Antisocial behaviour and mental health. Findings from three communities.

AIM: To investigate the relationship between antisocial behaviour and psychopathology (depression, somatization, anxiety), expectations for the future, and sensation seeking in adolescents. METHOD: A cross-national self-report study assessing 955 students in Antwerp (Belgium), 1026 in Arkhangelsk (Russia) and 1391 in New Haven (US) was conducted. Adolescents were assigned antisocial group status according to the nature of their reported deviant behaviour. A non-antisocial group, a moderate antisocial group (non-aggressive behaviour) and a severe antisocial group (mainly aggressive behaviour) were identified. RESULTS: In both genders and in all three countries, depression, somatization, negative expectations for the future and sensation seeking gradually increased from the non-antisocial group to the moderate antisocial group, and finally to the severe antisocial group. Levels of anxiety were insignificant across most groups. CONCLUSION: Although cross-national differences exist, the variables of interest showed markedly similar trends between antisocial groups across countries. The current study adds to the debate over the relationship between anxiety and antisocial behaviour.

Cultural considerations in the treatment of children and adolescents. Operationalizing the importance of culture in treatment.

Culture is complex and fluid, constantly changing with the tides of internal and external influence. It is vital for the transcultural therapist to understand the roles, context, and therapeutic consequences that follow from culture. The constructs mentioned previously are interdependent and often inseparable from one another. The interwoven web of political, social, and cultural constructs must be considered to understand the context of mental illness. This being said, therapists should not be content with the broad brush of cultural definition. Subcultural and intracultural dynamics also may play a role in a patient's world view, and the therapist must remain open to these variations. Likewise, one should be careful of stereotype. Culture plays a vital role in shaping physical and psychological conceptions but in and of itself cannot define an individual.

Psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation.

OBJECTIVE: To identify the independent psychosocial and risk behavior correlates of suicidal ideation and attempts. METHOD: The relationships between suicidal ideation or attempts and family environment, subject characteristics, and various risk behaviors were examined among 1,285 randomly selected children and adolescents, aged 9 through 17 years, of whom 42 (3.3%) had attempted suicide and 67 (5.2%) had expressed suicidal ideation only. The youths and their parents were enumerated and interviewed between December 1991 and July 1992 as part of the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. RESULTS: Compared with subjects with suicidal ideation only, attempters were significantly more likely to have experienced stressful life events, to have become sexually active, to have smoked more than one cigarette daily, and to have a history of ever having smoked marijuana. After adjusting for sociodemographic characteristics, a statistically significant association was found between suicidal ideation or attempt and stressful life events, poor family environment, parental psychiatric history, low parental monitoring, low instrumental and social competence, sexual activity, marijuana use, recent drunkenness, current smoking, and physical fighting. Even after further adjusting for the presence of a mood, anxiety, or disruptive disorder, a significant association persisted between suicidal ideation or attempts and poor family environment, low parental monitoring, low youth instrumental competence, sexual activity, recent drunkenness, current smoking, and physical fighting. CONCLUSION: Low parental monitoring and risk behaviors (such as smoking, physical fighting, alcohol intoxication, and sexual activity) are independently associated with increased risk of suicidal ideation and attempts, even after adjusting for the presence of psychiatric disorder and sociodemographic variables.

Age and gender differences in oppositional behavior and conduct problems: a cross-sectional household study of middle childhood and adolescence.

Behavior problems among youths cannot be understood without explaining their age and gender differences, but age and gender differences cannot be explained until they have been accurately described. In a household survey of 1,285 youths aged 9 to 17 years, there were no gender differences in oppositional behavior, but aggression, property offenses, and status offenses were more common among boys. Levels of oppositional behavior were greater at younger ages, aggression peaked near the middle of this age range, and property and status offenses were more prevalent at older ages. These findings are generally consistent with developmental models of conduct problems but are inconsistent with a recent model of gender differences and raise questions about the external validity of current taxonomies.

Epidemiology of ADHD in school-age children.

Attention-Deficit/Hyperactivity Disorder is a relatively common condition of childhood onset and is of significant public health concern. Over the past two decades there have been 19 community-based studies offering estimates of prevalence ranging from 2% to 17%. The dramatic differences in these estimates are due to the choice of informant, methods of sampling and data collection, and the diagnostic definition. This article provides a critical review of the community-based studies on the prevalence of ADHD in children and adolescents. Based on the 19 studies reviewed, the best estimate of prevalence is 5% to 10% in school-aged children. The review also examines age and gender effects on the frequency of ADHD. The article closes with a discussion of psychosocial correlates and patterns of comorbidity in ADHD.

