Massachusetts Youth Screening Instrument for mental health needs of juvenile justice youths.

OBJECTIVE: This report describes the development of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), a brief screening measure to identify youths with potential mental, emotional, or behavioral problems at entry points in the juvenile justice system. METHOD: This 52-item self-report measure, with content relevant to common mental health problems in delinquent populations, was administered to 1,279 male and female youths, aged 12 to 17, in Massachusetts juvenile justice facilities. A subsample of youths also received the Millon Adolescent Clinical Inventory (MACI) and the Youth Self-Report (YSR). The instrument was subsequently administered to 3,804 male and female youths in California Youth Authority custody. RESULTS: Factor analyses of the 52 items identified seven scales that were conceptually associated with various mental, emotional, and behavioral problems of youths, which were generally confirmed by separate factor analyses with the California sample. The scales manifested adequate internal consistency and test-retest reliability. Most scales were substantially correlated with conceptually similar scales in the MACI and YSR, and they identified most youths who scored at clinically significant levels on those instruments. CONCLUSIONS: The MAYSI-2 shows promise as a reliable and valid screening tool to assist juvenile justice staff in identifying youths who may need an immediate response to mental or emotional problems.

Early sexual abuse and low cortisol.

Post-traumatic stress disorder (PTSD) is a mental health disorder precipitated by a stressful event that produces fear or terror in the individual. Post-traumatic stress disorder studies, particularly in early sexual abuse, have been associated with neuroendocrine dysfunction, most notably the hypothalamic-pituitary-adrenal (HPA) axis. Since the literature on PTSD and neuroendocrine factors in young subjects has been sparse, the present studies were designed to look at the basal functioning of the HPA axis in response to early sexual abuse in girls aged 5 to 7 years. Morning salivary samples were collected for cortisol determination from subjects and controls who were scheduled for a physical exam by their pediatrician. The present study shows that subjects who had been abused within the last couple of months had significantly lower cortisol in comparison to control subjects (age, social economic status and race matched). The data suggest that children may have an impaired HPA axis after early trauma.

Neuroleptic-related dyskinesias in children and adolescents.

BACKGROUND: Few studies have investigated the comparative risk of neuroleptic-related dyskinesias in children and adolescents receiving typical versus newer, atypical antipsychotics. This prospective study was completed to test whether clinical use of atypical antipsychotics is associated with less risk for developing neuroleptic-related dyskinesias than clinical use of typical neuroleptics in an unselected heterogeneous population of seriously emotionally disturbed youths admitted to acute residential treatment. We also tested a novel model of predictive risk for neuroleptic-related dyskinesias in children and adolescents. METHOD: 102 children and adolescents receiving typical neuroleptics, atypical antipsychotics, or the combination were studied. Youths developing neuroleptic-related dyskinesias were compared with youths free of dyskinesias over a 3-month study period on demographic, diagnostic, and treatment variables. Logistic regression was utilized to develop a novel model of predictive risk. RESULTS: Of neuroleptic-treated youths, 5.9% had probable tardive dyskinesia, a rate less than the prevalence of tardive dyskinesia in chronic neuroleptic-treated adults. Use of typical neuroleptics was significantly (p = .03) associated with dyskinesia compared with use of atypical antipsychotics. Four variables including IQ, initial Abnormal Involuntary Movement Scale score, type of antipsychotic, and cumulative number of risk factors accounted for 35.8% of the variance when predicting dyskinetic status. CONCLUSION: Use of atypical antipsychotics appears to be associated with less dyskinesia risk than typical neuroleptics in an unselected group of seriously emotionally disturbed children and adolescents. Results support a cumulative risk model of neuroleptic-related dyskinesia in youths.

Clinical predictors of acute response with quetiapine in psychotic mood disorders.

