Disease and family contributors to adaptation in juvenile rheumatoid arthritis and juvenile diabetes.

OBJECTIVE: Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. METHODS: A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. RESULTS: Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. CONCLUSION: Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual.

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Dysthymic disorder in clinically referred preschool children.

OBJECTIVE: This clinical and descriptive study examined the existence, phenomenology, and frequency of dysthymic disorder in a sample of clinically referred preschool children. In addition, the frequency of DSM-IV symptoms and the alternative research criterion for dysthymic disorder were investigated. METHOD: Three hundred consecutive preschool admissions (aged 2 to 6 years) to a child development unit were given a comprehensive evaluation by a treatment team. Data were collected from multiple informants based on the suitability of each source. RESULTS: The findings indicated that eight children met criteria for dysthymic disorder according to the DSM-IV criteria and the alternative research criterion for dysthymic disorder. CONCLUSIONS: The results support the existence of dysthymic disorder in preschool-age children. Recommendations are made for future versions of DSM as well as the appropriateness and significance of various sources of information, such as the child, parents, teachers, and clinician observations, for the evaluation of symptoms of dysthymic disorder in preschoolers.

Risperidone in the management of violent, treatment-resistant schizophrenics hospitalized in a maximum security forensic facility.

This study examines the effectiveness of risperidone compared with traditional neuroleptic medications in the areas of clinical functioning and aggressive behaviors in a sample of inpatients diagnosed with chronic schizophrenia. Similar to the methodology of Menditto et al. (Psychiatr Serv 47:46-51, 1996), two groups of 10 patients were selected from those being treated in a comprehensive psychosocial rehabilitation program. Group 1 subjects were placed on risperidone at various times during their treatment. Group 2 subjects, who were matched with Group 1 subjects on pre-study levels of clinical functioning as measured by the Time-Sample Behavioral Checklist (TSBC), remained on traditional neuroleptics throughout the study period. For each subject, scores on six TSBC subscales were examined at four time points; data were analyzed with repeated-measures multivariate analyses of variance and univariate analyses of variance. Frequency counts of aggressive behaviors (threats and assaults) were compiled into two six-month time periods and analyzed with nonparametric techniques. The risperidone group did not differ from the traditional neuroleptic group on measures of clinical functioning and aggressiveness measured over time. Both groups evidenced improvements in bizarre motor behaviors over the study period. The risperidone group evidenced some deterioration in measures of appropriate interpersonal interaction over time. No differences in aggressive behaviors were noted for either group. The study concludes that for forensic patients with chronic schizophrenia, risperidone failed to produce therapeutic effects in overall clinical functioning and aggressive behaviors that were significantly different from traditional neuroleptics. Descriptive comparisons are made between the receptor-binding profiles and clinical effectiveness of risperidone and clozapine in an attempt to explain these findings.

Sport psychiatry in childhood and adolescence: an overview.

This review explores the importance and relevance of sport during childhood and adolescence, utilizing traditional stage theories of development. The literature supports the notion that sport is a necessary study as a health issue and a preventative tool in the field of psychiatry. Play and sport in childhood and adolescence enhance development physically, mentally, and socially. Participating in athletics encourages the development of leadership skills, self-esteem, muscle development and overall physical health. There is a lack of literature in the important area of sport psychiatry especially when considering beneficial, not deficit oriented youth athletic development. Child psychiatrists need to begin researching sport in order to develop a comprehensive understanding of how athletics can enhance the mental and physical health of youth.

Effectiveness of clozapine and a social learning program for severely disabled psychiatric inpatients.

OBJECTIVE: This study examined the combined effectiveness of clozapine and a comprehensive inpatient psychosocial rehabilitation program on the clinical functioning and aggressive behaviors of patients with chronic schizophrenia. METHODS: Two groups of 11 subjects each were selected from among patients being treated in the social learning program at Fulton (Mo.) State Hospital. Group 1 subjects were placed on clozapine at various times after the introduction of the program, while group 2 subjects remained on traditional antipsychotics throughout the study period. Group 1 and group 2 subjects were matched on clinical functioning as measured by the Time-Sample Behavioral Checklist (TSBC). For each subject, scores on six TSBC subscales were examined at five time points. Data were analyzed using repeated-measures multiple analysis of variance and univariate analyses of variance. Data on frequency of aggressive behaviors were aggregated into three six-month time periods and were analyzed using Wilcoxon signed-rank tests. RESULTS: Both groups demonstrated significant improvement on several measures. However, the addition of clozapine resulted in accelerated improvement for group 1 subjects, especially in aggressive behaviors. CONCLUSIONS: Comprehensive psychosocial treatment programming resulted in significant improvements in clinical functioning for many inpatients. Clozapine may enhance responsiveness to such programming for some patients.

