Psychiatric disorder in children with speech and language retardation. A critical review.

This article critically reviews the literature concerning psychiatric disorder in children with speech and language retardation. The data indicate that speech- and language-disordered children are at risk for psychiatric disorder, that there is some correlation between the presence of psychiatric disorder and the type of speech and language disturbance, and that there is a likely correlation between certain types of speech and language problems and the type of psychiatric difficulty. Firm conclusions in this area are hampered by many methodological difficulties. Finally, a review of the nature of the association between psychiatric disorder and speech and language retardation reveals that except in rare instances psychiatric disorder does not cause speech and language retardation, and that in most cases psychiatric disorder is indirectly caused by speech and language retardation.

Characteristics of children admitted to inpatient community mental health center.

Comparison of 100 children, aged 7 to 12 years, admitted to an inpatient service of a community mental health center (CMHC) with a matched control group of 100 children from the outpatient department of the same CMHC showed that a combination of several factors (rather than a single factor) led to inpatient admission. These factors included differences in Initial symptoms, diagnosis in DSM-III, axes I, II, and III, and family factors.

Psychiatric disorders in children with speech and langauge retardation. Factors associated with development.

One hundred children (mean age, 5 to 6 years) who were seen consecutively at a suburban speech and hearing clinic were systematically evaluated for speech and language disorders and psychiatric disorders. Fifty-three were found to have a psychiatric illness. The three groups were compared with the psychiatrically well group to ascertain factors associated with the presence of a psychiatric disorder. Significantly differentiating the ill group were more academic and classroom behavior problems and the presence of both speech and language problems. The two groups were not significantly different in intellectual retardation, hearing impairment, medical factors, nonlanguage development disorders, and a variety of family and demographic factors. Common in both groups were psychiatric illness in parents and first-degree relatives. The data indicate that children with speech and langauge disorders are highly at risk for the development of significant psychiatric problems, which suggests the need for proper screening and multimodal treatment planning.

Families of autistic and dysphasic children. I. Family life and interaction patterns.

Patterns of parent-child interaction and family functioning were systematically examined in well-matched groups of 15 autistic and 14 dysphasic children. The measures used included the Douglas 24-hour standard day analysis, the Brown and Rutter interview measure of positive interaction, the Ittleson scales (based on a four- to six-hour period of home observation, specially developed time-sampled measures of observed mother-child interaction at home), and the Eysenck Personality Inventory. The findings from all measures agreed in showing that family life and interaction patterns were closely similar in the two groups. The results were compared with those of previous investigations; we concluded that autism is most unlikely to be due to abnormal psychogenic influences in the family.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. I. Agreement with expected diagnosis.

This study was conducted to compare DSM-II and DSM-III in the diagnosis of childhood and adolescent psychiatric disorders. Twenty psychiatrist-raters completed standardized diagnostic questionnaires for 24 actual case histories. This report, the first of four, presents the rater agreement with the "expected diagnosis," ie, the diagnosis that we considered most appropriate for each case. The average rater agreement with the expected diagnosis was less than 50%. It was highest in cases of mental retardation, psychosis, hyperactivity, and conduct disorder. In only five cases did the most common diagnosis of the raters differ from the expected diagnosis. Analyses of these cases and those we selected to present specific diagnostic problems to the raters have produced suggestions to improve the reliability of DSM-III.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. II. Interrater agreement.

A case-history format was utilized to compare interrater agreement on childhood and adolescent psychiatric disorders, using DSM-II and DSM-III. The average interrater agreement was 57% for DSM-II and 54% for axis I (clinical psychiatric syndrome) of DSM-III. There was high agreement in both systems on cases of psychosis, conduct disorder, hyperactivity, and mental retardation, with DSM-III appearing slightly better. There was noteworthy interrater disagreement in both systems for "anxiety" disorders, complex cases, and in the subtyping of depression. Overall, the reliability of DSM-III appears to be good and is comparable with that of DSM-II and other classification systems of childhood psychiatric disorders.

