Father absence and familial antisocial characteristics.

This study examined family antisocial characteristics according to whether biological fathers live at home and agree to be study participants. Antisocial symptoms were tabulated for 161 clinic-referred children and their parents. Families with fathers at home had fewer paternal, maternal, and child antisocial symptoms, and scored higher on multiple SES indicators, than did families with departed fathers. Antisocial characteristics were highest, and SES was lowest, when fathers could not be located or recruited. Results suggest that requiring father participation (as in family-trio genetic designs) screens out the more antisocial families. Of clinical interest, antisocial behavior in any family member is more likely if the father is absent and nonparticipating. The heightened antisocial behavior in children associated with absent biological fathers was not mitigated by presence of stepfathers and was not accounted for by lower SES. The ethical use of mother report on absent fathers is discussed.

Antisocial personality, substance abuse, and exposure to parental violence in males referred for domestic violence.

This study investigated whether childhood disruptive behavior (hyperactivity, oppositional-defiance, conduct problems) plus adult psychopathic adjustment are associated with domestic violence. Adult males (n = 66) in diversion programs completed the Wender Utah Rating Scale (WURS), MMPI Psychopathic Deviate scale (PD), Conflict Tactics Scales representing themselves and their parents, and substance use measures. Substance use and lifespan antisocial personality (measured by high WURS and PD scores) were robust predictors of verbal and moderate physical domestic abuse. Violence in the family of origin was associated with abuse when tested alone, but failed to exhibit unique association with abuse when other predictors were taken into account. The possibility that antisocial batterers respond to contingencies by moderating physical harm, while persisting at psychological harm, is discussed.

Randomized, controlled trial of oros methylphenidate once a day in children with attention-deficit/hyperactivity disorder.

OBJECTIVE: A new once-a-day methylphenidate (MPH) formulation, Concerta (methylphenidate HCl) extended-release tablets (OROS MPH), has been developed. This study was conducted to determine the safety and efficacy of OROS MPH in a multicenter, randomized, clinical trial. METHODS: Children with attention-deficit/hyperactivity disorder (ADHD; n = 282), all subtypes, ages 6 to 12 years, were randomized to placebo (n = 90), immediate-release methylphenidate (IR MPH) 3 times a day (tid; dosed every 4 hours; n = 97), or OROS MPH once a day (qd; n = 95) in a double-blind, 28-day trial. Outcomes in multiple domains were assessed, and data were analyzed using analysis of variance and Kaplan Meier product limit estimates for time to study cessation. The primary time point for analysis was the last available patient visit using last observation carried forward. RESULTS: Children in the OROS and IR MPH groups showed significantly greater reductions in core ADHD symptoms than did children on placebo. This was true both at the end of week 1 and at the end of treatment on the basis of mean teacher and parent IOWA Conners ratings. IR MPH tid and OROS MPH qd did not differ significantly on any direct comparisons. Forty-eight percent of the placebo group discontinued early compared with 14% and 16% in the IR MPH and OROS MPH groups, respectively. CONCLUSIONS: For the treatment of core ADHD symptoms, OROS MPH dosed qd and IR MPH dosed tid were superior to placebo and were not significantly different from each other.attention-deficit/hyperactivity disorder, methylphenidate, OROS, Concerta.

Symptom properties as a function of ADHD type: an argument for continued study of sluggish cognitive tempo.

Inconsistent alertness and orientation (sluggishness, drowsiness, daydreaming) were reported to accompany Attention Deficit Disorder (ADD) without Hyperactivity in DSM-III. Such Sluggish Cognitive Tempo items were tested in the DSM-IV Field Trial for ADHD, but were discarded from the Inattention symptom list because of poor negative predictive power. Using 692 children referred to a pediatric subspecialty clinic for ADHD, Sluggish Tempo items were re-evaluated. When Hyperactivity-Impulsivity was absent (i.e., using only cases of Inattentive Type plus clinic controls), Sluggish Tempo items showed substantially improved utility as symptoms of Inattention. Factor analyses distinguished a Sluggish Tempo factor from an Inattention factor. When DSM-IV ADHD types were compared, Inattentive Type was uniquely elevated on Sluggish Tempo. These findings suggest that (a) Sluggish Tempo items are adequate symptoms for Inattentive Type, or (b) Sluggish Tempo may distinguish two subtypes of Inattentive Type. Either conclusion is incompatible with ADHD nosology in DSM-IV.

Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program.

As part of the behavioral treatment in the Multimodal Treatment Study of Children with ADHD (MTA9), children participated in an intensive summer treatment program (STP). This study examined the differences between 57 children in the combined treatment (Comb) group, who were medicated, and 60 children in the behavioral treatment (Beh) group, who were unmedicated throughout the STP. Comb children were significantly better than Beh on 5 measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment ratings of inattention/overactivity. Groups did not differ on any of the other 30 measures, and responded similarly to the STP over time. Comparisons to normative data revealed that Comb children were more likely to fall within the normative range on 6 measures. The differences between these results and the main MTA results, in which Comb was always superior to Beh, are discussed in terms of the relative intensity of combined treatments. The implications for future studies of pharmacological and behavioral treatment for ADHD are discussed.

Interventions to enhance social competence.

Social Impairment associated with attention deficit/hyperactivity disorder (ADHD) is difficult to treat. Stimulant treatment often improves social functioning, but rarely results in normalization. Behavioral approaches to improving social skills have progressed from unimodal techniques (contingency management) to packages that may combine multiple cognitive and behavioral techniques targeted directly to children and mediated by parents, teachers, other adults, and peers. Medication and behavioral treatment may improve different aspects of social impairment and may complement each other when used together. Much of the progress of treating social problems can be attributed to efforts to increase generalization across settings and durability of effects. A promising multimodal psychosocial approach is presented in detail.

Low salivary cortisol and persistent aggression in boys referred for disruptive behavior.

BACKGROUND: Persistent antisocial behavior in adulthood is often preceded by childhood-onset aggressive conduct disorder. Aggressive syndromes in both children and adults have previously been associated with abnormalities in peripheral responses to stress. One peripheral measure, salivary cortisol concentration, may reflect individual differences in the hypothalamic-pituitary-adrenal axis that underlie propensities for aggression, socialization, and adaptation to stress. METHODS: The relationship between salivary cortisol levels and aggression was tested in 38 clinic-referred school-aged boys. Persistent aggression was measured by collecting disruptive behavior disorder symptoms in 4 annual clinical evaluations and peer nominations of aggression in the first 2 annual evaluations. Salivary cortisol levels were measured during years 2 and 4 of the study. RESULTS: Low cortisol levels were associated with persistence and early onset of aggression, particularly when measures of cortisol concentrations were pooled. Boys with low cortisol concentrations at both time points exhibited triple the number of aggressive symptoms and were named as most aggressive by peers 3 times as often as boys who had higher cortisol concentrations at either sampling time. CONCLUSIONS: This suggests that low hypothalamic-pituitary-adrenal axis activity is a correlate of severe and persistent aggression in male children and adolescents. A restricted (low) range of cortisol variability may be more indicative of persistent aggression than a low concentration of cortisol at any single point in time.

Findings on disruptive behavior disorders from the first decade of the Developmental Trends Study.

The paper summarizes the first decade of the Developmental Trends Study, a prospective longitudinal study of 177 boys. Initially, they were referred to mental health clinics in Pennsylvania (Pittsburgh), and Georgia (Athens and Atlanta). Since 1987, the boys, their parents, and their teachers have been followed up almost annually. The study is unique because the cooperation rate of participants has remained very high over the years, psychiatric diagnoses were derived from structured interviews (especially disruptive behavior disorders), and many risk factors were measured over the years. The present paper summarizes key findings on the development of disruptive behavior, especially Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficit-Hyperactivity Disorder. The paper also highlights results on risk factors and comorbid conditions of disruptive behaviors.

Annotation: the development of antisocial behavior: an integrative causal model.

In this paper we have described an integrative causal model of the development of antisocial behavior in children and adolescents. The present model primarily integrates several previous models, but offers some new testable hypotheses. We believe that stable individual differences in propensity to antisocial behavior reflect variations in a number of dimensions of predisposing temperament and cognitive ability, each with its own genetic and environmental influences. The dimensions of predisposing temperament include oppositionality, harm avoidance, and callousness. Genetic influences are predicted to have only indirect effects on antisocial behavior via their influence on predisposition and on the youth's social environment. Environmental influences are expected to be important contributors to antisocial propensity, but these environmental influences reflect, in part, the genetic influences on the dimensions of predisposition (i.e. genotype-environment covariance). We also hypothesize that the levels of influence of the factors that determine individual differences in antisocial propensity change with development, such that genetic influences are of greater magnitude in early childhood and social influences contribute more strongly during later childhood and adolescence (both through independent effects and genotype-environment covariance). However, low levels of heritable predisposing child characteristics may protect against peer influences at all ages.