BACKGROUND: In controlled studies of patients with schizophrenia, the atypical antipsychotic quetiapine, 300 mg/day, has been shown to be as effective in the treatment of positive and negative symptoms as haloperidol. However, little is known about the efficacy of quetiapine in patients with psychotic mood disorders. The purpose of this study was to assess the efficacy of quetiapine in the treatment of psychotic mood disorders in comparison with nonaffective psychotic disorders and identify clinical factors associated with quetiapine response. METHOD: In a naturalistic setting, by reviewing medical records, we assessed response to quetiapine and factors associated with response to quetiapine in 145 consecutive patients newly treated with the drug at a nonprofit academic psychiatric hospital. These patients had received a discharge diagnosis of bipolar disorder (manic, mixed, or depressive type), major depression with psychotic features, schizophrenia, schizoaffective disorder (bipolar or depressive type), delusional disorder, or psychosis not otherwise specified (NOS) according to DSM-IV criteria. RESULTS: Patients with a diagnosis of bipolar disorder, manic, mixed, or depressed and schizoaffective disorder, bipolar type displayed higher response rates (> 74%) compared with patients with schizophrenia. However, this finding did not achieve statistical significance. A diagnosis of major depression with psychotic features (p = .02) and longer duration of illness (p = .03) were associated with less chance of responding. CONCLUSION: Quetiapine may be a useful alternative or adjunctive treatment for patients with bipolar and schizoaffective disorders.

A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning.

STUDY OBJECTIVE: To compare the efficacy and safety of physostigmine with benzodiazepines for the treatment of agitation and delirium associated with anticholinergic poisoning. METHODS: We conducted a retrospective study of 52 consecutive patients referred to a university hospital toxicology consultation service who were treated with physostigmine, benzo-diazepines, or both for anticholinergic agitation and delirium. Patients treated with physostigmine were compared with those treated with benzodiazepines with respect to demographics, severity of poisoning, response to treatment, side effects of treatment, and complications. RESULTS: Physostigmine controlled agitation and reversed delirium in 96% and 87% of patients, respectively. Benzodiazepines controlled agitation in 24% of patients but were ineffective in reversing delirium. Initial treatment with physostigmine (n=30) resulted in a significant decrease in the incidence of agitation (P <.001) and level of central nervous system stimulation (P <.001), whereas initial treatment with benzodiazepines (n=22) did not (P =.03 and P =.05, respectively). Patients treated initially with physostigmine had a significantly lower incidence of complications (7% versus 46%; P <. 002) and a shorter time to recovery (median, 12 versus 24 hours; P =. 004) than those treated initially with benzodiazepines. There were no significant differences between these groups in the incidence of side effects (7% versus 14%; P =0.6) and length of stay (median, 32 versus 39 hours; P =.15). CONCLUSION: Results suggest that physostigmine is more effective and safer than benzodiazepines for the treatment of anticholinergic agitation and delirium. A prospective controlled study is necessary to confirm such findings.

Outcomes in work-related upper extremity and low back injuries: results of a retrospective study.

BACKGROUND: The outcomes of treatment for work-related injuries and illnesses are multidimensional and complex, but have rarely been explored in detail. This study was intended to provide information on a sample of workers representing a range of jobs and employers typical of the workers compensation system. METHODS: A mailed, self-report survey measuring multiple dimensions was conducted. Identified through the New Hampshire Division of Workers' Compensation First Report of Injury database, a sample of workers with injuries to their lower back (60%) or upper extremities (40%) a year prior to the study were surveyed. Response rate was 80% (N=169; upper extremity cases=70; low back cases=99). RESULTS: Most (82.8%) were working one year post-injury. Over half reported residual effects of the injury on work or activities of daily living. Many working subjects reported persistent injury-related anxiety and pain at the end of the work day, worse in those with low back pain compared to those with upper extremity injuries. Almost 40% of those who returned to work suffered a reinjury. Forty-four percent of respondents suffered significant injury-related financial problems, which were worse in those who had been out of work for longer periods. CONCLUSIONS: Occupational musculoskeletal injuries do result in significant, long-term adverse physical, economic, and psychological consequences, as demonstrated in self-reported surveys.

A meta-analysis of clonidine for symptoms of attention-deficit hyperactivity disorder.