A comparison of DSM-II and DSM-III in the diagnosis of childhood psychiatric disorders. III. Multiaxial features.

A major feature of DSM-III is its multiaxial format. One purpose of this study was to examine the purported advantages of a multiaxial system as compared to those of a multicategory system, eg., DSM-II. We found that the multiaxial system led to a more complete and reliable diagnosis of complex clinical cases. Concomitant medical disorder and psychosocial stressors were coded with high levels of interrater agreement. We conclude that the multiaxial framework is a major strength of DSM-III.

Multimodality treatment. A one-year follow-up of 84 hyperactive boys.

This study reports findings at the end of the first year of a three-year prospective study of 84 hyperactive boys. A multidimensional approach to evaluation and an individualized multimodality treatment plan commensurate with each child's disabilities was used. Treatment plans were implemented by members of the research staff working together as a coordinated therapeutic team. Measures of the child's behavior at home and at school, academic performance, delinquent behavior, and emotional adjustment were obtained initially and at one year. Results suggest that the combination of a clinically useful medication with appropriate psychological treatments simultaneously directed to each of the child's many disabilities is associated with an unexpectedly good outcome. Whether this will continue to be true when these children are followed up over a longer period of time awaits further investigation.

Multimodality treatment. A two-year evaluation of 61 hyperactive boys.

This study reports findings at the end of the second year of a three-year prospective study of 61 hyperactive boys. Individualized multimodality treatment plans commensurate with each child's disabilities were implemented by the research staff. Measures of the child's behavior at home and at school, academic performance, delinquent behavior, and emotional adjustment were obtained initially and at the end of each treatment year. The combination of a clinically useful medication in appropriate dosage schedules with relevant psychological treatments simultaneously directed to each of the child's many disabilities were associated with an unexpectedly good outcome at the end of one and two years. Whether this improvement will be maintained over a longer period of time and whether young adult outcome will be affected await further investigation.

Growth of hyperactive children treated with methylphenidate.

This is a study of the growth of 72 hyperactive boys treated continuously with methylphenidate hydrochloride. Major findings were that methylphenidate produces an adverse effect on growth in height and in weight in the first year of treatment, but not in the second year; the first year height deficit is offset in the second year by a greater-than-expected growth rate. No clinical predictors of growth deficits were found; growth in height deficits are not related to total dosage or summer drug holidays, but weight deficits may be related to these factors. Side effects did not correlate with dosage. The temporary growth deficits of the first year are of such minor magnitude as to have little clinical significance.

Anorexia nervosa. An affective disorder?

Follow-up data on 26 patients hospitalized during adolescence for anorexia nervosa are presented. The mean length of follow-up was 4.9 years. There were no mortalities. Only one patient at the time of follow-up was still possibly anorexic. However, a substantial number of the patients did have other eating difficulties. Most striking was the clinical psychopathology present at follow-up, particularly the incidence of affective disorder. A large number of patients manifested depressive symptomatology in both the premorbid and the postmorbid states, as well as at the time of follow-up. A family history of affective disorder was particularly common in the mothers of the anorexic patients. Data from this study are consistent with the hypothesis that there is a strong relationship between anorexia nervosa and affective disorder.

National Institute of Mental Health Collaborative Multimodal Treatment Study of Children with ADHD (the MTA). Design challenges and choices.

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.

Whole blood serotonin in juvenile obsessive-compulsive disorder.

Whole blood serotonin (5-HT) concentration was assessed in 16 children and adolescents with severe obsessive-compulsive disorder (OCD) and in 14 normal adolescent controls. There was no difference in blood 5-HT content between the OCD patients and the normal controls. However, the OCD patients with a family history of OCD had significantly higher blood 5-HT levels than did either the OCD patients without a family history of OCD or the normal controls. Blood 5-HT content was not associated with a history of major depressive disorder or chronic tic disorder. These preliminary results suggest that studies of serotonergic functioning in OCD may need to control for family history of OCD and that blood 5-HT may be a useful biochemical measure in family-genetic studies of OCD.

Siblings as therapists: a behavioral approach.

