Pre-school children with and without developmental delay: behaviour problems and parenting stress over time.

BACKGROUND: Children with intellectual disability are at heightened risk for behaviour problems and diagnosed mental disorder. METHODS: The present authors studied the early manifestation and continuity of problem behaviours in 205 pre-school children with and without developmental delays. RESULTS: Behaviour problems were quite stable over the year from age 36-48 months. Children with developmental delays were rated higher on behaviour problems than their non-delayed peers, and were three times as likely to score in the clinical range. Mothers and fathers showed high agreement in their rating of child problems, especially in the delayed group. Parenting stress was also higher in the delayed group, but was related to the extent of behaviour problems rather than to the child's developmental delay. CONCLUSIONS: Over time, a transactional model fit the relationship between parenting stress and behaviour problems: high parenting stress contributed to a worsening in child behaviour problems over time, and high child behaviour problems contributed to a worsening in parenting stress. Findings for mothers and fathers were quite similar.

Subject and interview characteristics affecting reliability of the Diagnostic Interview Schedule for Children.

Despite the well-known difficulties in obtaining reliable and valid assessments of child psychopathology, investigators generally have not examined the influence of factors such as subject characteristics or the specific assessment procedures themselves on the validity of the information obtained. To address these issues, this special section presents four studies of the Diagnostic Interview Schedule for Children, in which investigators examined the impact of a range of variables on the reliability of its symptom and diagnostic information. Factors studied include interview structural characteristics; question length, complexity, and placement within the interview; and interview subject characteristics. Overall findings suggest that interview and subject characteristics exert important influences on the data obtained, and that novel approaches, such as allowing subjects a greater role in the ordering of questions to be answered, may improve the precision and accuracy of such measures of children's psychopathology.

Interviewing as communication: an alternative way of administering the Diagnostic Interview Schedule for Children.

Parents of 24 children referred to an outpatient psychology clinic (mean child age 10.8, range 6-15) were administered the Diagnostic Interview Schedule for Children Version 2.3 (DSIC-2.3) twice in a 1-week test-retest reliability design (mean retesting interval = 7.5 days, range = 6-11 days). An alternative mode of administration of the DISC, based on communication principles, was used, involving (a) a schematic representation of the areas to be covered; (b) definition of a common language for the categories, diagnoses, and criteria; and (c) the respondent being allowed to select the order in which the diagnostic areas were covered. The DISC items and modules were unchanged. Symptom scores derived from the DISC were highly reliable over 1 week (average ICC = .85, range = .67-.95) and showed no attenuation from Time 1 to Time 2. Reliability of DSM diagnoses averaged kappa = .80 (range = .63-1.0). There was no significant attenuation in diagnoses from Time 1 to Time 2. Overall, this alternative way of administering the DISC appears to have promise for reducing attenuation and boosting the reliability-and ultimately the validity--of child psychiatric diagnoses. Further investigations of the mechanisms underlying these effects, and further studies with child and adolescent respondents and nonreferred community samples are recommended.

Parent-child relationship disorders. Part II. The vulnerable child syndrome and its relation to parental overprotection.

Parents who are excessively concerned about their child's health are often characterized as being overprotective. We hypothesized that parental overprotection is independent of parental perception of child vulnerability to illness or injury despite their presumed interchangeability. A community-based sample of 892 parents (92% white, 84% married, 88% middle-upper socioeconomic status, 90% mothers) completed a three-part protocol (clinical background data, the Child Vulnerability Scale, and the Parent Protection Scale). Correlates of high parental perception of child vulnerability included a medical condition in the child, a history of life-threatening illness or injury, and the child being seen for a sick visit. Correlates of high parental overprotection included younger age of child and parent. Only 20% of those parents who considered their child vulnerable were also considered overprotective.

Parent-child relationship disorders. Part I. Parental overprotection and the development of the Parent Protection Scale.

There is a spectrum of parental protective behaviors promoting child safety and security, ranging from neglect to overprotection. This paper describes the development and psychometric properties of a new measure of parental protective behaviors toward children age 2 to 10 years, the Parent Protection Scale (PPS). Items were selected to represent key dimensions of protective behaviors. Factor analyses suggested four subscales: Supervision, Separation Problems, Dependence, and Control. The PPS has acceptable internal consistency, test-retest reliability, and clinical validity. Norms by child age in the form of cutoff points corresponding to +1 SD were determined. Clinical and research uses for the PPS are noted.

