Postoperative fractures of the lingual plate after bilateral sagittal split osteotomies.

We encountered the unusual complication of postoperative fracture of the lingual plate in four patients after bilateral sagittal split osteotomy. We then did a retrospective review to identify possible risk factors. Over a 1-year period we did 52 bilateral split osteotomies. The patients' casenotes were examined and a number of variables were recorded, including surgical technique, and the patient's sex, age, presence or absence of third molars, and the height of the mandible in the region of the osteotomy. Significant risk factors were a vertical mandibular height of 2 cm or less distal to the last molar tooth (p=0.02), and a depth of 0.6 cm or less from the apex of last molar root or impacted third molar to the lower border (p=0.005).

The effects of co-morbidity on the onset and persistence of generalized anxiety disorder in the ICPE surveys. International Consortium in Psychiatric Epidemiology.

BACKGROUND: Although it is well known that generalized anxiety disorder (GAD) is highly co-morbid with other mental disorders, little is known about the extent to which earlier disorders predict the subsequent first onset and persistence of GAD. These associations are examined in the current report using data from four community surveys in the World Health Organization (WHO) International Consortium in Psychiatric Epidemiology (ICPE). METHOD: The surveys come from Brazil, Canada, the Netherlands and the United States. The Composite International Diagnostic Interview (CIDI) was used to assess DSM-III-R anxiety, mood and substance use disorders in these surveys. Discrete-time survival analysis was used to examine the associations of retrospectively reported earlier disorders with first onset of GAD. Logistic regression analysis was used to examine the associations of the disorders with persistence of GAD. RESULTS: Six disorders predict first onset of GAD in all four surveys: agoraphobia, panic disorder, simple phobia, dysthymia, major depression and mania. With the exception of simple phobia, only respondents with active disorders have elevated risk of GAD. In the case of simple phobia, in comparison, respondents with a history of remitted disorder also have consistently elevated risk of GAD. Simple phobia is also the only disorder that predicts the persistence of GAD. CONCLUSIONS: The causal processes linking temporally primary disorders to onset of GAD are likely to be state-dependent. History of simple phobia might be a GAD risk marker. Further research is needed to explore the mechanisms involved in the relationship between simple phobia and subsequent GAD.

DSM-IV internal construct validity: when a taxonomy meets data.

The use of DSM-IV based questionnaires in child psychopathology is on the increase. The internal construct validity of a DSM-IV based model of ADHD, CD, ODD, Generalised Anxiety, and Depression was investigated in 11 samples by confirmatory factor analysis. The factorial structure of these syndrome dimensions was supported by the data. However, the model did not meet absolute standards of good model fit. Two sources of error are discussed in detail: multidimensionality of syndrome scales, and the presence of many symptoms that are diagnostically ambiguous with regard to the targeted syndrome dimension. It is argued that measurement precision may be increased by more careful operationalisation of the symptoms in the questionnaire. Additional approaches towards improved conceptualisation of DSM-IV are briefly discussed. A sharper DSM-IV model may improve the accuracy of inferences based on scale scores and provide more precise research findings with regard to relations with variables external to the taxonomy.

Screening for anxiety and depression in early adolescence.

OBJECTIVE: To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths. METHOD: Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions. RESULTS: MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate. CONCLUSIONS: The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Familial influences on substance use by adolescents and young adults.

This study uses data from the Ontario Health Survey to examine within-family influences (sibship number, age and sex composition; family structure and parental substance use) on the use of tobacco, alcohol and marijuana in households (N = 4,643) among offspring aged 12 to 24 years. Using a modification of the kappa statistic, concordance among siblings is modest generally and undifferentiated across substance type. Concordance is stronger among sibships that are either all male or older (19-24 years) and is particularly strong for siblings < or = two years apart in age. The dominant influence of substance use behaviour appears to be from older siblings to younger siblings and not from parents to offspring. Sibling concordance for substance use suggests that the treatment and prevention of substance use (and abuse) among adolescents and young adults might be enhanced by including a family focus, especially where there are two or more siblings at home.

How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors.

OBJECTIVE: The authors developed a methodological basis for investigating how risk factors work together. Better methods are needed for understanding the etiology of disorders, such as psychiatric syndromes, that presumably are the result of complex causal chains. METHOD: Approaches from psychology, epidemiology, clinical trials, and basic sciences were synthesized. RESULTS: The authors define conceptually and operationally five different clinically important ways in which two risk factors may work together to influence an outcome: as proxy, overlapping, and independent risk factors and as mediators and moderators. CONCLUSIONS: Classifying putative risk factors into these qualitatively different types can help identify high-risk individuals in need of preventive interventions and can help inform the content of such interventions. These methods may also help bridge the gaps between theory, the basic and clinical sciences, and clinical and policy applications and thus aid the search for early diagnoses and for highly effective preventive and treatment interventions.

