Effect of concentration problems on the malleability of children's aggressive and shy behaviors.

OBJECTIVE: Previous research has demonstrated the central role of early childhood concentration problems in the development of aggression and other maladaptive behaviors. The present study investigated the moderating effect of concentration problems on the impact of a classroom-based preventive intervention directed at aggressive and shy behaviors in an epidemiologically defined sample of 1,084 urban first-grade children. METHOD: Concentration problems, aggressive behavior, and shy behavior were assessed by a structured teacher interview (the Teacher Observation of Classroom Adaptation-Revised) in the fall and spring of first grade. RESULTS: Children with high ratings on concentration problems in the fall had higher levels of teacher-rated aggressive and shy behavior in the spring than did children without such problems. The intervention reduced aggressive and shy behavior in children regardless of fall concentration level. Boys, but not girls, in the intervention condition with high concentration problems had higher levels of spring aggression than those without such problems, but they also showed the greatest reductions in aggressive behavior from fall to spring. CONCLUSIONS: These results suggest that aggressive behavior is malleable in children with concentration problems, provide further evidence on the etiological significance of concentration problems for the development of maladaptive behavior, and highlight the importance of directly targeting concentration problems to maximize preventive intervention impact.

Asymmetrical visual-spatial attentional performance in ADHD: evidence for a right hemispheric deficit.

This study was designed to confirm the presence of a lateralizing deficit in visual-spatial attention in children with ADHD, to further characterize the nature of this deficit and to specify the likely hemispheric locus of dysfunction. Two versions of the covert orienting of attention procedure which evaluated separately endogenous and exogenous cuing effects were administered to 20 unmedicated children aged 9-12 with ADHD and 20 matched controls. Both groups also underwent thorough psychiatric assessment and testing using the TOVA and the Wisconsin Card Sorting Task (WCST). Children with ADHD showed an asymmetrical performance deficit characterized by a loss of costs on controlled (endogenous) attentional orienting to invalidly cured left visual field targets. The degree of cost asymmetry correlated negatively with the number of categories sorted on the WCST. It was concluded that unmedicated children with ADHD show an asymmetrical performance deficit on the covert orienting procedure characterized by a disruption of right hemispheric attentional mechanisms. This deficit may be related to diminished right hemispheric frontal-striatal catecholamine activity.

Abnormal processing of irrelevant information in attention deficit hyperactivity disorder.

The presence of a selective attention deficit in children with attention deficit hyperactivity disorder (ADHD) was investigated by administering a trial-by-trial version of the Stroop Color-Naming Task to children, aged 9-12, with ADHD (n = 19) and age-matched normal control children (n = 19). Performance was evaluated on both interference and facilitation components of the task. On the standard version of the task, with equal numbers of color words and neutral words, children with ADHD showed increased Stroop interference (prolongation of color-naming times by color-incongruent stimuli) but normal amounts of facilitation (speeding of color naming by color-congruent stimuli). This finding suggests that children with ADHD show increased disruption of color-naming performance by task-irrelevant information, probably secondary to decreased attentional control over the interference process. In contrast to findings of studies in adults, both groups of children failed to use an attentional strategy to reduce interference when they were administered blocks of trials that varied their expectancy for color word trials. This precluded a direct test of the diminished control hypothesis. There were no significant correlations between abnormal Stroop performance and impairment on the Continuous Performance Test or the Wisconsin Card Sorting Test or measures of IQ or reading performance. The implications of these findings for our understanding of information-processing deficits in children with ADHD and of the neurobiological underpinnings of these deficits are discussed.

Factitious disorders and the psychosomatic continuum in children.

A continuum may be described as spanning between the psychological reactions of children and families to a child's illness, the exaggeration or simulation of symptoms for psychological reasons, and the production of factitious symptoms in the child by the parent. However, there are critical clues that allow the alert clinician to recognize where his patient falls on the continuum. Because factitious disorders are uncommon and Munchausen syndrome by proxy is rare, awareness of psychiatric and clinical signs is important to prevent morbidity or mortality.

Gender differences in career paths in psychiatry.

