effects of drug exposure are delayed and expressed once the vulnerable system reaches maturation (i.e., typically during adulthood). This phenomenon is known as neuronal imprinting and occurs when the effects of drug exposure outlast the drug itself. Thus, understanding the persistent effects critically depends on the window of observation. Embracing this concept should influence how we conduct preclinical assessments of developmental drug exposure, and ultimately how we conduct clinical assessments of drug efficacy, effectiveness, and safety for the treatment of childhood psychiatric disorders. In this article, we present a model to provide a heuristic framework for making predictions about imprinted effects of childhood drug exposure. We then review epidemiological data on attention deficit hyperactivity disorder (ADHD) and childhood depression, prescription practices, and what is known regarding the long-term consequences of drug exposure in these populations. We conclude with a discussion of the current status of preclinical studies on juvenile stimulant exposure.

Delivering more effective treatment to adolescents: Improving the juvenile drug court model

Juvenile drug courts (JDC) emerged in response to a perceived need to intervene more effectively in the substance abuse-delinquency cycle. The influx of drug and alcohol offenders, lack of other juvenile justice system interventions, and positive experiences with adult drug courts helped drive interest in adapting the drug court model for juveniles. This article: (1) provides an overview of substance use and the juvenile justice system; (2) describes the current status of JDC programs; and (3) proposes a model for planning, implementing and evaluating JDCs based on adolescent drug use and treatment research as well as current JDC models. The lack of science-based JDC models and empirically sound JDC evaluations has limited the effectiveness of JDCs. The proposed model is designed to create a new generation of JDCs that maximizes the effectiveness of local resources and delivers research-based interventions to youth and families impacted by substance abuse and delinquency.

Substance use problems and associated psychiatric symptoms among adolescents in primary care

OBJECTIVE

Substance use disorders (SUDs) are associated with other mental disorders in adolescence, but it is unclear whether less severe substance use problems (SUPs) also increase risk. Because youths with SUPs are most likely to present first to their site of primary care, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent primary care patients with subdiagnostic use of alcohol or other drugs. The objective of this study was to determine the association between level of substance use and psychiatric symptoms among adolescents in a primary care setting.

METHODS

Patients who were aged 14 to 18 years and receiving routine care at a hospital-based adolescent clinic were eligible. Participants completed the Problem Oriented Screening Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect social and legal problems associated with alcohol and other drugs, and the Adolescent Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8 types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic substance use (NSU), SUP, and SUD with psychiatric symptom presence (any symptoms within each type), score (symptom scores summed across all types), and number of types (number of different symptom types endorsed).

RESULTS

Of 538 adolescents (68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most common (60% of both boys and girls), followed by symptoms of depression among girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%). Compared with those with NSU, youths with SUP and those with SUD were more likely to report symptom presence for several types of psychiatric symptoms. Girls with SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct disorder; girls with SUD were at increased risk for symptoms of depression, eating disorders, and hallucinations or delusions. Boys with SUP had increased odds of ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom scores and reported a wider range of psychiatric symptom types (number of types) compared with youths with NSU.

CONCLUSIONS

Like those with SUD, adolescents with subdiagnostic SUP were at increased risk for experiencing a greater number of psychiatric symptoms and a wider range of psychiatric symptom types than youths with NSU. Specifically, adolescents with SUP are at increased risk for symptoms of mood (girls) and disruptive behavior disorders (girls and boys). These findings suggest the clinical importance of SUP and support the concept of a continuum between subthreshold and diagnostic substance use among adolescents in primary care. Identification of youths with SUP may allow for intervention before either the substance use or any associated psychiatric problems progress to more severe levels.

Social skills training in children with attention deficit hyperactivity disorder: a randomized-controlled clinical trial

Evaluated efficacy of social skills training (SST) on children with 2 subtypes of attention deficit hyperactivity disorder (ADHD). Participants were 120 children (30 girls, 90 boys), ages 8 to 12 with ADHD-Inattentive type (ADHD-I; n = 59) or Combined type (ADHD-C; n = 61). The children were randomly assigned within diagnosis subtype to the treatment condition (8 weeks of SST) or the no-intervention control condition. SST led to greater improvements in both parent- and child-perceived assertion skills in the children with ADHD, yet did not affect the other domains of social competence. Diagnostically heterogeneous groups led to greater improvements on parent-report of their child's cooperation and assertion abilities as well as children's report of their own empathy skills. Diagnostically homogeneous groups led to greater decreases in externalizing behaviors at posttreatment but not at follow-up. Children with comorbid oppositional defiant disorder (ODD) did not benefit as much from the intervention. Children with ADHD-I improved in assertion skills more than children with ADHD-C, yet the 2 diagnostic entities did not differ in improvement levels across all other social skills.

Child, parent, and peer predictors of early-onset substance use: a multisite longitudinal study

The purpose of this study was to identify kindergarten-age predictors of early-onset substance use from demographic, environmental, parenting, child psychological, behavioral, and social functioning domains. Data from a longitudinal study of 295 children were gathered using multiple-assessment methods and multiple informants in kindergarten and 1st grade. Annual assessments at ages 10, 11, and 12 reflected that 21% of children reported having initiated substance use by age 12. Results from longitudinal logistic regression models indicated that risk factors at kindergarten include being male, having a parent who abused substances, lower levels of parental verbal reasoning, higher levels of overactivity, more thought problems, and more social problem solving skills deficits. Children with no risk factors had less than a 10% chance of initiating substance use by age 12, whereas children with 2 or more risk factors had greater than a 50% chance of initiating substance use. Implications for typology, etiology, and prevention are discussed.