Doing better with "bad kids": explaining the policy-research gap with conduct disorder in Canada.

Conduct disorder (severe and persistent antisocial behaviour in children and youth) is an important community mental health problem in Canada and has been the focus of considerable recent public policy debate. Good research evidence is available on effective (and ineffective) interventions for conduct disorder. Paradoxically, however, relatively little of the research evidence is incorporated into policy decision-making. There is a policy-research gap. An example (Hamilton, Ontario) is used to illustrate this gap. The gap is then explained using a framework for health policy analysis that incorporates values, institutional structures, and information. Values and institutional structures greatly outweigh research evidence in influencing current Canadian policy-making for the problem of conduct disorder. Possibilities for improving the situation are suggested.

Screening for conduct problems: does the predictive accuracy of conduct disorder symptoms improve with age?

OBJECTIVES: To investigate the influence of age on the predictive accuracy of conduct disorder (CD) symptoms for future CD and to evaluate the usefulness of CD symptoms as a screening tool in normal populations. METHOD: Two cohorts were derived from the Canadian National Longitudinal Survey of Children and Youth based on age at baseline (cohort 1: ages 5-6, n = 881; cohort 2: ages 8-9, n = 859). CD symptoms were assessed with behavior symptom checklists at baseline and the 2-year follow-up assessment. Predictive accuracy (PA) was evaluated with logistic regression and receiver operating characteristic curves. RESULTS: The PA of teacher-identified CD symptoms, alone or in combination with other risk factors (gender, socioeconomic status, familial factors), was higher in the older cohort. PA increased when CD symptoms were combined with other risk factors. However, none of the predictors evaluated achieved minimum criteria for sensitivity and positive predictive value of at least 50%. CONCLUSIONS: The PA of CD symptoms improves with age. However, the results show that the PA of CD symptoms assessed at a single point in time in children in normal populations is insufficient. Screening initiatives that use this approach to detect risk for CD should be abandoned.

Selection of levels of prevention.

This article outlines the advantages and disadvantages of universal and targeted intervention programs. Two advantages of universal programs are the absence of labeling and stigmatization, and the inclusion of the middle class which makes it more likely that the program will be well run. Two disadvantages are that they are unappealing to the public and politicians, and they may have their greatest effect on those at lowest risk. Targeted programs have the potential of addressing problems early on, and are potentially efficient if targeting can be done accurately. Disadvantages include difficulties around screening and the possibility of labeling and stigmatization. The argument is put forth that what is needed to reduce the immense burden of suffering from child and adolescent psychiatric disorders is the optimal mix of universal, targeted, and clinical programs carried out in the context of a civic community. There will always be trade-offs among these strategies, and the elements of the combination will change as knowledge accumulates.

Tri-ministry study: correlates of school-based parenting course utilization.

This study examined factors associated with the utilization of universally available school-based parent training. In a randomly selected, prospectively screened, unreferred community sample of 1,498 5- to 8-year-olds, 28% to 46% of families of children with high parent-reported externalizing problems enrolled. Externalizing problems, first-child status, and a high school education were associated with increased enrollment. Single-parent status, immigrant background, and limited extracurricular child activities were associated with lower enrollment. Economic disadvantage, stress, family dysfunction, and parental depressive symptoms were not associated with participation. Most families attributed nonparticipation to busy personal schedules, inconvenient times, and logistical difficulties.

The influence of early and frequent use of marijuana on the risk of desistance and of progression to marijuana-related harm.

BACKGROUND: A significant minority of lifetime marijuana users will eventually receive a diagnosis of abuse or dependence. Yet little is known regarding the effect of age at onset and frequency of lifetime marijuana use on desistance from use and on progression to marijuana disorders. METHODS: To address this issue, data were obtained from a community sample of 2,729 lifetime marijuana users participating in the Ontario Mental Health Supplement. RESULTS: Early and frequent lifetime marijuana use was associated with highly persistent use and rapid progression to marijuana-related harm. Multivariate analyses revealed a monotonic increase in the risk of desistance with less frequent categories of use and later ages of onset. Results also indicated a threshold of use (100-199 times) associated with an elevated risk of developing marijuana disorders. A lower threshold of risk for marijuana problems was observed for females (50-99 times). CONCLUSIONS: Early and frequent marijuana use are potent risk factors for prolonging desistance and hastening marijuana-related harm. Required are prevention programs aimed at delaying the onset of first use as well as harm reduction strategies that encourage cessation or reduced levels of consumption among those already using.

Age at first alcohol use: a risk factor for the development of alcohol disorders.