Although psychiatry has one of the highest proportions of women entering its residency programs, women have not assumed a proportionate amount of academic or research leadership positions in the field. This literature review identifies three general groups of models that explain disparities between men's and women's careers, but these do not fully account for observed differences in psychiatric practice and academic progression of women in psychiatry. Gender differences in career paths in psychiatry are not only affected by individual traits and choices, but also by economic factors. Theories based on organizational discrimination, and systems and market factors are also reviewed. No single explanatory model accounts for disparities between the careers of men and those of women. Because psychiatric practice patterns may be broadly distributed across labor sectors, more diverse career patterns are possible in psychiatry than in more constrained and traditional fields. Research on gender differences in psychiatry careers must consider not only the individual work style and choice, but also the position of individuals within the organization and the position of those organizations across the labor market.

Research in pregnancy and mental illness: testing old wives' hypotheses.

Methodological challenges encountered in evaluating the relationships between life stress, mental illness and pregnancy outcome are identified and several studies on the relationships between pregnancy and childbirth and psychosocial factors, including life stresses, major psychiatric disorders, and puerperal depression, are reviewed. Certain methodological pitfalls are illustrated by showing how relationships between psychiatric diagnosis, severity of psychiatric symptomatology, life stresses, strains specific to the pregnancy, amount of intervention received and outcome of keeping or losing the infant have been explored. Five stages of research are identified and particular difficulties encountered at each stage are described with application to the authors' longitudinal study.

Perinatal toxicology screening.

Accurate identification of substance abusing mothers and their infants is critical for appropriate medical management as well as the collection of accurate information on the effects of illicit drug use on perinatal morbidity, mortality, and long-term neurobehavioral outcome in the infants. This study examines the differences found using two methods for urine toxicology screening at the time of obstetrical admission to the hospital. The institution of universal screening identified significantly more women than were previously identified through the use of a risk-directed protocol (P less than .0001). Women identified using either protocol were significantly more likely than toxicology-negative women to have had poor prenatal care and to have smoked and used alcohol during pregnancy (P less than .001). In the population studied, the multiple criteria needed to accurately identify mothers with positive-toxicology screens would also include screening over one half of the toxicology-negative mothers.

The many faces of AIDS: opportunities for intervention.

Social and cultural issues may have a profound impact on different populations' responses to the AIDS epidemic. To maximize their own effectiveness, clinicians need to be aware of special needs and concerns.

School children with neuropsychological handicap: coping strategies and parents' impact.

One hundred forty six boys (mean age 9 years 1 months, SD = two years, nine months) and forty one girls (mean age 8 years 6 months, SD = three years, three months) received medical, developmental, psychoeducational, and psychiatric evaluations in a multidisciplinary developmental pediatric clinic. Two hundred fifty variables were analyzed by developing ten scales to quantitatively evaluate neuropsychological risk factors, family and parent functioning, and outcome measures of academic achievement, social adjustment and coping or psychiatric symptom pattern. Higher academic achievement, and lower behavioral symptomatology were associated with high IQ scores but not with higher scores on neurobehavioral risk factors. Chief complaints reported by parents did not correlate with their children's final psychiatric diagnoses and also were found to be independent of children's coping styles observed in the office. Problem parenting, as observed in the pediatrician's office, was associated with behavioral problems, and also with decreased competence on language measures and lower academic achievement in relation to IQ. In this sample, assessing parenting yielded a stronger prediction of the child's school and behavioral functioning than did taking a detailed history of neuropsychological risk factors.

Psychiatric response to HIV spectrum disease in children and adolescents.

Five clinical situations involving children and adolescents exposed to human immunodeficiency virus illustrate the psychosocial spectrum of the disease. For at-risk gay youth, anxiety and stigma complicate developing sexual practices. Children with perinatal infection may survive for years with a chronic illness, management of which is complicated by parental illness or death. Hemophiliac families must deal with the intrusion of a lethal virus into a long illness course. "Street" adolescents and substance-abusing youth pose particular challenges to public health and education. The range of child psychiatric responses described includes individual and family therapy, neuropsychological assessment, psychopharmacological management, and consultation liaison work.

The Child Consultation Rating Scale.

A consultation psychopathology rating scale is described for use in assessing psychopathology in pediatric patients and their families in a tertiary care general teaching hospital setting with high acuity and rapid patient turnover. The scale is composed of twelve consultation variables, thirty patient variables, and fourteen parent variables. It includes a global rating and a DSM-III-R diagnosis for both parent and child. Pilot findings using the scale are described for sixty pediatric patients and thirty controls. Interrater reliability using Kendall nonparametric correlations between raters was obtained for each variable and achieves significance ranges from p less than .05 to p less than .001. Applications to training pediatric and psychiatry residents in the systemic observation of child psychopathology are discussed.

Effect of pregnancy on psychosis: life circumstances and psychiatric symptoms.

