Substance use among HIV-infected adolescents in Uganda: rates and association with potential risks and outcome factors.

This article sets out to investigate alcohol and substance use (ASU) among adolescents living with HIV (ALWH) in the sub-Saharan African setting of Uganda. A cross-sectional analysis of the records of 479 adolescents (aged between 12and 17 years) attending the study, "Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)" was undertaken. ASU was assessed through both youth self-report and caregiver report using the Diagnostic and Statistical Manual of Mental Disorders-5 referenced instruments, the Youth Inventory-4R and the Child and Adolescent Symptom Inventory-5 (CASI-5). Rates and association with potential risk and outcome factors were investigated using logistic regression models. The rate of ASU was 29/484 (5.9%) with the most frequently reported ASU being alcohol 22/484 (4.3%) and marijuana 10/484 (2.1%). Functional impairment secondary to ASU was reported by 10/484 (2.1%) of the youth. ASU was significantly associated with urban residence, caregiver psychological distress and the psychiatric diagnosis of post-traumatic stress disorder. On associations with negative outcomes, ASU was significantly associated with only "ever had sex". Health care for ALWH in sub-Saharan Africa should include ASU prevention and management strategies.

Efficacy of methylphenidate for attention-deficit hyperactivity disorder in children with tic disorder.

BACKGROUND: The findings from case reports and patient questionnaire surveys have been interpreted as indicating that administration of stimulants is ill-advised for the treatment of attention-deficit hyperactivity disorder in children with tic disorder. METHODS: Thirty-four prepubertal children with attention-deficit hyperactivity disorder and tic disorder received placebo and three dosages of methylphenidate hydrochloride (0.1, 0.3, and 0.5 mg/kg) twice daily for 2 weeks each, under double-blind conditions. Treatment effects were assessed using direct observations of child behavior in a simulated (clinic-based) classroom and using rating scales completed by the parents, teachers, and physician. RESULTS: Methylphenidate effectively suppressed hyperactive, disruptive, and aggressive behavior. There was no evidence that methylphenidate altered the severity of tic disorder, but it may have a weak effect on the frequency of motor (increase) and vocal (decrease) tics. CONCLUSION: Methylphenidate appears to be a safe and effective treatment for attention-deficit hyperactivity disorder in the majority of children with comorbid tic disorder.

Long-term methylphenidate therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder.

BACKGROUND: This study examined changes in attention-deficit hyperactivity (ADHD) behaviors and motor and vocal tics during long-term treatment with methylphenidate. METHODS: Thirty-four prepubertal children with ADHD and chronic multiple tic disorder (who had participated in an 8-week, double-blind, placebo-controlled methylphenidate evaluation) were evaluated at 6-month intervals for 2 years as part of a prospective, nonblind, follow-up study. Treatment effects were assessed using direct observations of child behavior in a simulated (clinic-based) classroom and behavior rating scales completed by parents and physician. Videotapes of the simulated classroom were scored by coders who were blind to treatment status. RESULTS: There was no evidence (group data) that motor tics or vocal tics changed in frequency or severity during maintenance therapy compared with diagnostic or initial double-blind placebo evaluations. Behavioral improvements demonstrated during the acute drug trial were maintained during follow-up. There was no evidence (group data) of clinically significant adverse drug effects on cardiovascular function or growth at the end of 2 years of treatment. CONCLUSIONS: Long-term treatment with methylphenidate seems to be safe and effective for the management of ADHD behaviors in many (but not necessarily all) children with mild to moderate tic disorder. Nevertheless, careful clinical monitoring is mandatory to rule out the possibility of drug-induced tic exacerbation in individual patients.

Field experiments of television violence with children: evidence for an environmental hazard?

The findings from 20 field experiments were examined to determine the short-term effects of viewing aggression-laden television shows on child social behavior. The available literature provides little support for an effect that is peculiar to aggressive content. In fact, although almost all studies showed elevated levels of antisocial behavior following the viewing of similar material, they also revealed similar, and sometimes greater, effects in response to low or nonaggressive fare. These findings are discussed with regard to their clinical relevance for preventive medicine and implications for imposing "wholesome" television programming on child viewers.

Stimulant medication withdrawal during long-term therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder.

