Internalizing behavior problems and scholastic achievement in children: cognitive and behavioral pathways as mediators of outcome.

Examined a conceptual model in which dual developmental pathways (behavioral and cognitive) are hypothesized to account for the relation among internalizing behavior problems, intelligence, and later scholastic achievement using a cross-sectional sample of 325 children. Classroom behavior and select aspects of cognitive functioning (vigilance, short-term memory) were hypothesized to mediate the relations among internalizing problems, IQ, and long-term scholastic achievement. Hierarchical tests applied to a nested series of models demonstrated that (a) individual differences in measured intelligence among children are associated with variations in classroom performance and cognitive functioning, (b) classroom performance and cognitive functioning make unique contributions to prediction of later achievement over and above the influence of intelligence, (c) anxious/depressive features are correlated but separable constructs, and (d) anxiety/depression and withdrawal contribute to prediction of classroom performance and cognitive functioning over and above the effects of intelligence. Classroom performance and cognitive functioning thus appear to mediate the effects of internalizing behaviors as well as intelligence. Particular attention to the presence and potential impact of social withdrawal on children's functioning, both alone and concomitant with anxiety/depression, appears warranted during the course of clinical evaluations owing to the strong continuity among these variables.

Bridging theory and practice: conceptual understanding of treatments for children with attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), autism, and depression.

Serves as an introduction to a special edition of the journal on bridging theory and clinical practice for childhood disorders. Issues concerning the current trend of developing and evaluating new treatments devoid of a theoretical perspective are discussed. A conceptual model of child psychopathology is presented to illustrate the relevance and interplay between theory and the design and evaluation of treatments with particular emphasis on the selection and measurement of target behaviors. The means by which theory and empirical evidence interact and their relevance to understanding particular childhood disorders are discussed and emphasize the need for theoretical and conceptual models that describe the linkages among hypothesized brain substrates, cognitive function, behavior, and the environment to augment the development of potent biological and psychological interventions.

A conceptual model of child psychopathology: implications for understanding attention deficit hyperactivity disorder and treatment efficacy.

Highlights the desirability of using a theoretical framework for guiding the design and evaluation of therapeutic interventions for children with attention deficit hyperactivity disorder (ADHD). A general conceptual model is introduced and used to evaluate ADHD treatment outcome research. Treatments designed to target the substrate level (pharmacological interventions) result in broad, robust improvement in both core and peripheral areas of functioning. Those targeting hypothesized core features of the disorder (i.e., attention, impulsivity-hyperactivity) produce corresponding improvement in core and peripheral outcome measures with the exception of studies employing cognitive-behavior therapy. Those targeting peripheral features of the disorder effect change only in corresponding peripheral areas of functioning. Implications for clinical practice are discussed, and an alternative conceptual model of ADHD is introduced and compared with existing models.

Upgrading the science and technology of assessment and diagnosis: laboratory and clinic-based assessment of children with ADHD.

Reviews the usefulness of clinic-based and laboratory-based instruments and paradigms for diagnosing attention deficit hyperactivity disorder (ADHD) and monitoring treatment effects. Extant literature examining the performance of normal children and those with ADHD on an extensive range of neurocognitive tests, tasks, and experimental paradigms indicates that particular types of instruments may be more reliable than others with respect to detecting between-group differences. We review task parameters that may distinguish the more reliable from less reliable instruments. The value of clinic-based and laboratory-based instruments for monitoring treatment response in children with ADHD is questionable when evaluated in the context of ecologically relevant variables such as classroom behavior and academic functioning. We present a general conceptual model to highlight conceptual issues relevant to designing clinic-based and laboratory-based instruments for the purposes of diagnosing and monitoring treatment effects in children with ADHD. Application of the model to currently conceptualized core variables indicates that attention and impulsivity-hyperactivity may represent correlative rather than core features of the disorder. We discuss implications of these findings for designing the next generation of clinic-based and laboratory-based instruments.

