Child and familial pathways to academic achievement and behavioral adjustment: a prospective six-year study of children with and without ADHD.

This longitudinal study examined familial and child predictors of academic achievement and behavioral adjustment. Participants included 115 children with ADHD and 59 normative comparisons. Data analyses spanned three assessment waves from elementary- through secondary-school grades. We evaluated the degree to which child and familial factors present during middle school mediated relationships between childhood ADHD, subsequent academic achievement, and behavioral adjustment during high school. We found that emotional and behavioral well-being of ADHD children during middle school mediated relations between childhood ADHD and adverse academic and behavioral outcomes during high school. In addition, familial factors in middle school years predicted the behavioral adjustment of children in both the ADHD and non-ADHD groups. Academic achievement during high school was strongly associated with previous achievement levels. Our results provide support for tailoring preventive interventions to the unique needs of children with ADHD and their parents at various stages of adolescent development.

An integrated components preventive intervention for aggressive elementary school children: the early risers program.

The Early Risers prevention program aims to alter the developmental trajectory of children with early onset aggressive behavior. The program features 4 CORE components: (a) an annual 6-week summer school program, (b) a teacher consultation and student mentoring program, (c) child social skills groups, and (d) parent education and skills-training groups, all delivered in tandem with a FLEX family support program individually tailored to address the unique needs of families. At baseline, the mean age of the sample was 6.6 years. Following 2 years of intervention, program children showed significant improvement relative to controls in academic achievement and school behaviors. Change on behavioral self-regulation was moderated by level of child aggression, with intervention effects found for only the most severely aggressive children. Parents with high program attendance rates showed improvement in discipline methods.

Reduction in anti-apoptotic protein Bcl-2 in autistic cerebellum.

Autism is a neurodevelopmental disorder with genetic and environmental etiologies. Neurohistologic findings have shown Purkinje cell depletion and atrophy in the cerebellum of autistic subjects. We hypothesized that apoptotic mechanisms might explain these Purkinje cell findings. Bcl-2 is a potent anti-apoptotic regulatory protein, which is reduced in schizophrenic brains. Autistic and normal control cerebellar cortices matched for age, sex and PMI were prepared for SDS-gel electrophoresis and Western blotting using specific anti-Bcl-2 antibodies. Quantification of Bcl-2 showed a significant 34-51% reduction in autistic cerebellum (mean (+/- s.d.) optical density/75 microg protein 0.290 +/- 0.08, n = 5) compared with controls (0.595 +/- 0.31, n = 8; p < 0.04); levels of neuronal-specific class III beta-tubulin (controls 49.8 +/- 6.7; autistics 36.2 +/- 18.2), or beta-actin (controls 7.3 +/- 2.7; autistics 6.77 +/- 0.66) in the same homogenates did not differ significantly between groups. These results indicate for the first time that autistic cerebellum may be vulnerable to pro-apoptotic stimuli and to neuronal atrophy as a consequence of decreased Bcl-2 levels.

Dysregulation of Reelin and Bcl-2 proteins in autistic cerebellum.

Autism is a severe neurodevelopmental disorder with potential genetic and environmental causes. Cerebellar pathology including Purkinje cell atrophy has been demonstrated previously. We hypothesized that cell migration and apoptotic mechanisms may account for observed Purkinje cell abnormalities. Reelin is an important secretory glycoprotein responsible for normal layering of the brain. Bcl-2 is a regulatory protein responsible for control of programmed cell death in the brain. Autistic and normal control cerebellar corteces matched for age, sex, and post-mortem interval (PMI) were prepared for SDS-gel electrophoresis and Western blotting using specific anti-Reelin and anti-Bcl-2 antibodies. Quantification of Reelin bands showed 43%, 44%, and 44% reductions in autistic cerebellum (mean optical density +/- SD per 30 microg protein 4.05 +/- 4.0, 1.98 +/- 2.0, 13.88 +/- 11.9 for 410 kDa, 330 kDa, and 180 kDa bands, respectively; N = 5) compared with controls (mean optical density +/- SD per 30 microg protein, 7.1 +/- 1.6, 3.5 +/- 1.0, 24.7 +/- 5.0; N = 8, p < 0.0402 for 180 kDa band). Quantification of Bcl-2 levels showed a 34% to 51% reduction in autistic cerebellum (M +/- SD per 75 microg protein 0.29 +/- 0.08; N = 5) compared with controls (M +/- SD per 75 microg protein 0.59 +/- 0.31; N = 8, p < 0.0451). Measurement of beta-actin (M +/- SD for controls 7.3 +/- 2.9; for autistics 6.77 +/- 0.66) in the same homogenates did not differ significantly between groups. These results demonstrate for the first time that dysregulation of Reelin and Bcl-2 may be responsible for some of the brain structural and behavioral abnormalities observed in autism.