OBJECTIVES: In this study we examined changes in attention-deficit hyperactivity disorder behaviors and motor and vocal tics during withdrawal from long-term maintenance therapy with stimulant medication. METHODS: Subjects were 19 children with attention-deficit hyperactivity disorder and chronic tic disorder who had received methylphenidate (n = 17) or dextroamphetamine (n = 2) for a minimum of 1 year. Children were switched to placebo under double-blind conditions. Treatment effects were assessed by using direct observations of child behavior in a simulated (clinic-based) classroom and behavior rating scales completed by parents and clinician. RESULTS: There was no change (group data) in the frequency or severity of motor tics or vocal tics during the placebo condition compared with maintenance dose of stimulant medication (ie, no evidence of tic exacerbation while receiving medication or of a withdrawal reaction). There was no evidence of tic exacerbation in the evening as a rebound effect. Treatment with the maintenance dose was also associated with behavioral improvement in attention-deficit hyperactivity disorder behaviors, indicating continued efficacy. CONCLUSIONS: Abrupt withdrawal of stimulant medication in children receiving long-term maintenance therapy does not appear to result in worsening of tic frequency or severity. Nevertheless, these findings do not preclude the possibility of drug withdrawal reactions in susceptible individuals.

Effects of methylphenidate on learning a 'beginning reading vocabulary' by normal adults.

The effects of methylphenidate on reading was studied by having nine adults learn a beginning vocabulary of 96 Chinese characters under placebo and 5 mg and 10 mg methylphenidate by two teaching methods which differed in the rate at which new items were introduced for practice. Using lists composed of 12 characters and their English equivalents, all items were presented prior to the start of practice trials (simultaneous method), or each item was introduced only as the subject practiced items previously presented (progressive method). Learning performance was analyzed in terms of total errors and errors made at two criterion stages in list acquisition. Overall performance was significantly facilitated by the low (5 mg) dose or methylphenidate, but only with the simultaneous method. Significant drug effects were also obtained at criterion stages which were associated with high error rates. It was concluded that drug effects are likely to be most pronounced in difficult learning situations and that dosage appears to be an important variable for consideration in further studies.

Children with ADHD and tic disorder and their classmates: behavioral normalization with methylphenidate.

OBJECTIVES: To examine behavioral differences between children with attention-deficit hyperactivity disorder (ADHD) and tics and their peers and the extent to which methylphenidate (0.1, 0.3, and 0.5 mg/kg) normalized the behavior of probands and indirectly influenced the behavior of peers (treatment spillover). METHOD: Thirty-four prepubertal children with ADHD and chronic tic disorder (who were participating in a double-blind, placebo-controlled methylphenidate evaluation) and their peers were observed for approximately 20 hours in the school setting (classroom seatwork activities, lunchroom, and playground). RESULTS: Children with ADHD and tics were more inattentive and more disruptive in the classroom and more aggressive in all school settings than their peers. Although treatment with methylphenidate made probands less easily distinguished from their peers (normalization), many children still scored in the deviant range for at least one ADHD behavior when receiving the 0.5-mg/kg dose. There was little evidence that peer behavior improved as a function of the proband's dose of medication. CONCLUSIONS: Although conventional doses of methylphenidate produced dramatic clinical improvement in ADHD-related behavior, complete behavioral normalization is often not attained.

Methylphenidate in hyperactive boys with comorbid tic disorder: II. Short-term behavioral effects in school settings.

In this study, 11 prepubertal hyperactive boys with tic disorder received placebo and three doses of methylphenidate (0.1, 0.3, and 0.5 mg/kg) for 2 weeks each, under double-blind conditions. Each boy was observed for approximately 20 hours in the school setting (classroom seatwork activities, lunchroom, and playground). Results showed that methylphenidate effectively suppressed hyperactive/disruptive behaviors in the classroom and physical aggression in the lunchroom and on the playground. Methylphenidate also reduced the occurrence of vocal tics in the classroom and the lunchroom. None of the motor tic measures revealed drug effects, but the lowest mean rate of motor tics occurred on the 0.3 mg/kg dose. On an operationally defined minimal effective dose, only one boy experienced motor tic exacerbation.

Teacher reports of DSM-IV ADHD, ODD, and CD symptoms in schoolchildren.