Mental health in pediatric settings: distribution of disorders and factors related to service use.

OBJECTIVES: To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services. METHOD: The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services. RESULTS: The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events. CONCLUSIONS: The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.

Risk behavior in a community sample of children and adolescents.

OBJECTIVES: First, to investigate whether there is covariation between risk behaviors, including suicidality, in a community probability sample of children and adolescents; and second, to investigate whether risk behavior is associated with selected potential correlates. METHOD: A sample of 9- to 17-year-old youths (N = 1,285) and their caretakers were interviewed in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The risk behaviors were marijuana smoking, alcohol use, intercourse, fighting, cigarette smoking, and suicidal ideation/attempts. Relationships between the risk behaviors were described using odds ratios. Linear regression analyses of an index of risk behavior on the selected potential correlates of risk behavior were conducted. RESULTS: There were significant relationships between all pairs of risk behaviors. The score on the index of risk behavior was associated with stressors, lack of resources, family psychiatric disorder, psychopathology, and functional impairment. CONCLUSIONS: Clinicians should be alerted to the possibility of risk behaviors, especially in children and adolescents engaging in other risk behaviors and those with inadequate resources, stressors, functional impairment, or psychopathology.

Major depression and dysthymia in children and adolescents: discriminant validity and differential consequences in a community sample.

OBJECTIVES: To evaluate evidence, in a community sample, for discriminant validity between major depression (MDD) and dysthymia (Dy) in children and adolescents and to examine differential consequences of the 2 disorders for functioning. METHOD: The National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study consists of probability samples of youths. Data for this study are derived from interviews with 1,285 complete parent-youth pairs aged 9 to 17 years from 4 geographic areas in the United States. Youths with MDD were contrasted with those with Dy and those with both (MDD-Dy) on the NIMH Diagnostic Interview Schedule for Children, Non-Clinician Children's Global Assessment Scale, Columbia Impairment Scale, and the Service Utilization and Risk Factors Module. RESULTS: Groups with MDD, Dy, or MDD-Dy did not differ on sociodemographic, clinical, or family and life event variables. Youths with combined MDD-Dy were significantly less competent and more impaired than youths with either disorder alone. CONCLUSIONS: The findings do not provide support for the differentiation of MDD and Dy but strongly suggest the importance of addressing the needs of youths who meet criteria for both MDD and Dy because this combination is likely to be both serious and disruptive of normal developmental processes.

NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses.

OBJECTIVE: To describe the National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV) and how it differs from earlier versions of the interview. The NIMH DISC-IV is a highly structured diagnostic interview, designed to assess more than 30 psychiatric disorders occurring in children and adolescents, and can be administered by "lay" interviewers after a minimal training period. The interview is available in both English and Spanish versions. METHOD: An editorial board was established in 1992 to guide DISC development and ensure that a standard version of the instrument is maintained. Preliminary reliability and acceptability results of the NIMH DISC-IV in a clinical sample of 84 parents and 82 children (aged 9-17 years) drawn from outpatient child and adolescent psychiatric clinics at 3 sites are presented. Results of the previous version in a community sample are reviewed. RESULTS: Despite its greater length and complexity, the NIMH DISC-IV compares favorably with earlier versions. Alternative versions of the interview are in development (the Present State DISC, the Teacher DISC, the Quick DISC, the Voice DISC). CONCLUSIONS: The NIMH DISC is an acceptable, inexpensive, and convenient instrument for ascertaining a comprehensive range of child and adolescent diagnoses.

Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?