As part of an ongoing prospective study to correlate mother and infant outcome with social isolation during pregnancy, the Schedule for Affective Disorders, SADS-C, was administered to twenty-seven psychotic patients late in pregnancy. Extensive standardized evaluation of life stresses and social supports included a Prenatal Interview with sixty items relating to demographics, drug use, health and obstetrical history, family involvement and development expectations of the infant, and a thirty-item Difficult Life Circumstances questionnaire. In this sample the patients' previous life adjustments were stabilized by their pregnancy unless the pregnancy itself created personal stress for the patient. Higher scores on Difficult Life Circumstances were found to be associated with more psychiatric symptomatology. Symptoms of pregnancy confounded SADS-C items measuring vegetative signs of depression. One group of items on the SADS-C appeared to selectively identify a subset of women whose underlying affective symptomatology was potentiated by pregnancy. A second group of items identified women whose symptoms appeared to be reactive to current situational strains.

Parent salvage and parent sabotage in the care of chronically ill children.

Adaptive parental behaviors produced from dealing with prolonged illness may sabotage medical care of the chronically ill pediatric patient. Such parental behaviors may be the result of unsuccessful intrapsychic or interpersonal salvage operations in the response to the strains resulting from illness in their child. They may resemble psychopathology, but actually can be reversible. Five cases are presented to illustrate differential diagnosis of parent difficulties ranging from adaptive strain in normal parents to Munchausen's syndrome by proxy in parents of children with chronic illness. A typology of parent-child pathology in health and chronic illness is presented. The literature is reviewed, diagnostic features are elaborated, and management strategies are suggested.

Psychiatric liaison to liver transplant recipients.

Child psychiatric consultants perform psychiatric assessment and liaison among various clinical services. Execution of these familiar roles for pediatric liver transplantation recipients exposes unfamiliar and difficult bioethical problems. Administrative problems arise if the recipient's suitability is too narrowly evaluated. Assessment may be time-limited. The intensive care unit environment and the VIP characteristics of child transplantation patients may distort observations and constrain opportunities for preventive preoperative psychologic management. Unnecessary psychiatric complications may ensue, which imperil the transplantation surgery. The primary caretakers may have an extraordinary emotional investment, so liaison is pressured. Three cases are presented to illustrate these points. Medical ethical perspectives and the limitations of medical training to prepare physicians to perceive them are indicated. That these limitations also affect the psychiatrist is acknowledged, and a clinical research approach is suggested.

Impact of the diagnosis of AIDS on hospital care of an infant.

Detailed analysis of caretaker response to the first infant newly diagnosed with AIDS at a university hospital was done by review of nursing notes for three periods: before diagnosis of AIDS, after diagnosis, and after psychiatric consultation. Five consultation questions were posed, and the findings on investigation of these questions are discussed. It was found that the percentage of time that PRN medication was given dropped after diagnosis of AIDS but rose above the initial level after the consultation. The number of times per shift the nurse touched the baby (TLCs) was not found to be associated with use of PRN medication; rather it was explained by which nurse was caring for the child. This study focuses on variations in nursing care of one infant to illustrate how variation in caretaker response can amplify the range of perturbations of the infant's behavioral response. It is speculated that caretakers of patients with AIDS may normally have feelings considered unacceptable in medical settings, including fear, blaming the patient, or a wish to avoid the patient. Such feelings are more difficult to tolerate in the care of children or infants and are superimposed upon the familiar stains associated with the care of chronically ill or dying pediatric patients.

Relation of family factor to treatment outcome for bulimic patients.

The psychotherapy of 25 normal weight bulimic adolescent and late adolescent women (age 15-32 years, mean = 21 years), was reviewed to evaluate developmental and diagnostic precursors and the outcome of psychoanalytically oriented long-term therapy (mean = 33 sessions). Psychotherapy outcome was scored in these categories: bingeing and purging; food obsession; school/work satisfaction; equilibration with family of origin, and achievement of heterosexual closeness. On factor analysis, all factors loaded highly and a global outcome score was derived which was used as the dependent variable in a step-wise regression analysis with 18 family factors as independent variables. To identify family patterns that predicted degree of improvement, a multiple regression analysis was performed. Results indicated that family variables associated with maternal warmth explained an appreciable proportion of the variance in outcome. Such a finding is consistent with the formulation that patients with benign archaic maternal representations were better able than their counterparts with less benign maternal images to form a positive transference and better working alliance with the (female) therapist.