OBJECTIVE: Meta-analysis was used to review the literature on the clinical use of clonidine to treat symptoms of attention-deficit hyperactivity disorder (ADHD). METHOD: A review of the literature from 1980 to 1999 revealed 39 studies that reported clonidine's efficacy and side effects for symptoms of ADHD and comorbid conditions. Of these, 11 reports provided sufficient information to be included in a meta-analysis. RESULTS: Meta-analysis using weighted variables revealed clonidine demonstrates a moderate effect size of 0.58 +/- 0.16 (95% confidence interval = 0.27-0.89) on symptoms of ADHD in children and adolescents with ADHD and ADHD comorbid with conduct disorder, developmental delay, and tic disorders. CONCLUSIONS: Clonidine may be an effective second-tier treatment for symptoms of ADHD, but it has an effect size less than that of stimulants. Clinical use of clonidine is associated with many side effects.

Physicians and smoking cessation. Development of survey measures.

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged.

A pilot study of nadolol for overt aggression in developmentally delayed individuals.

OBJECTIVE: The aim of this preliminary pilot study was to investigate the safety and efficacy of open-label nadolol as an adjunctive pharmacological treatment for aggression and/or inattention/overactivity in a developmentally delayed child, adolescent, and young adult population. METHOD: Twelve subjects enrolled and completed (mean age 13.8 years, range 9 through 24) a 5-month, open, prospective protocol of nadolol (mean dose 109 mg, range 30 through 220 mg) with systematic baseline and outcome evaluations and weekly clinical assessment. RESULTS: All subjects were developmentally delayed and most were cognitively delayed. Ten subjects (83%) showed clinical improvement while receiving nadolol. Significant improvements were noted on observer-rated overt categorical aggression, severity of illness, and global impressions of improvement. No significant effects were found for inattention/overactivity. Nadolol was well tolerated, with few side effects. CONCLUSIONS: Overt categorical aggression presenting in developmentally delayed children, adolescents, and young adults may respond to nadolol treatment.

A sequential analysis of the mother-adolescent interactions of ADHD, ADHD/ODD, and normal teenagers during neutral and conflict discussions.

The sequential interactions of three groups of teenagers conversing with their mothers during both neutral and conflict discussion situations were evaluated. Groups consisted of (1) attention deficit hyperactivity disorder (ADHD) alone (n = 21), (2) ADHD with comorbid oppositional defiant disorder (ADHD/ODD; n = 40), and (3) a community control group of adolescents (n = 49). All groups had been followed concurrently for the past 8 to 10 years before being reevaluated in this study. Results indicated that (1) teens and parents in all groups interacted in a tightly linked manner, with the behavior of each member being significantly related only to the immediate antecedent behavior of the other; (2) mothers in all groups were more likely than teens to initiate positive behaviors; (3) teen interactions could be characterized as tit-for-tat while mothers could be typified as be-nice-and-forgive; (4) mother-teen dyads in the ADHD/ODD group displayed significantly higher rates of conflict behaviors than dyads in the other two groups, who did not differ significantly from each other on most measures; and (5) mothers in the ADHD/ODD group responded in a manner similar to their teens (greater negativity) and less like that of mothers in the other groups. The majority of conflict between ADHD children and their parents seemed due to comorbid ODD and such ODD is a family, not just a teen, characteristic.

Head injury in partner-abusive men.

Research into etiology of marital aggression has focused primarily on psychosocial, political, and cultural factors, to the exclusion of physiological influences. Fifty-three partner abusive men, 45 maritally satisfied, and 32 maritally discordant, nonviolent men were evaluated for past history of head injury, by a physician who was not informed of group membership and aggression history. Logistic regressions confirmed that head injury was a significant predictor of being a battered. The implications of these findings for both marital aggression and post-head injury rehabilitation are discussed.

Primary structure of the human platelet serotonin 5-HT2A receptor: identify with frontal cortex serotonin 5-HT2A receptor.

Previous radioligand binding studies have demonstrated human platelet serotonin2A (5-HT2A) receptor binding sites. Pharmacological similarities between platelet and frontal cortex 5-HT2A receptor binding parameters have been demonstrated. However, it is not clear whether the platelet 5-HT2A receptor primary structure is identical to that of the brain receptor. Three overlapping cDNAs were obtained to span completely the coding region of the 5-HT2A receptor. These clones were sequenced with external and internal primers. The nucleotide sequence of human platelet 5-HT2A cDNA was identical to that reported for the human frontal cortex 5-HT2A receptor, except for nucleotide 102 (T-->C), which has been reported to represent a normal DNA polymorphism that does not alter the amino acid sequence. This finding may have implications in the study of neuropsychiatric disorders for which altered platelet 5-HT2A receptor binding has been demonstrated.