Assessing anger expression in children and adolescents.

Anger expression styles are associated with psychological and physical well-being among adults. Little is known about the role of anger expression in children's functioning. This lack of knowledge has resulted, in part, from a lack of validated tools for anger expression measurement. The Pediatric Anger Expression Scale-3rd edition (PAES-III; Jacobs, Phelps, & Rohrs, 1989; Jacobs & Kronaizl, 1991) has been proposed as a reliable and valid assessment instrument of anger expression styles. The PAES-III includes three scales that measure anger turned inward, anger expressed outwardly, and anger controlled cognitively or behaviorally. We evaluated the psychometric properties of this instrument when it is administered verbally to children with juvenile rheumatoid arthritis, children with juvenile diabetes mellitus, and healthy children. Internal consistency was adequate for anger-in and anger-out, but marginal for anger-control. Concurrent validity was supported for the total sample. A principal components analysis suggested a four-factor model of anger expression. Overall, the PAES-III was found to have psychometric limitations. Use of a modified PAES-III may facilitate pediatric behavioral medicine research addressing risk factors for maladjustment among children with chronic illnesses.

Patient Stage of Change predicts outcome in a panic disorder medication trial.

OBJECTIVE: The authors test the hypothesis that patient readiness to change predicts outcome in a placebo-controlled medication trial. METHOD: Out-patients with panic disorder and agoraphobia completed the Stages of Change (SOC) questionnaire, a measure of readiness to change, before being randomly assigned either sustained release (SR) adinazolam or placebo in a 4 week double-blind trial. RESULTS: In the "intent to treat" analysis, for the 202 subjects who made at least one visit after baseline, adinazolam SR was significantly more effective than placebo on most major outcome measures. Of the 126 subjects who completed the SOC questionnaire, regression analyses showed significant correlations between SOC scores and all 5 outcome measures. In a second analysis, cluster membership based on SOC scores was predictive of outcome on 3 of 5 measures. In each statistical analysis, subjects who were not predisposed to change as measured by the SOC were significantly less likely to change. CONCLUSIONS: Patient readiness to change was strongly correlated with outcome in a placebo-controlled panic disorder trial with an effective medication. In this study, the SOC category, Precontemplation (i.e., those subjects who reported the belief that they had no problem) were less likely to change compared to those who believed that they had a problem.

Dysphoria: a major symptom factor in persons with disability or chronic illness.

Depression frequently is diagnosed in persons with chronic illness or following the onset of disability. The overlap of symptoms of many chronic illnesses and disabling conditions with depression may lead to an overestimation of depression in such populations. Some investigators have proposed revised criteria for diagnosing depression in these conditions without an understanding of the contribution of diagnostic criteria in disabling conditions. This study investigated the nature of depressive symptom criteria constellations by individually factor analyzing the Inventory to Diagnose Depression (based on DSM-III diagnostic criteria) in spinal cord injury (n = 134), rheumatoid arthritis (n = 78), student (n = 140), and community (n = 150) groups. A four-factor solution emerged, with the first factor labeled "dysphoria" being represented by symptoms of negative self-evaluations, depressed affect, and suicidal ideation. The results indicate that a core element of the syndrome of depression is dysphoria, which suggests that the contribution of somatic items may be less important to the identification of the depressive syndrome in chronic illness.

Social-learning procedures for increasing attention and improving basic skills in severely regressed institutionalized patients.

Seven severely debilitated and chronically institutionalized forensic psychiatric patients were enrolled in intensive shaping classes as part of a comprehensive social-learning treatment program. Results compiled over 1 year reveal that six of these patients demonstrated marked improvements in their ability to attend to basic academic tasks and five also showed consistently high rates of successful task completion or increased rates over time. Evidence for the generalization of these effects comes from the fact that all four of the residents who went on to regular academic classes demonstrated consistently high rates of successful task completion. Recommendations are made for further applications of intensive shaping procedures for such severely impaired subgroups.

Psychological screening in rheumatoid arthritis.

Our objective was to examine the utility of the Symptom Checklist-90-R (SCL-90-R) as a psychological screening instrument for patients with rheumatoid arthritis (RA). Subjects were 81 male and 3 female patients with classic or definite RA who were categorized into 3 anatomic stage groups based on roentgenograms. Erythrocyte sedimentation rates, joint counts, and the SCL-90-R were obtained on all subjects. In addition, rheumatologists were surveyed, and items were analyzed to identify potential disease related items on the SCL-90-R. Both the survey and the item analyses supported the utility of the SCL-90-R as a psychological screening instrument in a population with RA.

Pain control and rational thinking. Implications for rheumatoid arthritis.