OBJECTIVE: To examine the unique cases contributed by parent and child informants to diagnostic classification, with the goal of identifying those diagnoses for which either or both informants are needed. METHOD: The authors examined survey data from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a 4-community epidemiology survey of 9- to 17-year-old children and their parents. Parent-child dyads (1,285 pairs) were independently interviewed by lay persons with the Diagnostic Interview Schedule for Children; a subset of these pairs (n = 247) were also interviewed by clinicians. Agreement between parents and children was examined with respect to levels of impairment, need for/use of services, and clinicians' diagnoses. RESULTS: Parents and children rarely agreed on the presence of diagnostic conditions, regardless of diagnostic type. Nonetheless, most child-only- and parent-only-identified diagnoses were similarly related to impairment and clinical validation, with 2 exceptions: child-only-identified attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). CONCLUSIONS: Overall findings suggest that most "discrepant" diagnoses (those reported by one but not the other informant) reflect meaningful clinical conditions. In some instances, however, diagnoses reported by one but not the other informant should be treated with caution, as they may not reflect the full diagnostic condition (e.g., possibly child-only-identified ADHD or ODD). Further research is needed to determine the salience of child-only- or parent-only-reported cases.

Psychosocial and clinical correlates of ADHD in a community sample of school-age children.

OBJECTIVE: To identify the psychosocial and clinical correlates of attention-deficit hyperactivity disorder (ADHD) in a community sample of children and to examine the validity of a subclinical form of ADHD. METHOD: The sample of 449 children (mean age 9.2 years, SD 1.78; 53.6% boys) participated in the second stage of a community survey. Of these, 359 (80%) screened positive at stage 1. On the basis of a structured diagnostic interview with a parent, children were classified into 1 of 3 mutually exclusive groups: ADHD (n = 89), subthreshold ADHD (n = 100), and non-ADHD (n = 260). RESULTS: As measured by the Children's Global Assessment Scale, the ADHD group was more impaired than the subthreshold group, which was more impaired than the non-ADHD group (p < .05 for each test). Children in the ADHD group were more likely to be male, to have mothers with a history of psychiatric treatment, to have fathers with a history of excessive alcohol use, and to live in low-income families with higher levels of family dysfunction (p < .05 for all variables). A model containing male gender, family dysfunction, and low income was most predictive of ADHD status (p < .01). ADHD was also associated with psychiatric comorbidity, especially disruptive behavior disorders. CONCLUSIONS: These results support a dimensional approach to ADHD. More severe forms of ADHD are associated with psychosocial adversity and psychiatric comorbidity.

Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study.

OBJECTIVE: To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders. METHOD: Diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. RESULTS: The rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults. CONCLUSIONS: The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.

No safe haven. II: The effects of violence exposure on urban youth.

OBJECTIVES: To examine the moderating effects of gender, grade level, and ethnicity on the associations between violence exposure and adolescents' internalizing symptoms and externalizing behavior and to explore whether such relationships persist over time. METHOD: A survey of adolescents' exposure to violence, internalizing symptoms, and externalizing behavior was administered to 2 cross-sectional samples of 6th, 8th, and 10th graders (N = 2,748 in 1994 and 2,600 in 1996) in an urban school system. Approximately 1,100 adolescents participated in both surveys and served as the longitudinal sample. RESULTS: Structural equation models indicated that violence exposure was closely associated with both externalizing behavior (r = 0.74-0.79) and internalizing symptoms (r = 0.36-0.38). The strength of association was similar across gender and ethnic groups. However, violence exposure was more closely related with internalizing symptoms for younger adolescents than their older counterparts. The longitudinal analysis suggested that exposure to violence reported at time 1 was related to adolescents' internalizing symptoms and externalizing behavior 2 years later. CONCLUSIONS: These results document high levels of violence exposure for urban youths and indicate links to a range of psychiatric symptoms and indicators of poor adjustment. Such findings carry implications for direct clinical work with young people, as well as for program development and public policy.

Informant-based determinants of symptom attenuation in structured child psychiatric interviews.

Informant-related determinants of item attenuation, that is, the drop-off in symptom endorsement rates at retest, were examined in an enriched community subsample of 245 parent-child pairs drawn from the National Institute of Mental Health Methods for Epidemiology of Child and Adolescent Mental Disorders Study. Youngsters and their parents were interviewed with the Diagnostic Interview Schedule for Children (Version 2.3; DISC-2.3) on two occasions with a mean test-retest interval of 12 days. Item attenuation rates were high for both informants, with adults failing to confirm 42% and children 58% of baseline responses at retest. Stepwise regressions revealed that item attenuation at DISC-P retest was higher for adult informants who were younger, and who reported on older and less impaired children. On the DISC-C, attenuation was higher for children who were less impaired, rated as doing worse in school, and who had a longer test-retest interval. These results are broadly consistent with past studies examining the determinants of attenuation and test-retest reliability and have implications for the design and use of structured diagnostic instruments.