Patterns and temporal changes in peer affiliation among aggressive and nonaggressive children participating in a summer school program.

Examined the behavior and affiliation patterns of 118 highly, moderately, and nonaggressive 7-year-old children over the course of a 6-week summer school program. During free play, participants did not selectively associate on the basis of behavioral similarity, but initial mutual friendship choices did show a preference for similarly behaved peers. Nonreciprocated friendships at the beginning and end of the program and mutual friendships at the end revealed a preference of all children to be-friend nonaggressive peers. Moderately aggressive children increased their number of mutual friendships and their association with nonaggressive peers during free play, whereas highly aggressive children lost mutual friends. The aggressiveness of a child's playmates predicted the likelihood of that child behaving inappropriately during free play. Results suggest that selective affiliation may be the result of peer rejection rather than an active process of seeking similarly aggressive peers.

Predictive power of peer behavioral assessment for subsequent maladjustment in community samples of disruptive and nondisruptive children.

In a prospective, longitudinal study with community samples of disruptive and nondisruptive children, the predictive relations between peer-assessed dimensions of behavioral reputation in elementary school and teacher-rated behavioral adjustment and test scores of academic achievement were examined over a 4-year period. The Revised Class Play (RCP), a social role matching instrument completed by students about their classmates, was used to assess behavioral dimensions of children's peer reputation at baseline. Regression analyses showed that the RCP dimensions of aggressive-disruptive, sensitive-isolated, and social etiquette were the best predictors of later teacher-rated externalizing problems, internalizing problems, and subsequent adaptive skills respectively. Only IQ predicted later academic achievement. When IQ and disruptive/nondisruptive group status were added to each regression equation they further contributed as significant predictors. When parent and teacher ratings of behavior problems at baseline were entered jointly with RCP dimensions into regression equations, the peer dimensions further explained outcome variance. Additive effects of the RCP dimensions were found only for the externalizing problems outcome. Disruptive children with mild levels of aggressive behavior and high levels of sensitive-isolated behavior had less externalizing problems at outcome. A comparison of the difference between disruptive and nondisruptive groups in the relationship of baseline RCP scores to teacher outcomes showed no difference between groups, suggesting that the groups did not depart appreciably from their initial differences relative to each other over time.

Imipramine compliance in adolescents.

OBJECTIVE: To investigate side effects, medication compliance, and assumption of medication assignment in adolescents taking imipramine versus placebo in a clinical trial. METHOD: Sixty-three anxious-depressed adolescents in an 8-week double-blind study of imipramine versus placebo, each in combination with cognitive-behavioral therapy for school refusal, were evaluated. Measures of side effects, global improvement, family functioning, medication compliance based on pill counts, and guesses of drug assignment (imipramine versus placebo) were analyzed. RESULTS: Mean side effects ratings were significantly higher for the imipramine group compared with the placebo group (p = .001). Side effects were not associated with noncompliance or with dropping out. Oppositional defiant disorder (ODD) in the adolescents was significantly associated with medication noncompliance (p = .036). On the Family Adaptability and Cohesion Evaluation Scale II (FACES II), low family adaptability (i.e., rigidity), low family cohesion (i.e., disengagement), and extreme family type were significantly associated with greater noncompliance with medications. Accuracy rates for guessing medication assignment (imipramine versus placebo) were 66% for subjects, 62.5% for mothers, and 79.5% for the psychiatrist. Logistic regression demonstrated that side effects (p = .005) and global improvement scores (p = .06) predicted the psychiatrist's guesses of drug assignment. CONCLUSIONS: Side effects were not associated with noncompliance. Nonadherence with taking medications was associated with ODD in the adolescents and problematic family functioning on FACES II. The psychiatrist, who was blind to treatment condition, guessed the subjects' medication assignments with high accuracy. Thus, because of expectancy bias, the data support the use of blind independent evaluators for rating changes in medication trials.