Attention-deficit/hyperactivity disorder and scholastic achievement: a model of dual developmental pathways.

A conceptual model has recently been hypothesized in which parallel but correlated developmental pathways exist for attention deficit behaviors and conduct problems. An important component of this model suggests that attention deficit behaviors are related to later scholastic underachievement, whereas conduct problems are unrelated to scholastic underachievement except by their common correlation with attention deficit and intelligence. The present study replicated the general model using a cross-sectional sample of 325 children, and examined whether hypothesized dual pathways (behavioral and cognitive) better account for the relationship between attention deficit, intelligence, and later scholastic achievement. Results of the structural equation modeling analysis were consistent with the hypothesized dual pathway model and suggest that school behavior and select cognitive abilities serve as important mediators between attention deficit, intelligence, and later scholastic achievement. Implications of these results for understanding the developmental trajectory of children with attention deficit and general theoretical models of ADHD are discussed.

Predicting methylphenidate response in children with ADHD: theoretical, empirical, and conceptual models.

OBJECTIVE: To evaluate the theoretical merit and empirical validity of models designed to predict response to methylphenidate (MPH) among children with attention-deficit/hyperactivity disorder (ADHD). METHOD: Seventy-six children with ADHD received each of 4 counterbalanced doses of MPH (5, 10, 15, and 20 mg) in the context of a double-blind, placebo-controlled, within-subject (crossover) experimental design. Logical and conceptual foundations of 3 models of MPH response were subjected to critical scrutiny, and patterns of relationship anticipated on the basis of these models were subjected to empirical analysis. RESULTS: The conceptual foundations of all reviewed models were found to be substantially flawed, and none provided an adequate empirical basis for predicting response to MPH among children with ADHD. CONCLUSIONS: The observed pattern of relationships suggests that magnitudes of response to MPH in domains of classroom attention and behavioral disinhibition are correlated and differentially predictive of response on measures of academic performance and teacher-rated behavior.

The fear survey schedule for children-revised (FSSC-HI): ethnocultural variations in children's fearfulness.

A revised Fear Survey Schedule for Children was used to examine the structure and developmental pattern of fearfulness in an ethnoculturally diverse sample of 385 Hawaii schoolchildren aged 7 to 16 years. The instrument's psychometric properties compared favorably with previous versions of the FSSC, and a 7-factor solution provided the best conceptual fit for the data. Six factors were similar to those described in previous versions of the FSSC, whereas the seventh was unique, reflecting children's social conformity fears. Between-group comparisons revealed significantly less fearfulness in children of Caucasian than of Asian, Filipino, and Hawaiian ethnocultural backgrounds. Gender and age differences were similar to previous reports in finding greater fearfulness in girl than boys, and in younger than older children on most factors. Results corroborate previous reports concerning gender and age trajectories of fearfulness and indicate that culture may mediate the expression of fears in culturally diverse populations.

Ethnic variations in children's problem behaviors: a cross-sectional, developmental study of Hawaii school children.

Variations in children's problem behaviors associated with ethnicity and other demographic variables were examined in 6-18-year-old children (N = 804) residing in a multicultural environment. The Child Behavior Checklist-Teacher's Report Form was used to compare the frequency of behavior problems among clinic-referred and nonreferred children of Hawaiian, Asian, and Caucasian ethnicities. Children who were male, clinic-referred, or of Caucasian or Hawaiian ancestry experienced greater levels of behavioral problems. Explanations concerning ethnic variations in children's problem behaviors include: teacher's perceptual bias, differences in teacher threshold to report problem behaviors, and/or true variations in children's behavior.

Titrating methylphenidate in children with attention-deficit/hyperactivity disorder: is body mass predictive of clinical response?