A twin study of competence and problem behavior in childhood and early adolescence.

The Child Behavior Checklist (CBCL) was completed by parents of 181 pairs of same-sex twins ages 7-15 (mean age = 11.0 years). Correlations between scores on the CBCL scales for 99 pairs of monozygotic twins and 82 pairs of dizygotic twins indicated significant genetic influences that varied according to the specific area of competence and problem behavior. Model-fitting estimates derived from multiple regression analyses indicated significant genetic influence on competence in school and on all areas of problem behavior. In addition, significant shared environmental influence was detected for amount and quality of participation in activities, quality of social relationships, performance in school, anxiety/depression, and delinquent behaviour. Implications for future work on the mechanisms underlying these effects are discussed.

The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology.

The present study reports the results of a prospective, 8-year follow-up study of 100 hyperactive and 60 normal children followed from childhood into adolescence. Ratings of child behavior problems and family conflicts as well as direct observations of mother-child interactions were taken in childhood and again at adolescent follow-up. At outcome, hyperactives continued to have more conduct and learning problems and to be more hyperactive, inattentive, and impulsive than controls. Hyperactives were also rated by their mothers as having more numerous and intense family conflicts than the normal controls, although the adolescents in both groups did not differ in their own ratings of these conflicts. Observations of mother-adolescent interactions at outcome found the hyperactive dyads displaying more negative and controlling behaviors and less positive and facilitating behaviors towards each other than in the normal dyads. These interaction patterns were significantly related to similar patterns in mother-child interactions observed 8 years earlier. Mothers of hyperactives also reported more personal psychological distress than normal mothers at outcome. Further analyses of subgroups of hyperactives at outcome, formed on the presence or absence of ADHD and oppositional defiant disorder (ODD), indicated that the presence of ODD accounted for most of the differences between hyperactives and normals on the interaction measures, ratings of home conflicts, and ratings of maternal psychological distress. Results suggest that the development and maintenance of ODD into adolescence in hyperactive children is strongly associated with aggression and negative parent-child interactions in childhood.

The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status.

One hundred hyperactive children meeting research diagnostic criteria and 60 community control children were followed prospectively over an 8-year period into adolescence. Younger (12-14 years) and older (15-20 years) groups were tested on measures of academic skills, attention and impulse control, and select frontal lobe functions. At follow-up, hyperactive Ss demonstrated impaired academic achievement, impaired attention and impulse control, and greater off-task, restless, and vocal behavior during an academic task, compared with control Ss. The limited set of frontal lobe measures did not differentiate the groups. Age did not interact with group membership. However, several measures showed age-related declines in both groups. It is concluded that hyperactive children may remain chronically impaired in academic achievement, inattention, and behavioral disinhibition well into their late adolescent years.

Cosleeping in a community sample of 2- and 3-year-old children.

A randomly selected community sample of 303 parents of 2- and 3-year-olds were interviewed about child sleep behaviors and completed the Child Behavior Checklist for Ages 2-3, a standardized rating scale for child problem behaviors. Most parents (55%) reported that the child slept in their bed at least occasionally and for at least part of the night, particularly during periods of minor stress or disruption of the family routine. The prevalence of cosleeping did not vary by the child's age or sex, but frequent cosleeping (more than once per week) was more common among nonwhite families and single-mother households. Cosleeping was not significantly related to child behavior problems, but frequent cosleepers were more likely to report sleep problems, including difficulty getting to sleep and night waking. Children who were still cosleeping frequently 1 year after the initial assessment maintained high levels of sleep problems, compared with those who stopped cosleeping and non-cosleepers. Cosleeping is common at this age and is not related to general maladjustment. However, frequent cosleeping is closely intertwined with child sleep problems.

Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systemic, placebo-controlled evaluation.