OBJECTIVE: To examine the prevalence of DSM-IV symptoms of attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder and age, gender, and comorbidity differences between ADHD subtypes. METHOD: Teachers completed a DSM-IV-referenced symptom inventory for 3,006 schoolchildren aged between 3 and 18 years. RESULTS: The screening prevalence rate of ADHD behaviors was 15.8%; rates for individual subtypes were 9.9% for inattentive, 2.4% for hyperactive-impulsive, and 3.6% for combined. The inattentive type was relatively uncommon in preschool children (3.9%), whereas the hyperactive-impulsive type was least common in teenagers (0.8%). Screening prevalence rates were higher for African-American (39.5%) than white (14.2%) students, but did not vary significantly (p < .05) as a function of geographic region or socioeconomic status. ADHD subtypes were rated as more impaired than the non-ADHD group on most measures and were easily differentiated on the basis of comorbid symptoms, social skills impairment, and special education services. CONCLUSIONS: The findings of this and similar studies show relatively high convergence for the prevalence of ADHD behaviors and differences between ADHD subtypes.

Methylphenidate treatment of attention-deficit hyperactivity disorder in boys with Tourette's syndrome.

The effects of methylphenidate on four boys diagnosed as attention-deficit hyperactivity disorder (ADHD) and Tourette's syndrome (TS) were examined under single-blind, placebo-controlled conditions. Clinical ratings and playroom observations showed improvement in ADHD symptoms with methylphenidate. Results also indicated that methylphenidate had no untoward effects on the frequency of tic occurrence. In all four children, the highest dose resulted in improved classroom ratings of tics compared with initial placebo treatment. In three cases, mild tic exacerbation was reported for a lower dose. Because variability of tic status was observed in the experimental conditions, the findings suggest the possibility that tic response was independent of clinical doses of methylphenidate. The findings were also consistent with the theory that methylphenidate, a dopamine agonist, might effect tic status by altering dopamine receptor sensitivity. Further investigation of these effects is indicated, given the efficacy of methylphenidate in treating ADHD symptoms of TS patients.

DSM-IVSymptoms in community and clinic preschool children.

OBJECTIVE: To describe and compare ratings of psychiatric symptoms in community and clinic samples (ages 3-6 years) using a DSM-IV-referenced rating scale. METHOD: Parent (/and teacher) ratings were obtained for community (N = 531/398) and special education (N = 64/140) samples (1995-1997) and an outpatient clinic (N = 224/189) sample (1994-1996). RESULTS: Age and socioeconomic status were only minimally (r< 0.20) correlated with ratings of psychopathology. The most commonly endorsed symptom categories were attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorder, conduct disorder (teacher), and pervasive developmental disorder (clinic). Groups were easily differentiated by the rate and severity of symptoms (clinic > special education > community). Males generally received higher scores than females (especially teacher ratings). Children with ADHD symptoms had higher ratings of impairment (developmental deficits) than the non-ADHD group. CONCLUSIONS: Although these findings share a number of similarities with studies of older children, there are also differences that attest to the uniqueness of this age group.

Associated psychopathology in children with both ADHD and chronic tic disorder.

OBJECTIVE: To examine the relation between severity of tic disorder and comorbid psychopathology in 47 prepubertal children with tic disorder who were referred for clinical evaluation of and treatment for attention-deficit hyperactivity disorder (ADHD), oppositional behaviors, and aggressive behaviors. METHOD: Parents and teachers completed the Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF) for each child. RESULTS: Seventy-five percent of the sample was in the clinical range in at least two categories of psychopathology. When the children were divided into two groups on the basis of tic severity, significantly higher scores were obtained for children with more severe tics on the narrow-band Depressed, Uncommunicative, Obsessive-Compulsive, and Aggressive scales, and the broad-band internalizing scale of the CBCL. The severity groups did not differ on TRF scores. Children who were more aggressive also received higher CBCL scores. CONCLUSIONS: The findings from this study suggest that the severity of chronic tics is a clinical indicator of complex psychopathology in children with ADHD who are referred for psychiatric evaluation.

Methylphenidate in aggressive-hyperactive boys: I. Effects on peer aggression in public school settings.