OBJECTIVE: This study aimed to describe the natural course of DSM-III-R alcohol disorders as a function of age at first alcohol use and to investigate the influence of early use as a risk factor for progression to the development of alcohol disorders, exclusive of the effect of confounding influences. METHOD: Data were obtained from a community sample (N=5,856) of lifetime drinkers participating in the 1990-1991 Mental Health Supplement of the Ontario Health Survey. RESULTS: Survival analyses revealed a rapid progression to alcohol-related harm among those who reported having their first drink at ages 11-14. After 10 years, 13.5% of the subjects who began to drink at ages 11 and 12 met the criteria for a diagnosis of alcohol abuse, and 15.9% had a diagnosis of dependence. Rates for subjects who began to drink at ages 13 and 14 were 13.7% and 9.0%, respectively. In contrast, rates for those who started drinking at ages 19 and older were 2.0% and 1.0%. Unexpectedly, a delay in progression to harm was observed for the youngest drinkers (ages 10 and under). Hazard regression analyses revealed a nonlinear effect of age at first alcohol use, marked by an elevated risk of developing disorders among subjects first using alcohol at ages 11-14. CONCLUSIONS: First use of alcohol at ages 11-14 greatly heightens the risk of progression to the development of alcohol disorders and therefore is a reasonable target for intervention strategies that seek to delay first use as a means of averting problems later in life.

Tracking the use and impact of a community social report: where does the information go?

The purpose of this paper is to report on a study evaluating the extent to which a social report (entitled "Hamilton-Wentworth Profile on Children and Youth") was read and used by recipients. Subjects were divided into two groups: an Active Group which had worked on producing the Profile and/or requested copies of it once it had been released, and a Passive Group which had received copies of the Profile through a general mailing list used for other research reports. Approximately one year later, 90% of the Active Group recalled the Profile compared to 21% of the Passive Group. Similarly, 83% of Active Group respondents had read the Profile compared to 8% of Passive Group subjects. 80% of Active Group respondents and 5% of Passive Group respondents used the Profile. The results suggest that if social reports are read by local community agencies and individuals, they will be used to help improve conditions for children and youth. Social reports at the local level are more likely to be read if potential users are engaged in the process of report production and if the reports are disseminated to the appropriate target audience.

Helping children adjust--a Tri-Ministry Study: I. Evaluation methodology.

This report describes the evaluation methodology of the Tri-Ministry Study--a school-based trial evaluating the effectiveness of three universal programs: (a) a classwide social skills program (SS), (b) a partner reading program (RE); and, (c) a combination of both (SS & RE), to reduce and prevent behavioural maladjustment among children in the primary division (up to grade 3) of Ontario schools. The trial was done between 1991 and 1995. Sixty schools in 11 boards of education took part and were assigned randomly to program(s) during the study. Contributing to the evaluation database are detailed follow-up assessments (observations, ratings, and standard tests) on 2439 children. Three-level growth trajectory models are used to evaluate program effects. The analysis presented for illustration in this report focuses on reading achievement measured by the Wide Range Achievement Test. A companion paper presents the results of the study and discusses important methodological and programmatic issues applicable to this and other prevention studies in the field.

Helping children adjust--a Tri-Ministry Study: II. Program effects.

This report describes program effects of the Tri-Ministry Study a school-based, longitudinal trial carried out over a 5-year period to assess the effectiveness of classwide social skills training (SS), partner reading (RE), and a combination of both (SS & RE) to reduce maladjustment among children in the primary division (up to grade 3) of Ontario schools. It also places these effects in the context of other school-based prevention studies and discusses them in view of important methodological and programmatic issues. The incremental effects attributable to the intervention programs were small and sporadic. There were statistically significant increases in prosocial behaviour observed in the playgrounds of intervention schools with no differentiation by program type. Furthermore, there was some evidence--a reduction in teacher and parent-rated externalising problems--that the combination of SS & RE and SS alone may have had modest beneficial effects. A review of nine other school-based studies, which evaluated universally delivered mental health prevention programs in general populations of students, revealed similar mixed results. There are both methodologic and programmatic issues implicated in the weak findings that have been reported to date. These issues need to be addressed to advance knowledge about the potential impact of mental-health prevention initiatives delivered universally through school-based programs. A companion paper gives the specific details on the programs, randomisation of schools, selection of subjects, measurements, and analysis.

Predicting conduct problems: can high-risk children be identified in kindergarten and grade 1?