The frequency and severity of 17 side effects presumably associated with stimulant medication were assessed during a rigorous, triple-blind, placebo-controlled, crossover evaluation of methylphenidate, 0.3 and 0.5 mg/kg twice a day, in 83 children with attention deficit hyperactivity disorder. Side effects were rated by parents and teachers at the end of each weekly drug condition. Three children (3.6%) had side effects that were sufficiently serious to warrant immediate discontinuation of medication. Parent ratings indicated that only the side effects of decreased appetite, insomnia, stomachaches, and headaches increased significantly in frequency and severity during the two active medication doses as compared with the placebo condition. Fewer than half of the children experienced these side effects and among those who did, ratings of mean severity remained in the mild range. Teacher ratings showed little change over drug conditions, except on ratings of staring, sadness, and anxiety, which declined with increasing dose of medication. Parent ratings indicated that only the side effects of decreased appetite, insomnia, stomachaches, and headaches increased significantly in frequency and severity during the two active medication doses as compared with the placebo condition. Fewer than half of the children experienced these side effects and among those who did, ratings of mean severity remained in the mild range. Teacher ratings showed little change over drug conditions, except on ratings of staring, sadness, and anxiety, which declined with increasing dose of medication. Surprisingly, a high frequency of these behavior side effects were reported during the placebo condition. Stimulant medication within this therapeutic range, therefore, results in few, generally mild side effects.(ABSTRACT TRUNCATED AT 250 WORDS)

The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study.

The psychiatric outcome is reported for a large sample of hyperactive children (N = 123), meeting research diagnostic criteria, and normal control children (N = 66) followed prospectively over an 8-year period into adolescence. Over 80% of the hyperactives were attention deficit hyperactivity disorder (ADHD) and 60% had either oppositional defiant disorder and/or conduct disorder at outcome. Rates of antisocial acts were considerably higher among hyperactives than normals, as were cigarette and marijuana use and negative academic outcomes. The presence of conduct disorder accounted for much though not all of these outcomes. Family status of hyperactives was much less stable over time than in the normal subjects. The use of research criteria for diagnosing children as hyperactive identifies a pattern of behavioral symptoms that is highly stable over time and associated with considerably greater risk for family disturbance and negative academic and social outcomes in adolescence than has been previously reported.

The pediatrician as gatekeeper to mental health care for children: do parents' concerns open the gate?

Data from a study of children seen for pediatric care in a Health Maintenance Organization are used to examine factors which influence the likelihood that a pediatrician will identify a psychiatric problem and refer an identified child to a mental health specialist for further evaluation and treatment. Parental level of distress, family psychiatric history, and discussion of parental concerns with the pediatrician were found to be important. Characteristics of the service delivery system which may impede appropriate identification and referral are discussed. Implications for participation of child and adolescent psychiatrists in the training of pediatricians are presented.

The response of aggressive and nonaggressive ADHD children to two doses of methylphenidate.

Differences between 37 aggressive and 37 nonaggressive children with attention deficit hyperactivity disorder (ADHD) were evaluated as was their response to two doses of methylphenidate (0.3 and 0.5 mg/kg) using a multimethod battery of behavior ratings, laboratory tests, and direct observations. Aggressive ADHD children differed little from nonaggressive ADHD children except that nonaggressives displayed more problems with inattentiveness at school than aggressives while mothers of aggressives reported more symptoms of psychopathology in themselves than mothers of nonaggressives. In their drug responding, aggressives and nonaggressives were quite similar. The few exceptions were on measures of conduct, on which the aggressives were initially rated as more extreme and subsequently showed the greater degree of improvement from medication than nonaggressives. Results replicated those of a previous study and further indicate that aggressive and nonaggressive ADHD children share a common disorder of ADHD but aggressives have more impaired family situations.

Psychiatric disorders in pediatric primary care. Prevalence and risk factors.

Children aged 7 to 11 years visiting their primary care pediatrician for a wide range of reasons were studied to determine the one-year prevalence of DSM-III disorders and the risk factors associated with them. Parents completing the Child Behavior Checklist about their children identified problems that placed 24.7% of 789 children in the clinical range. Detailed psychiatric interviews with 300 parents and children, using the Diagnostic Interview Schedule for Children, yielded a one-year weighted prevalence of one or more DSM-III disorders of 22.0% +/- 3.4%, combining diagnoses based on either the child or the parent interview.

Psychopathology in pediatric primary care: the new hidden morbidity.