The prospective relation between dimensions of anxiety and the initiation of adolescent alcohol use

Examined the relation between early anxiety symptomatology (generalized and separation) and initiation of alcohol use 4 years later in an epidemiological sample of 936 children (45% girls), assessed at ages 9, 11, and 13, while controlling for the effects of depression. Although earlier overall anxiety symptomatology was unrelated to later onset of drinking, children with early symptoms of generalized anxiety were found to be at increased risk for initiation of alcohol use, whereas children with early symptoms of separation anxiety were at decreased risk. The magnitude of these relations was equally strong for boys and girls. In addition, early depressive symptomatology was associated with increased risk for initiation of alcohol use in adolescence. Results indicate that it is important to consider specific dimensions of anxiety symptomatology when attempting to identify those individuals at risk for early initiation of alcohol use.

Risk factors for adolescent substance abuse

Reviews research on risk factors for adolescent substance use disorders (SUD) and discusses possible relationships between SUDs and learning disabilities (LD). Individual level factors (genetic, biologic, other familial, and psychiatric) emerge as very important in the risk equation, as well as the interaction between individual risk and environmental conditions. Commonalities between SUD risk and LD include prenatal substance exposure, family history of SUD, conduct disorder, social skills deficits, and academic failure; however, further research is needed to establish whether individuals with LD face a specific risk for SUDs, and if so, what the nature of that risk might be.

Social impairment in girls with ADHD: patterns, gender comparisons, and correlates

OBJECTIVE

To investigate social impairment in girls with attention-deficit/hyperactivity disorder (ADHD), compare the social functioning of boys and girls with ADHD, and explore the association between social dysfunction and conditions comorbid with ADHD.

METHOD

Four groups of index children were studied: 267 children (127 girls) with ADHD and 234 non-ADHD comparison children (114 girls). Groups were compared on social functioning, psychopathology, and demographic characteristics.

RESULTS

Girls with ADHD manifested significant deficits in interpersonal functioning compared with girls without ADHD and evidenced a similar degree of social impairment compared with boys with ADHD. ADHD and associated comorbid disorders were significant correlates of specific domains of social dysfunction in boys and girls with ADHD.

CONCLUSIONS

Interpersonal deficits are a major correlate of ADHD, irrespective of gender, and appear to stem from the behaviors associated with ADHD as well as behaviors characteristic of conditions comorbid with ADHD.

What does the MTA study tell us about effective psychosocial treatment for ADHD?

Discussed the initial findings from the recently published, National Institute of Mental Health-sponsored Multimodal Treatment Study (MTA) of attention deficit hyperactivity disorder (ADHD). These findings can be summarized as follows: Medical management alone was found to be significantly more effective for the core symptoms of ADHD as compared to behavioral treatment alone and routine (community) care, and behavioral treatment did not significantly improve outcome when combined with medical treatment. In discussing these findings, it is important to be explicit about the research questions the study was and was not designed to answer. The MTA study provided useful information regarding the question, "Does a very intensive form of behavioral treatment deliver greater benefits than the less intensive forms of behavioral treatment investigated in prior studies?" but little insight on the question, "What type of treatment by what type of therapist is most effective in dealing with what specific problems among specific children with ADHD?" It is suggested that the clearest finding from the MTA study is that the effectiveness of psychosocial intervention for ADHD hinges on the degree to which a broad range of treatment ingredients are considered, carefully selected, matched, and tailored to the individual needs of each child with the disorder, and implemented and monitored over the long term.

Effective school-based mental health interventions: advancing the social skills training paradigm

Psychotherapeutic interventions with children have not been as successful in practice as laboratory studies suggest. Two weaknesses frequently cited include the failure of treatment gains to generalize to other times and settings and the lack of individualization. Although social skills interventions have inherent appeal and appear appropriate to address many of the social and emotional problems encountered by children and youth, they have not demonstrated effectiveness despite their widespread use. This article outlines four steps to improve social skills interventions that take advantage of the unique environments of schools and increase the likelihood that social skills interventions can achieve individualization and generalization.

Toward a transactional conceptualization of oppositional defiant disorder: implications for assessment and treatment

The conceptualization and treatment of oppositional defiant disorder (ODD) has been characterized by surprising homogeneity. In this paper evidence is presented to underscore the heterogeneity within ODD, including research demonstrating (a) the distinction between reactive and proactive forms of aggression; (b) the importance of affective modulation and self-regulation, and associated cognitive skills, in the development of the skill of compliance; and (c) high levels of comorbidity between ODD and other disorders. The disparate pathways that give rise to oppositional behavior suggest that different children with ODD may require different forms of intervention. The necessity of a transactional conceptualization, of achieving a comprehensive understanding of the factors underlying the difficulties of individual children with ODD, and of matching intervention ingredients to the specific needs of different children and families is discussed.