Externalizing behavior symptoms (EBS) in childhood are a strong predictor of future conduct problems. This study evaluated their predictive accuracy using logistic regression and receiver operating characteristic curve techniques. EBS, alone and in combination with other child and familial risk factors, were used to predict conduct problems 30 months later in a nonclinic population of kindergartners and Grade 1 children. The sensitivity (Sn) and positive predictive value (PPV) of EBS alone were below preset criteria of > or = 50% for each (prevalence < or = 15%). Sn and PPV increased when other child and familial factors were combined with symptoms but did not exceed the preset criteria. From a developmental perspective, substantial stability of EBS exists over time. However, from the perspective of prevention science, significant levels of misclassification will occur when EBS are used to designate high-risk status under the low-prevalence conditions of normal populations.

Age-of-onset classification of conduct disorder: reliability and validity in a prospective cohort study.

OBJECTIVE: To test in a prospective clinical cohort study the reliability and validity of the age-of-onset subtyping of conduct disorder. METHOD: Participants were adolescents referred to psychiatric clinics who met DSM-III-R criteria for conduct disorder by structured diagnostic interview. Age of onset was the reported age of the first conduct disorder symptom. The reliability of age-of-onset report was tested by assessing agreement within informant on interviews 2 to 4 weeks apart. Age-of-onset groups were compared within informant on rates of correlates and symptom and social functioning outcomes over a period of 3 years. RESULTS: The reliability of age-of-onset report was low (kappa of 0.1 and 0.4 by adolescent and parent informant, respectively). Although the early-onset group had elevated rates of attention-deficit/hyperactivity disorder, family disadvantage, and aggressive and nonaggressive antisocial behaviors at inclusion, growth curve analysis showed that age-of-onset subtyping had no predictive validity. CONCLUSIONS: The reliability of ascertainment of age of onset of antisocial behavior requires further study. While age-of-onset subtyping has heuristic value with respect to the study of the causal pathways to conduct disorder, it is premature to use this system in clinic settings.

Antecedents of the risk of recovery from DSM-III-R social phobia.

BACKGROUND: This study reports antecedents of recovery from DSM-III-R social phobia. METHODS: Retrospective data were obtained from 1116 individuals age 15 to 64 participating in a large population health survey in the province of Ontario, Canada RESULTS: Approximately 50% of the sample recovered from their illness. Survival analysis revealed a median length of illness of 25 years with peak periods of risk of recovery occurring between 30 and 45 years duration. Using discrete time multivariate hazard regression analysis, statistically significant predictors of recovery from social phobia included: childhood social contextual factors (one or no childhood siblings, a small town childhood place of residence), characteristics of the disorder (onset past the age of 7, less than three disorder symptoms), an absence of co-morbid health-related conditions and psychiatric disorders (chronic health problems and major depression), and the occurrence of co-morbid chronic health problems and major depression prior to the onset of the disorder. CONCLUSIONS: Our data indicate that social phobia in the general population is a chronic and unremittent disorder. Determinants of recovery are rooted in distal childhood circumstances, disorder attributes, and the physical and mental health status of individuals over the life course.

Highly somatizing young adolescents and the risk of depression.

OBJECTIVE: To determine if high levels of somatization symptoms in 13- to 16-year-olds from the general population predict risk of major depression and other psychiatric disorders 4 years later. METHOD: Cohort study, using interview and self-report survey data from the 1983 Ontario Child Health Study (OCHS) and 1987 OCHS Follow-up. The study population included 1015 13- to 16-year-olds from the general community within Ontario. Baseline levels of somatization and emotional disorder were measured by the Survey Diagnostic Instrument, a checklist based on DSM-III criteria. Data were also collected for a range of sociodemographic factors, as well as the presence of chronic health problems. Major depression, anxiety disorders, and substance abuse and dependency at follow-up were measured using a self-administered questionnaire derived from the Diagnostic Interview Schedule. Bivariate and multiple logistic regression techniques were used to assess the relationship between high levels of somatization symptoms (>90th percentile) and later emotional morbidity, with adjustment for potential confounding factors, including gender and baseline disorders. RESULTS: Highly somatizing adolescents are at increased risk of major depression 4 years later, an association that is not explained by detectable emotional disorder at baseline or gender differences between groups. There is an important interaction between somatization and emotional disorder in predicting risk of major depression. It is primarily the group of 13- to 16-year-olds not recognized as being emotionally disordered at the initial OCHS survey in which somatization symptoms increased risk of later depression. The young teen with high levels of somatic complaints had as much risk of later depression as his/her peer with more typical symptoms of emotional disorder. Highly somatizing adolescents were also more likely to describe panic attacks at 4-year follow-up. There was no increased risk of substance abuse/dependency in the highly somatizing group or in generalized anxiety. CONCLUSIONS: High levels of somatic symptoms identified in young adolescents in the community represent a significant risk factor for major depression 4 years later, particularly in those individuals who do not present with more typical symptoms of emotional disorder. To detect the emergence of this serious emotional morbidity, adequate follow-up and continuity of care for these challenging patients are needed.