In a study of emotional and behavioral problems seen in children attending pediatric primary care clinics in a health maintenance organization, parents of 789 children 7 to 11 years of age completed a behavior screening questionnaire, the Child Behavior Checklist. Of the 195 (24.7%) children identified by the checklist as disturbed, 126 were given a detailed psychiatric assessment using the Diagnostic Interview Schedule for Children, a structured psychiatric interview of known validity and reliability. A randomly selected group of 174 nondisturbed children was also assessed. The pediatricians' judgment about the presence of emotional and behavioral problems, made at the index clinic visit, was compared with diagnoses made from the computer-scored interviews. Pediatricians diagnosed one or more such problems in 5.6% of the children (weighted estimate: 95% confidence limits 3.8% to 7.6%), compared with 11.8% (95% confidence interval 9.3% to 13.5%) based on the interview with the parent. Pediatricians were highly specific, ie, 84% of children assessed as nondisturbed had no psychiatric disorder, but they showed low sensitivity, ie, they only identified 17% of the children with behavioral or emotional problems, giving a "hidden morbidity rate" of 83% (ie, 83% of cases were not identified). The role of primary care pediatricians in the identification, prevention and treatment of what has been called "the new morbidity" is discussed. We suggest that, on the basis of these findings, emotional and behavioral problems in children have to be seen as "the new hidden morbidity."

Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper.

Levels of morbidity in 789 children 7 to 11 years of age attending two primary care pediatric clinics in a health maintenance organization were examined in relation to psychiatric disturbance. Physical morbidity was measured as mean number of illness episodes per year enrolled, based on the child's medical record. Two measures of psychiatric disturbance were compared: the pediatricians' judgment and a detailed assessment using standard psychiatric interviews with parent and child. Children identified by pediatricians as disturbed had more than twice as many physical illness episodes as nonidentified children. Children identified by the standard psychiatric assessment had the same number of physical illness episodes as nondisturbed children. Pediatricians showed high specificity but low sensitivity to mental illness. Their sensitivity in the high user group was double that in the low user group. These results suggest that (1) the association between mental illness and high use may be, in part, the result of the confounding factor of physicians' judgment; (2) in settings where primary care practitioners serve as "gatekeepers" to mental health services, the offset effect of lower medical service use following psychiatric treatment may be partially explained by this; (3) the source of referral must be taken into account when assessing the offset effect in other settings.

Convergence between statistically derived behavior problem syndromes and child psychiatric diagnoses.

The relations between scores on statistically derived behavior problem syndromes and DSM-III diagnoses were examined for 270 clinically referred children aged 6 through 16. Each child's parent completed the Child Behavior Checklist (CBCL) and was administered the NIMH Diagnostic Interview Schedule for Children (DISC)--a structured interview covering DSM-III diagnostic criteria. Numerous behavior problems scales scored from the CBCL were significantly related to one or more diagnoses. The strongest relations were between scores on the Hyperactive, Delinquent, and Depressed scales and diagnoses of Attention Deficit Disorder, Conduct Disorder, and Depression/Dysthymia, respectively. This convergence supports the validity of some syndromal constructs common to both assessment paradigms.

Empirically based assessment of the behavioral/emotional problems of 2- and 3- year-old children.

The aim was to determine whether ratings of 2- and 3-year-olds could yield more differentiation among their behavioral/emotional problems than the internalizing-externalizing dichotomy found in previous studies. The 99-item Child Behavior Checklist for Ages 2-3 (CBCL/2-3) was designed to extend previously developed empirically based assessment procedures to 2-and 3-year-olds. Factor analyses of the CBCL/2-3 completed by parents of 398 2- and 3-year-olds yielded six syndromes having at least eight items loading greater than or equal to .30 and designated as Social Withdrawal, Depressed, Sleep Problems, Somatic Problems, Aggressive, and Destructive. Second-order analyses showed that the first two were related to a broad-band internalizing grouping, whereas the last two were related to a broad-band externalizing grouping. Scales for the six syndromes, two broad-band groupings, and total problem score were constructed from scores obtained by 273 children in a general population sample. Mean test-retest reliability r was .87, 1-year stability r was .69, 1-year predictive r with CBCL/4-16 scales at age 4 was .63, 2-year predictive r was .55, and 3-year predictive r was .49. Children referred for mental health services scored significantly higher than nonreferred children on all scales. A lack of significant r's with the Minnesota Child Development Inventory, Bayley, and McCarthy indicate that the CBCL/2-3 taps behavioral/emotional problems independently of the developmental variance tapped by these measures.