Experimental cross-validation of DSM-IV types of attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine the discriminant validity of DSM-IV attention-deficit/hyperactivity disorder (ADHD) types by testing the hypothesis that types are associated with specific kinds of functional impairment and to compare overlap of DSM-IV and DSM-III-R ADHD. METHOD: Consecutive referrals (n = 692) to a pediatric subspecialty clinic for ADHD were classified into 1 of each of the 3 DSM-IV types of ADHD using parent and teacher checklist ratings of ADHD symptoms. The resulting types were compared on clinical correlates and on whether the children also met criteria for DSM-III-R ADHD. RESULTS: The validity of DSM-IV types was supported by dimension-specific impairment and other distinct correlates. Academic problems aggregated in the 2 types defined by extreme inattention, and externalizing problems aggregated in the 2 types defined by extreme hyperactivity. CONCLUSION: DSM-IV appeared superior to DSM-III-R in subcategorical homogeneity and in exhaustiveness (ability to classify all apparent cases).

Validity of DSM-IV subtypes of conduct disorder based on age of onset.

OBJECTIVE: To present data from the DSM-IV field trials that led to the distinction between subtypes of conduct disorder (CD) that emerge in childhood or adolescence. In addition, data from a household sample were used to attempt to cross-validate these findings. METHOD: Differences between youths who met criteria for the two subtypes of CD were examined in the field trials sample of 440 youths aged 4 through 17 years and in a household sample of 1,285 youths aged 9 through 17 years. RESULTS: In both samples, there was a steep decline in aggression occurring around an age of onset of 10 years, but the number of nonaggressive behaviors was unrelated to the age of onset of CD. In the field trials sample, youths who met criteria for the adolescent-onset type were more likely to be girls, less likely to meet criteria for oppositional defiant disorder, and less likely to have a family history of antisocial behavior than the childhood-onset type, but these latter findings were not confirmed in the household sample. CONCLUSIONS: The DSM-IV approach to subtyping CD distinguishes subgroups that differ markedly in level of physical aggression. The advantages of a developmental approach to subtyping are discussed.

Social skills training with parent generalization: treatment effects for children with attention deficit disorder.

The effectiveness of brief social skills training (SST) was evaluated in a controlled outcome study with 27 children meeting criteria of the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; American Psychiatric Association, 1987) for an attention deficit disorder. Children were randomly assigned to either SST with parent-mediated generalization (SST-PG), child-only SST, or a wait-list control group. SST consisted of 8 group sessions in which skill modules were taught sequentially. Parents of children in the SST-PG group simultaneously participated in group generalization training designed to support their children's transfer of skills. Significant improvement in children's skill knowledge and in parent reports of social skills and disruptive behavior occurred for both treatment groups relative to the wait-list control group and maintained at a 4-month follow-up. More modest evidence was found for generalization of SST to the school setting.

Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials.

OBJECTIVE: To examine the validity of the DSM-IV requirement of an age of onset of impairment due to symptoms before 7 years of age for the diagnosis of attention-deficit/hyperactivity disorder (ADHD). METHOD: The validity of this criterion was examined in a clinic sample of 380 youths aged 4 through 17 years by comparing youths who met symptom criteria for ADHD and either did or did not display impairment before age 7 years. RESULTS: Nearly all youths who met symptom criteria for the predominantly hyperactive-impulsive subtype also met the age of onset of impairment criterion, but 18% of youths who met symptom criteria for the combined type, and 43% of youths who met symptom criteria for the predominantly inattentive type, did not manifest impairment before 7 years. For the latter two subtypes, requiring impairment before age 7 years reduced the accuracy of identification of currently impaired cases of ADHD and reduced agreement with clinicians' judgments. CONCLUSIONS: These findings raise questions about the validity of the DSM-IV definition of age of onset of ADHD. Marked differences in the ages of onset of both symptoms and impairment for the three subtypes of ADHD support the validity of distinguishing among these subtypes in DSM-IV.