Head-injured males: a population at risk for relationship aggression?

Several recent studies suggest that head injury may be a potentially useful factor in explaining some types of aggressive behavior. In our research, we have been able to demonstrate an association between head injury and marital aggression using a sample of male batterers and appropriate comparison groups. Anecdotal and empirical literature also supports the hypothesis that aggression, relationship problems, and negative changes in personality and behavior are common sequelae to a head injury. This article explores the hypothesis that flows intuitively from the above, namely, that head-injured males are at increased risk for physical aggression in their intimate relationships. Empirical data are presented identifying several risk factors for relationship aggression and marital discord that may be sequelae of a significant head injury. Nevertheless, head-injured men were not found to be more physically aggressive with their female partners. The implications of these results are discussed.

Pharmacotherapeutic management strategies for mentally ill substance abusers.

In order to determine psychiatrists' strategies for managing the pharmacotherapy and treatment of mentally ill substance abusers, the authors constructed a series of standardized clinical vignettes, each with five multiple-choice treatment interventions. The vignettes, based on clinical experience, depict difficult dilemmas involving the use of medication in the treatment of a variety of dually diagnosed patients. The authors surveyed a heterogeneous reference group of 112 psychiatrists with these vignettes. The psychometric properties of the resultant Scale for Treatment Integration of the Dually Diagnosed (STIDD) are briefly described. The ten vignettes and the treatment interventions chosen by the reference group are described in detail. The results indicate that most clinicians favor an integrated treatment approach which attempts to address both diagnoses.

The stability of dimensions of behavior in ADHD and normal children over an 8-year followup.

The present study reports on standardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria (n = 108) and a community control sample of normal children (n = 61) who were followed prospectively over 8 years into adolescence. On some parent-report measures both groups declined in the severity of their behavior problems across time, while on other measures only the hyperactive group declined, but the hyperactives always remained more deviant than the controls at followup. The hyperactives and controls also differed on most teacher and self-report ratings at followup. The greatest degree of agreement between raters at adolescence was between parent and youth ratings. These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup. They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology.

The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment.

OBJECTIVE: To investigate predictors of adolescent outcome in a large sample of hyperactive children. METHOD: 123 hyperactive children were followed prospectively over an 8-year period. Multiple linear and logistical regression equations were used to relate childhood predictor variables to adolescent academic, psychiatric, social, and emotional adjustment. RESULTS: Adolescent academic skills were related to childhood cognitive and academic competence while school conduct was predicted by other variables including early family stress. Duration of mental health treatment received often was negatively related to outcome, apparently serving as a marker variable for severity of disturbance in the child. Childhood impulsivity-hyperactivity and paternal antisocial acts were associated with later oppositional-defiant behaviors. Only child defiance and not hyperactivity predicted later arrests, however. Emotional problems in adolescence were predicted by more special education enrollment. Adolescent social competence was associated with parental personal competence, whereas maternal mental health status at outcome was related to variables unassociated with child adjustment. CONCLUSIONS: Various outcome domains had different sets of predictors; no single predictor cut across all domains. Although a limited amount of variance in outcome was explained, findings suggest that promoting family and parental competence as well as assessing and treating defiance and aggression very early may improve outcome.

Clonidine treatment of hyperactive and impulsive children with autistic disorder.