Features of interviews questions associated with attenuation of symptom reports.

Previous studies have suggested that discrepant reporting in a test-retest reliability paradigm is not purely random measurement error, but partly a function of a systematic tendency to say "no" during retest to questions answered positively at initial testing ("attenuation"). To examine features of interview questions that may be associated with attenuation, three raters independently assessed the structural and content features of questions from the Diagnostic Interview Schedule for Children (version 2.3) and linked these to data from a test-retest reliability study of 223 community respondents (parent and child reports). Results indicated that for both parent and youth reports, item features most strongly associated with attenuation were (a) being a "stem" question (asked of all respondents, regardless of any skip structure); (b) question placement in the first half of the interview; (c) question length; (d) question complexity; or (e) requiring assessment of the timing, duration, or frequency of a symptom. Findings may be explained by participants' conscious efforts to avoid further questions or by their learning more about the nature and purpose of the interview as they gain more experience; alternatively, findings may represent a methodological artifact of structured interview design.

Psychopathology associated with suicidal ideation and attempts among children and adolescents.

OBJECTIVE: To identify the independent and differential diagnostic and symptom correlates of suicidal ideation and suicide attempts and determine whether there are gender- and age-specific diagnostic profiles. METHOD: The relationships between suicidal ideation, suicide attempts, and psychiatric disorders were examined among 1,285 randomly selected children and adolescents, aged 9 to 17 years, of whom 42 had attempted suicide and 67 had expressed suicidal ideation only. Youths and their parents were interviewed as part of the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using the Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3). RESULTS: Logistic regression analyses indicated that mood, anxiety, and substance abuse/dependence disorders independently increased the risk of suicide attempts, after controlling for sociodemographic characteristics. There was no significant independent contribution of disruptive disorders to suicide attempts, although its association with suicidal ideation was significant. Substance abuse/dependence independently differentiated suicide attempters from ideators. Noncriterion symptoms that remained significant predictors of suicide risk, after adjusting for psychiatric disorder, included panic attacks and aggressiveness. Perfectionism did not significantly increase suicide risk after adjusting for psychiatric disorder. The association of specific disorders and noncriterion symptoms with suicidality varied as a function of gender and age. CONCLUSION: A monolithic diagnostic risk profile for suicidality, ignoring gender- and age-specific risks, is inadequate. The contribution of substance abuse/dependence in the escalation from suicidal thoughts to suicide attempts is underscored.

Psychiatric disorders associated with substance use among children and adolescents: findings from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

The relationships between specific quantities and frequencies of alcohol, cigarette, and illicit substance use and substance use (SUD) and other psychiatric disorders were investigated among 1,285 randomly selected children and adolescents, aged 9 to 18, and their parents, from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Logistic regressions indicated that daily cigarette smoking, weekly alcohol consumption, and any illicit substance use in the past year were each independently associated with an elevated likelihood of diagnosis with SUD and other psychiatric disorders (anxiety, mood, or disruptive behavior disorders), controlling for sociodemographic characteristics (age, gender, ethnicity, family income). The associations between the use of specific substances and specific psychiatric disorders varied as a function of gender.

Discrepancies among mother, child, and teacher reports: examining the contributions of maternal depression and anxiety.

The relationship between maternal affective symptomatology and discrepancies in maternal reports of child symptoms, relative to teacher and child reports, was evaluated in a community sample of 188 children ages 9-12 years. Mothers, teachers, and children were administered a structured interview about child psychopathology. In general, mothers reported more child behavior problems than children and teachers regardless of maternal symptomatology. However, maternal affective symptoms were associated with discrepancies between mothers' and daughters' reports and between mothers' and teachers' reports of girls' externalizing symptoms. Furthermore, mothers who reported high levels of both anxiety and depressive symptomatology tended to report a large number of symptoms that were not confirmed by either their daughters or teachers. Findings are discussed as possible evidence of the role of maternal affective symptomatology in both actual increases in child symptomatology and maternal reporting distortions. Although maternal depressive and anxiety symptoms shared variance in reporting discrepancies, only anxiety explained unique variance. Consistent with previous studies, cross-informant agreement was modest to moderate (r = .16 to .50) and all informants reported more behavior problems in boys than in girls.