Psychopathy and conduct problems in children.

Factor analysis of a measure of psychopathy was conducted in a sample of 95 clinic-referred children between the ages of 6 and 13 years. These analyses revealed 2 dimensions of behavior, one associated with impulsivity and conduct problems (I/CP) and one associated with the interpersonal and motivational aspects of psychopathy (callous/unemotional: CU). In a subset of this sample (n = 64), analyses indicated that scores on the I/CP factor were highly associated with traditional measures of conduct problems. In contrast, scores derived from the CU factor were only moderately associated with measures of conduct problems and exhibited a different pattern of associations on several criteria that have been associated with psychopathy (e.g., sensation seeking) or childhood antisocial behavior (e.g., low intelligence, poor school achievement, and anxiety). These analyses suggest that psychopathic personality features and conduct problems are independent, yet interacting, constructs in children, analogous to findings in the adult literature.

DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents.

OBJECTIVE: Optimal diagnostic thresholds were determined for DSM-IV attention deficit hyperactivity disorder, and the psychometric properties were compared to alternative definitions. METHOD: Structured diagnostic interviews of multiple informants for 380 clinic-referred youths aged 4-17 years were conducted. In addition, standardized clinicians' validation diagnoses of attention deficit disorder were obtained to assess agreement with clinical judgment. Measures of impairment were obtained to assess the accuracy of identifying youth with an impairing condition. RESULTS: Three subtypes of attention deficit hyperactivity disorder (predominantly inattentive, predominantly hyperactive-impulsive, and combined types) were distinguished on the basis of the degree of deviance on separate dimensions of inattention and hyperactivity-impulsivity. These three subtypes were found to differ in terms of types of impairment, age, and sex ratio, but not ethnicity. In terms of case identification of attention deficit hyperactivity disorder, DSM-IV was found to be very similar to DSM-III-R, except that DSM-IV identified more impaired girls and preschool children. CONCLUSIONS: These results support the decision to subdivide the heterogeneous category of DSM-III-R attention deficit hyperactivity disorder into three subtypes. The resulting DSM-IV definition appears to be somewhat less biased toward the symptom pattern typical of elementary school boys.

DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents.

OBJECTIVE: The purpose of the field trials for oppositional defiant disorder and conduct disorder was to select valid diagnostic thresholds for these disorders and to compare the psychometric properties of DSM-IV criteria for oppositional defiant disorder and conduct disorder with previous DSM diagnostic formulations. METHOD: Structured diagnostic interviews, standardized clinician's validation diagnoses, and multiple measures of impairment were obtained for 440 clinic-referred children and adolescents aged 4-17 years. RESULTS: A diagnostic threshold of four symptoms of oppositional defiant disorder optimized identification of impaired children, improved agreement somewhat with the clinician's validation diagnosis, and had somewhat better test-retest agreement than DSM-III-R. In the case of conduct disorder, the optimal time window for ascertainment of symptoms was clarified. A diagnostic threshold of three symptoms of conduct disorder maximized accurate identification of impaired children and agreement with the clinician's validation diagnosis and resulted in slightly better test-retest agreement than DSM-III-R. Compared with the DSM-III-R definition, the DSM-IV definition of oppositional defiant disorder was somewhat more prevalent, but the prevalence of conduct disorder was essentially unchanged. CONCLUSIONS: DSM-IV definitions of oppositional defiant disorder and conduct disorder are somewhat better than DSM-III-R definitions in terms of internal consistency and test-retest agreement, and the validity of the DSM-IV definition of oppositional defiant disorder is slightly better than that of DSM-III-R.

Effects of stimulant medication on learning in children with ADHD.

It is well established that stimulant medication improves classroom manageability and attention in terms of time on task, but does stimulant medication improve learning or long-term academic achievement in children with ADHD? There is no clear evidence that it does, but there are at least two reasons why beneficial effects may be obscured in research studies and clinical practice: (1) Higher-than-optimal doses may be prescribed if behavioral response (rather than cognitive response) is used to titrate the dose, and (2) treatment may be overinclusive if diagnostic groups are targeted in which a significant proportion of cases do not have favorable cognitive responses to medication. This article addresses these two issues and describes a large clinical series of patients who were evaluated using a double-blind medication assessment protocol designed to overcome some of the theoretical deficiencies suggested by these issues.