One of the least documented "known" effects of methylphenidate in hyperactive children is the suppression of peer aggression. In this study, 11 aggressive-hyperactive children received a low (0.3 mg/kg) and moderate (0.6 mg/kg) dose of methylphenidate and placebo for 2 weeks each under double-blind conditions. Children were observed in public school settings during classroom seatwork activities, lunch, and recess. Results showed that methylphenidate suppressed nonphysical aggression (p = 0.06) in the classroom, and a moderate dose decreased physical aggression (p less than 0.01) and verbal aggression (p = 0.07) on the playground. The effect on the rate of appropriate social interaction was variable. The majority of subjects exhibited either the same or higher levels of appropriate social interaction on the 0.6 mg/kg dose compared with placebo. In the classroom, both doses of methylphenidate also resulted in reduced levels of motor movement, off-task behavior, noncompliance, and disruptiveness. Teacher ratings of hyperactivity and conduct problem symptoms revealed drug effects, whereas parallel parent instruments did not.

Comparison of attention-deficit/hyperactivity disorder symptom subtypes in Ukrainian schoolchildren.

OBJECTIVE: This study used a parent-completed, DSM-IV-referenced rating scale to examine prevalence rates of attention-deficit/hyperactivity disorder (ADHD) behaviors and differences between subtypes in 10- to 12-year-old Ukrainian children. METHOD: During 1997, a total of 600 parents and children residing in Kyiv, Ukraine, and their teachers participated in extensive clinical assessments using standard Western measures. RESULTS: The screening prevalence rate of ADHD behaviors was 19.8%: 7.2% for inattentive (I), 8.5% for hyperactive-impulsive (HI), and 4.2% for combined (C). Post hoc comparisons indicated a number of significant (p < .05) group differences. Mothers of children with ADHD symptoms reported higher rates of disruptive behavior, negative mother-child interactions, and physical punishment than the non-ADHD group. Teachers rated children with ADHD as more hyperactive and inattentive, but only the HI subtype was rated more oppositional than non-ADHD students. The I subtype was less academically proficient and socially adept (but less likely to have behavior problems). The C subtype was the most behaviorally disruptive (mother ratings), and their fathers were more likely to be aggressive and abuse alcohol. The HI subtype also had problems with disruptive behavior but were less socially impaired. CONCLUSIONS: Although symptom prevalence rates are higher in Ukraine than the United States, this study provides additional evidence supporting DSM-IV ADHD subtypes as distinct clinical entities.

Clinical issues in child and adolescent psychopharmacology.

During the past two decades psychopharmacologists have made considerable strides in establishing the safety and efficacy of psychotropic drug therapy for childhood behavior disorders. Most of the research has focused on children with disruptive behavior disorders, autism, or mental retardation, but more recently other disorders such as depression, obsessive compulsive disorder, separation anxiety (school refusal), and Tourette syndrome are also receiving attention. Psychopharmacotherapy has often been a matter of controversy, with most issues pertaining to either the appropriateness of medication (e.g., rationales for treatment, alternative interventions, toxicity, iatrogenic effects) or inadequacies of clinical management (e.g., availability of services, drug assessment procedures, limitations of research). This article presents a brief overview of the safety and efficacy of psychotropic drugs and the issues associated with their use in clinical settings.

An overview of three decades of research in pediatric psychopharmacoepidemiology.

Although psychotropic drugs are prescribed relatively often for childhood psychiatric and seizure disorders, relatively little is known about their use in everyday clinical settings--with the exception of children with ADHD and individuals with mental retardation. A legion of methodological and logistical obstacles are encountered when trying to gather information about pharmacotherapy for children, and this has often limited data collection to institutional settings or highly restricted geographic areas. Although initial efforts to study the extent of drug therapy focused primarily on the number of individuals receiving treatment and secondarily on drug dose, the breadth of topics quickly expanded to include numerous issues pertaining to the way psychotherapeutic agents are prescribed, evaluated, and monitored in typical clinical situations. This article presents an overview of treatment prevalence studies conducted during the past three decades and reviews a variety of clinical concerns raised by researchers in pediatric psychopharmacoepidemiology. The most salient findings from these studies are: (a) medication use continues to increase, (b) treatment prevalence rates in residential programs continue to be very high (40%-60%), and (c) many researchers continue to be concerned about the quality of treatment practices. The methodologies of this field show considerable promise for addressing pressing issues in health care for children and adolescents with emotional or behavioral disorders.

Double-blind versus open evaluations of stimulant drug response in children with attention-deficit hyperactivity disorder.