Although many family therapy programs have taught behavior modification techniques to parents, few have involved siblings as therapeutic agents in the treatment of retarded, emotionally disturbed, or physically handicapped children. The authors describe their experiences with two families in which siblings were taught to use simple procedures to encourage desired behaviors in a disturbed brother or sister. They conclude that further investigation is needed to refine sibling training techniques and suggest that involvement in treatment programs may have beneficial influences on the normal siblings of disturbed children.

Unmasking masked depression in children and adolescents.

The authors examined depressive symptoms and behavior disorders in 102 systematically interviewed children aged 7 to 17 years to elucidate the category of masked depression. They found that it was possible to diagnose these children using adult research criteria and that more children with depression were identified using a systematic interview than were identified using standard evaluation procedures. Although children with a depressive disorder may also exhibit behavior disorders that overshadow the depression, an alert clinician conducting a thorough interview should be able to identify the "masked" depression.

ADHD through the life span: the role of bupropion in treatment.

Attention-deficit/hyperactivity disorder (ADHD) is a common problem that begins early in life and in many cases persists through the life span. Psychostimulants have been the psychopharmacologic treatment of choice. Not all patients respond to psychostimulants, and some patients have significant side effects. This paper reviews the use of a nonstimulant psychopharmacologic agent, bupropion, to treat ADHD in both children and adults.

Parental mental illness and psychiatric disorders in "at risk" children.

Data are reported from psychiatric evaluations of a large group of communication disordered children and their parents who presented to a community speech clinic. Systematic psychiatric evaluations involving the use of standardized interviews, questionnaires, and DSM-III diagnostic criteria reveal that approximately 50% of the children have definable DSM-III psychiatric disorders and approximately the same percentage of children have at least one psychiatrically ill parent. Comparisons of children with psychiatrically ill parents and children with psychiatrically well parents show that parental psychiatric disorder is associated with increased psychopathology in the children. However, other factors, particularly psychosocial stress, are more strongly correlated with the presence of childhood psychopathology. There are few correlations between the types of parental psychiatric disorders and the types of childhood disorders.

DSM-III in the clinical practice of child psychiatry.

The clinical usefulness of DSM-III was assessed by examining its inclusiveness, its correspondence to DSM-II, and difficulties encountered in its use in evaluations of 108 children. DSM-III covered adequately a wide range of diagnostic entities, showed relatively good correspondence to DSM-II with some exceptions, and presented relatively few major difficulties in a child psychiatry clinic setting. DSM-III seems likely to be accepted and used by a majority of practicing child psychiatrists.

Anxiety and depressive disorders in psychiatrically disturbed children.

Of 102 systematically interviewed children, age 7 to 17 years, 28 met DSM-III criteria for depressive disorders and 14 for anxiety disorders. Because the adult psychiatric literature suggests overlapping symptomatology between these disorders, depressive and anxiety symptoms were compared in these groups of children. Depressed children, like depressed adults, reported many anxiety symptoms. However, anxious children, unlike their adult counterparts, never reported panic attacks and complained much less often of depressive symptoms. In contrast to adults with anxiety disorders, no child met criteria for a secondary depression. Longitudinal studies and validation measures for diagnoses of anxiety and depressive disorders are necessary for more definitive conclusions. This study suggests that there are more similarities between childhood and adult depressive disorders than anxiety disorders.

Attention deficit disorder: a review of the past 10 years.

OBJECTIVE: To summarize knowledge about attention deficit disorder in the areas of epidemiology, etiology, clinical predictors, assessments, natural history and outcome, and management. METHOD: A literature review of articles, books, and chapters primarily published in the past 10 years was completed. Articles presenting new information, most relevant to clinical practice, were reviewed. RESULTS: Key findings in the areas listed above are presented. CONCLUSIONS: Major advances have been made in all areas. The clinical picture has been refined and developmental manifestations have been delineated. Patterns of comorbidity have been detailed. Various etiological factors, particularly in the biological area, have been investigated. Multimodal management has been promulgated as the treatment of choice.