OBJECTIVE: To evaluate the hypothesis that gross body mass is functionally related to methylphenidate (MPH) response in children with attention deficit disorder/hyperactivity disorder (ADDH). METHOD: Seventy-six children with ADDH received each of five counterbalanced doses of MPH (placebo, 5 mg, 10 mg, 15 mg, 20 mg) in the context of a double-blind, placebo-controlled, within-subject (crossover) experimental design. Dependent measures included direct observations of attention, academic efficiency, and teacher ratings of behavior in the classroom. RESULTS: Dose-response profiles did not differ across children varying incrementally in body mass, nor were systematic variations in dose-response curve parameters observed across discrete groups of children differing in mean body mass. Neither did these groups differ with respect to gains from placebo at each dose. Finally, body mass failed to predict optimal dose or gains achieved at optimal dose and did not distinguish between drug responders and nonresponders. CONCLUSIONS: Collectively, the findings fail to support the practice of titrating MPH on the basis of body weight in children with ADDH.

Methylphenidate and attentional training. Comparative effects on behavior and neurocognitive performance in twin girls with attention-deficit/hyperactivity disorder.

The effectiveness of four doses (5-mg, 10-mg, 15-mg, 20-mg) of methylphenidate (MPH) and attentional training (AT) were evaluated using neurocognitive instruments (Continuous Performance Test; Matching Unfamiliar Figures Test), narrow- and broad-band rating scales in the context of a double-blind, placebo-control, within-subject reversal design for dizygotic twin girls with Attention-Deficit/Hyperactivity Disorder (ADHD). Both interventions proved effective for improving neurocognitive test performance and behavior, although broad-band ratings revealed dose-response curves different from those obtained from the neurocognitive tests. Implications for clinical management of girls with ADHD are discussed.

Attention deficit disorder and methylphenidate: normalization rates, clinical effectiveness, and response prediction in 76 children.

OBJECTIVE: To evaluate the magnitude and clinical significance of methylphenidate (MPH) effects on the classroom behavior and academic performance of 76 children with attention deficit disorder/hyperactivity (ADDH). METHOD: A double-blind, placebo controlled, within-subject (crossover) experimental design was used to evaluate acute MPH effects at four dose levels (5 mg, 10 mg, 15 mg, and 20 mg) on children's attention, academic functioning, and behavior in regular classroom settings. Results were contrasted with a normal control sample. RESULTS: Standard statistical analysis revealed MPH effects on classroom functioning that were primarily linear. Analysis of the clinical significance of effects indicated that large proportions of treated children exhibited significantly improved or normalized classroom functioning; however, a large subset of them failed to show improved academic functioning. Overall, children failing to respond at lower dose levels have a high probability of improving or becoming normalized as a function of increasing dose. CONCLUSIONS: For a majority of children with ADDH, MPH results in significantly improved or normalized attention and classroom behavior. A significant subset, however, fail to realize gains in their academic functioning and will require supplemental interventions.

Side effects of methylphenidate and desipramine alone and in combination in children.

OBJECTIVE: To investigate side effects of methylphenidate and desipramine alone and in combination in hospitalized children with symptoms of attention-deficit hyperactivity disorder and depression. METHOD: A double-blind placebo controlled crossover design was used to investigate each medication alone and in combination. Side effect ratings and EKGs were done weekly. Pulse and blood pressure were monitored daily. RESULTS: Nausea, dry mouth, and tremor were present in at least twice as many children on combined methylphenidate and desipramine compared with any other condition. Nausea/vomiting, headaches, other aches, refusal of food, and feeling "tired" were significantly more frequent during the combined methylphenidate plus desipramine condition when compared with either methylphenidate alone or with baseline. Significantly higher ventricular heart rate was found on combined methylphenidate plus desipramine compared with desipramine alone, methylphenidate alone, and baseline. Prolonged PR interval and significantly higher heart rate occurred during desipramine alone compared with baseline. CONCLUSIONS: During the several-month duration of the study, there were more frequent side effects during combined methylphenidate plus desipramine treatment than with either medication alone. Clinically, side effects present during combined medication appeared to be similar to and no more serious than those associated with desipramine alone.

Methylphenidate and desipramine in hospitalized children: I. Separate and combined effects on cognitive function.