Although placebo controls and double-blind conditions are considered to be essential for the unbiased scientific assessment of drug effects, there is very little research on these procedures in the pediatric psychopharmacology literature. To examine the impact of controlled assessment procedures on the magnitude of observed drug effects, two groups of children with attention-deficit hyperactivity disorder (ADHD) were evaluated for response to methylphenidate under two different assessment procedures. One group (n = 33) was part of a placebo-controlled, double-blind crossover research protocol, with randomized dose sequences, compliance checks, numerous dependent measures, written informed consent, and a considerable amount of staff involvement. The other group (n = 43) received pharmacotherapy at a community-based child psychiatry outpatient service where they were followed in a routine clinical manner, with "no treatment" as the only control condition, standard fixed-dose titration, parental responsibility for data collection, use of form letters, and minimal staff involvement. Each individual in both groups received divided doses of 0.3 and 0.5/0.6 mg/kg daily for a minimum of 1 week at each dose. Comparisons of teacher ratings obtained for the two assessment procedures revealed highly similar findings. The results of this study are discussed with regard to both their methodological and clinical implications.

A procedure for monitoring stimulant medication in hyperactive mentally retarded school children.

ABSTRACT Many hyperactive mentally retarded children in public school programs receive stimulant medication, but studies indicate that treatment monitoring practices are less than adequate. Standardized drug assessment instruments rarely are used, and the school typically plays a minor role in evaluating response to treatment. To improve upon this situation, a procedure developed originally for nonretarded children was adapted to evaluate drug effects in mentally retarded children in public school settings. This assessment procedure generates ecologically valid data, enables a high degree of precision in specifying target symptoms and measuring the magnitude of the therapeutic effect, and appears to generate useful information for making dosage adjustment decisions. Two case studies are presented to illustrate the use of this procedure and to highlight differences in the clinical utility of data from behavior rating scales versus direct observations. Although ratings and observations sometimes reveal similar dose-response profiles, the sole reliance on rating scales can lead to gross misperceptions of drug efficacy, even when the ratings are completed by highly motivated and cooperative teachers. Our experience in evaluating mentally retarded children supports (1) the value of assessment instruments designed specifically for this patient population (e.g., Aberrant Behavior Checklist), (2) the need for evaluating a broader range of target symptoms, and (3) the importance of being alert to the somewhat greater variability of responses to stimulant drugs in these children.

Methylphenidate in Aggressive Hyperactive Boys: II. Indirect Effects of Medication Treatment on Peer Behavior.

ABSTRACT The present study examines the indirect "spillover" effects of methylphenidate on the behavior of the classmates of drug-treated children in public school settings, and it measures the extent to which medication normalizes hyperactive and noncompliant-aggressive behaviors. Eleven aggressive hyperactive boys, who met DSM-III diagnostic criteria for attention deficit disorder, received placebo and methylphenidate in a double-blind crossover design. Medication effects were assessed by conducting observations of the drug-treated boy and his peers in the classroom and lunchroom settings. In most classrooms, a spillover effect did not occur for most of the behaviors assessed, but there was a decrease in the rate of nonphysical aggression exhibited by peers as a function of the hyperactive child's methylphenidate dose. Peers were generally less aggressive when the hyperactive boys were receiving methylphenidate than when they received placebo. In the lunchroom, in contrast, peers appeared slightly more noncompliant and aggressive when the aggressive hyperactive boys were receiving medication compared with placebo, but these differences did not attain statistical significance. Methylphenidate effectively normalized the negativistic behaviors of the aggressive hyperactive boys in the classroom. In some cases, the frequency of occurrence of certain behaviors dropped significantly below the level of the hyperactive child's peers. This "supranormalization" may reflect behavioral toxicity of the psychostimulant.

Observations and ratings of tics in school settings.

This paper describes the findings of a school-based tic assessment procedure (direct observations, teacher rating scales) for hyperactive children with comorbid tic disorder. Rates of motor tic frequency were found to be moderately stable across both days and school settings. Correlations between direct observations of tics and clinician rating scales were generally in the low to moderate range as were correlations between teacher and clinician rating scales. Overall rates of hyperactive/disruptive behaviors were not associated with rates of motor tic occurrence, and the behavioral symptoms of both disorders were also independent for specific intervals of time.