In this study, we examined the factor structure of the Coping Strategies Questionnaire and studied the relevance of the coping process to health status in rheumatoid arthritis patients. The 2 factors of the questionnaire that were analyzed were Coping Attempts and Pain Control and Rational Thinking. The Pain Control and Rational Thinking factor was related to pain and psychological status, even after demographic variables and disease severity were statistically controlled. In addition, increases in Pain Control and Rational Thinking scores were related to improvements in pain, psychological status, and health status. Implications for the psychological care of rheumatoid arthritis patients are discussed.

Replicated item level factor structure of the MMPI: racial and sexual differences.

Item-level factor studies of the MMPI date back to the work of Comrey (1957). Surprisingly, there are no extant studies of the items that clinicians use most in the course of daily MMPI interpretive reporting, namely, the 399 x 399 matrix that represents all of the items that comprise the traditional clinical and validity scales. Furthermore, there are no prior studies with adequate Ns that have examined the replicability of MMPI factor structure via available factor comparison techniques (Harman, 1976). In this study, 20,000 MMPIs were factored by the principal components method, followed by Varimax rotations of 6 through 25 factors. The coefficient of congruence was used to compare the factor structures of randomly divided subsamples, as well as males vs. females and Blacks vs. Whites. Differences in factor structure were found, and suggestions are made with regard to the significance of these findings in clinical and applied settings.

The latent factor structure of the WAIS-R: a factor analysis of individual item responses.

Factor analytic examination of a 166 x 166 intercorrelational matrix that represents individual item scores from the 11 subtests of the WAIS-R provided evidence of five interpretable factors (N = 409). Two of these were identified as the Verbal and Performance factors previously encountered in traditional WAIS-R subtest-based factor analyses. The other three factors were characterized readily as involving (1) Advanced Vocabulary skills; (2) Basic Responsivity and (3) Advanced Computational ability. All three of these "new" factors accounted for at least 10% of the total variance, and comments are made with regard to the possible significance of their discovery to such topics as subtest variation and profile psychodiagnostics, theories that pertain to the nature and structure of human intellectual functioning, and subtest-based personality measurement theories.

Factors predictive of panic disorder in cardiology patients with chest pain and no evidence of coronary artery disease: a cross-validation.

Recent data indicate that a substantial number of cardiology patients with chest pain and no clinical evidence of coronary artery disease suffer from panic disorder. Discriminant function analysis reveals that a self-report anxiety measure alone, or in conjunction with minimal demographic information, can predict whether such patients have panic disorder. Predictive accuracy ranges from 69 to 76% correct classification, significantly improving upon chance predictions alone. A 'split-half' design was used in order to cross-validate predictive equations, and the total sample was also analyzed so as to provide the most stable equation. Clinical and future research implications of these findings are discussed.

Antidepressant analgesia in rheumatoid arthritis.

Forty-seven patients with definite rheumatoid arthritis (RA) were treated in a 32 week, double blind, crossover trial of amitriptyline, desipramine, trazodone, and placebo. All drug regimens produced significant changes on pain measures relative to baseline, but only amitriptyline exceeded placebo. Amitriptyline was associated with a significant reduction in the number of painful/tender joints. Our study supports the efficacy of a moderate dose of amitriptyline as an adjunct drug for the treatment of pain in both depressed and nondepressed patients with RA.

Patients with rheumatoid arthritis at high risk for noncompliance with salicylate treatment regimens.

Recent studies indicate the adherence of many patients with rheumatoid arthritis (RA) to their treatment regimens is poor. Management of this problem depends on identification of noncompliant patients, followed by interventions to increase their level of adherence. In this study, 63 patients with RA receiving salicylate drugs completed a questionnaire during an outpatient visit. The questionnaire contained items believed to be predictive of future compliance, including patient self-predictions regarding future compliance, ratings of behavior in similar situations and barriers to compliance, such as ease of transportation to the clinic. Compliance was estimated via a salicylate assay that was taken during a subsequent outpatient appointment. Multivariate analyses of our data revealed that significant predictions could be made regarding future compliance, with 75% of the noncompliant patients correctly identified. Variables contributing significantly included behavioral self-predictions and a measure of current behavior in similar situations, as assessed by a salicylate assay that was collected during the 1st outpatient visit.

Depression in rheumatoid arthritis.

Operationalized diagnostic criteria for depression were used to assess 137 (76% male, 24% female) patients with rheumatoid arthritis (RA). Forty-two percent met criteria for some form of depression. Discriminant function analysis revealed a significant relationship between the presence or history of depression and higher levels of pain, but not between current depression and common indicators of RA activity or severity. These results suggest that depression is a frequent disorder among persons with RA. The importance of patient appraisal of disease and assessment of repeated depressive episodes is discussed. Attention to specific interventions for depression in conjunction with the treatment of the RA is suggested.