OBJECTIVE: The separate and combined effects of methylphenidate and desipramine on cognitive function were investigated in 16 psychiatrically hospitalized children with primary, secondary, and mixed features of attention-deficit hyperactivity disorder and mood disorder. METHOD: A double-blind, placebo controlled, crossover design was used to investigate drug effects on vigilance, short-term memory, visual problem solving, and higher-order learning. RESULTS: Methylphenidate alone improved vigilance, both drugs positively affected short-term memory and visual problem solving, and combined drugs affected learning of higher-order relationships. CONCLUSIONS: Separate and combined drug effects are related to the specific cognitive domain assessed and have implications for neurotransmitter models of action.

Does methylphenidate normalize the classroom performance of children with attention deficit disorder?

The present study examined the degree to which methylphenidate (MPH) normalized the classroom behavior and academic functioning of 31 children with attention deficit disorder (ADD). Subjects with ADD participated in a double-blind, placebo-controlled trial in which children received each of four doses (5, 10, 15, and 20 mg) of MPH and a placebo following baseline measures. Children with ADD were compared with a group of 25 normal control children on teacher ratings of social conduct, direct observations of on-task behavior, and academic efficiency. At a group level of analysis, MPH exerted a significant effect on classroom measures of attention and academic efficiency to a point where they were no longer statistically deviant from scores obtained by normal control children. Nevertheless, when examined at the individual level, 25% of the sample failed to show normalized levels of classroom performance, thus implying the need for ancillary school-based interventions.

The effects of methylphenidate and lithium on attention and activity level.

Seven psychiatrically hospitalized prepubertal children were treated with methylphenidate, placebo, lithium carbonate alone and in combination with methylphenidate. Children met DSM-III-R criteria for both disruptive behavior disorder and bipolar or major depressive disorder by structured interview and consensus diagnosis. Parents, children, teachers, staff, and raters were blind to medication condition. Children were rated weekly on measures of attention and activity to determine whether medications alone or in combination produced a differential effect on these variables. The nosological and practical implications of the results are discussed.

Lithium in hospitalized children at 4 and 8 weeks: mood, behavior and cognitive effects.

Eleven psychiatrically hospitalized children were treated with lithium carbonate for a minimum of 8 weeks. Based on literature review, their psychopathology, diagnoses and family history suggested they would be positive lithium responders. Weekly ratings in behavioral domains showed children's improvement in areas of self control, aggression and irritability, more obvious at 8 than 4 weeks. However, of seven children studied with double blind crossover, improvement behaviorally and cognitively was maintained on placebo. Only three of 11 children improved enough to be discharged on lithium. Implications of lithium's anti-aggressive and anti-manic effects in children are discussed.

Serum cholesterol and aggressive behavior in psychiatrically hospitalized children.

The relationship between serum cholesterol and a number of measures of impulsiveness and aggression was examined in 38 prepubertal, psychiatrically hospitalized children. Although care was taken to use reports and direct observations of both variables within 2 weeks of admission and 8 weeks later, no consistent relationship was found. The reasons for these findings are discussed.

Attention deficit disorder with hyperactivity and methylphenidate: the effects of dose and mastery level on children's learning performance.

This investigation examined the relationship between methylphenidate (MPH) and the learning and recall of paired associations by children with attention deficit disorder with hyperactivity (ADDH). Forty-five children with ADDH were randomly assigned to one of three groups (novel, partial mastery, and mastery learning) that varied in the amount of previous learning of paired associations and participated in a double-blind, placebo-control, repeated-measures-across-dose (crossover) design. Each child received four doses of MPH (5 mg, 10 mg, 15 mg, and 20 mg) and a placebo in a random, counterbalanced sequence. The results indicated that both the rate of acquisition and accuracy in learning paired associations were significantly, but differentially, affected by MPH dose and the degree of learning mastery. The implications of these results for psychopharmacological research and the monitoring of psychostimulant effects on children's learning performance in academic settings are discussed.