Many autistic children have associated problems of inattention, impulsivity, and hyperactivity that limit the effectiveness of educational and behavioral interventions. Few controlled psychopharmacologic trials have been conducted in autistic children to determine which agents may be effective for these associated features. Eight male children (8.1 +/- 2.8 years) with autistic disorder, diagnosed by DSM-III-R criteria, completed a placebo-controlled, double-blind crossover trial of clonidine. Subjects were included in the study if they had inattention, impulsivity, and hyperactivity that was excessive for their developmental level. Subjects had not tolerated or responded to other psychopharmacologic treatments (neuroleptics, methylphenidate, or desipramine). Teacher ratings on the Aberrant Behavior Checklist irritability, stereotypy, hyperactivity, and inappropriate speech factors were lower during treatment with clonidine than during treatment with placebo. Attention deficit disorder with hyperactivity: Comprehensive Teacher's Rating Scale ratings were not significantly improved during the study, except for oppositional behavior. Parent Conners Abbreviated Parent-Teacher Questionnaire ratings significantly improved during clonidine treatment. Clonidine led to increased ratings of the side effects of drowsiness and decreased activity. Clinician ratings (Children's Psychiatric Rating Scale Autism, Hyperactivity, Anger and Speech Deviance factors; Children's Global Assessment Scale; Clinical Global Impressions efficacy) of videotaped sessions were not significantly different between clonidine and placebo. Clonidine was modestly effective in the short-term treatment of irritability and hyperactivity in some children with autistic disorder.

Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders.

OBJECTIVE: This study was designed to determine the effectiveness of a group stress reduction program based on mindfulness meditation for patients with anxiety disorders. METHOD: The 22 study participants were screened with a structured clinical interview and found to meet the DSM-III-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia. Assessments, including self-ratings and therapists' ratings, were obtained weekly before and during the meditation-based stress reduction and relaxation program and monthly during the 3-month follow-up period. RESULTS: Repeated measures analyses of variance documented significant reductions in anxiety and depression scores after treatment for 20 of the subjects--changes that were maintained at follow-up. The number of subjects experiencing panic symptoms was also substantially reduced. A comparison of the study subjects with a group of nonstudy participants in the program who met the initial screening criteria for entry into the study showed that both groups achieved similar reductions in anxiety scores on the SCL-90-R and on the Medical Symptom Checklist, suggesting generalizability of the study findings. CONCLUSIONS: A group mindfulness meditation training program can effectively reduce symptoms of anxiety and panic and can help maintain these reductions in patients with generalized anxiety disorder, panic disorder, or panic disorder with agoraphobia.

Adolescents with attention deficit hyperactivity disorder: mother-adolescent interactions, family beliefs and conflicts, and maternal psychopathology.

A group of 83 adolescents with attention deficit hyperactivity disorder (ADHD) were subdivided into those with ADHD alone (n = 27) and those with ADHD and oppositional defiant disorder (ADHD/ODD, n = 56). They were compared to each other and a community control group (n = 77) on measures of family conflicts, family beliefs, maternal adjustment, and observations of mother-adolescent interactions during both a neutral and conflict discussion. Both ADHD groups had more topics on which there was conflict and more angry conflicts at home than control adolescents on parent reports. Only the ADHD/ODD adolescents reported more such conflicts, endorsed more extreme and unreasonable beliefs about their parent-teen relations, and demonstrated greater negative interactions during a neutral discussion than the control teenagers. Similarly, only mothers of the ADHD/ODD teens displayed greater negative interactions during a neutral discussion, more extreme and unreasonable beliefs about their parent-teen relations, greater personal distress, and less satisfaction in their marriages than the mothers in the control group. Most findings for the ADHD only group were between the control group and the group with mixed ADHD/ODD but did not differ from either group. Results imply that it is the combination of ODD symptoms with those of ADHD that is associated with the greater-than-normal conflicts, anger, poor communications, unreasonable beliefs, and negative interactive styles seen in ADHD adolescents. These same characteristics typify their mothers' interactions as well such that both the adolescents' ODD symptoms and maternal psychological distress (hostility) make unique contributions to the degree of conflict and anger in the parent-teen relations of ADHD adolescents.

Observation of pain behavior in rheumatoid arthritis patients during physical examination. Relationship to disease activity and psychological variables.

This study examined the reliability and validity of a behavioral observation method for the assessment of arthritis pain in a clinical practice setting. Trained observers measured the occurrence of seven pain behaviors in a group of 61 rheumatoid arthritis patients undergoing physical examinations. These observations were compared with videotaped observations of the patients in a laboratory setting. Significant differences were found between the pain behavior frequencies observed during the examinations and those observed during videotaped sessions. Total pain behavior scores obtained in both settings were significantly correlated with patients' self-reports of pain and with disease activity measures. Pain behavior observed during the exams was significantly associated with patients' self-reports of anxiety and depression.