Summary of the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and other Pervasive Developmental Disorders. American Academy of Child and Adolescent Psychiatry.

This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Autism and Other Pervasive Developmental Disorders. The parameters were written to aid clinicians in the assessment and treatment of children and adolescents with autism and other pervasive developmental disorders. Autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills, which arise in the first years of life. Although frequently associated with mental retardation, these conditions are distinctive in terms of their course and treatment. These conditions have a wide range of syndrome expression, and their management presents particular challenges for clinicians. Individuals with these conditions can present for clinical care at any point in development. The multiple developmental and behavioral problems associated with these conditions often require the care of multiple providers; coordination of services and advocacy for individuals and their families is important. Early, sustained intervention is indicated, as is the use of various treatment modalities (e.g., pharmacotherapy, special education, speech/communication therapy, and behavior modification.

Persistence and desistance of oppositional defiant disorder in a community sample of children with ADHD.

OBJECTIVE: To examine the developmental progression of comorbid oppositional defiant disorder (ODD) in a community sample of children with attention-deficit hyperactivity disorder (ADHD) with particular emphasis on persistence and desistance of ODD and the emergence of new cases of conduct disorder (CD). METHOD: A sample of disruptive children was identified from a multiple-gate epidemiological screen and stratified into diagnostic subgroups on the basis of a structured interview. A comparison sample of nondisruptive children was also identified. Group comparisons were performed on demographic, descriptive, family history, and clinical characteristics. Changes in rates of ODD symptoms and diagnostic subgroup membership were assessed after a 4-year longitudinal interval. Predictors of diagnostic group persistence were tested. RESULTS: Few differences distinguished diagnostic subgroups at baseline. Of the 43 children with baseline diagnoses of ADHD + ODD, only 1 (2.3%) was found to have developed CD at follow-up. Over time there was a 57% rate of ODD persistence and a 43% rate of ODD desistance. Negative parenting practices and mothers' psychiatric disorders predicted persistence of ODD. CONCLUSIONS: There was little evidence to show that ODD acted as a precursor to CD. However, when CD was diagnosed at baseline it was always associated with or preceded by ODD (i.e., prodrome). For a subgroup of children with ADHD, comorbid ODD symptoms are relatively unstable and may represent transient developmental perturbations that have little prognostic significance. For a larger subgroup of children with ADHD, ODD symptoms persist into the adolescent years and are associated with adverse parenting practices.

Sexual behaviors in autism: problems of definition and management.

Surveys of sexual behavior in autism suggest a variety of behavioral expression. However, the course of sexual development in autism is unplotted, leaving questions about the normalcy of specific behaviors. Even less is known about deviations of sexual development and the incidence of paraphilias in this population. We explore the problems of definition of sexual behaviors and describe a case report that highlights the difficulties of management. An application of a testosterone-suppressing medication and its effect on sexual behavior are reported. After failure of behavioral and educational programs, leuprolide, an injectable antiandrogen, resulted in suppression of behaviors and retention of the participants' community placement. Follow-up for almost 3 years shows no abnormal physical effects. Dosage has been tapered over that period to a low but effective dose. Directions for research are discussed.

Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues.

Autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills, which arise in the first years of life. Although frequently associated with mental retardation, these conditions are distinctive in terms of their course and treatment. These conditions have a wide range of syndrome expression, and their management presents particular challenges for clinicians. Individuals with these conditions can present for clinical care at any point in development. The multiple developmental and behavioral problems associated with these conditions often require the care of multiple providers; coordination of services and advocacy for individuals and their families is important. Early, sustained intervention is indicated, as is the use of various treatment modalities (e.g., pharmacotherapy, special education, speech/communication therapy, and behavior modification).

Fluoxetine in treatment of adolescent patients with autism: a longitudinal open trial.

Retrospective chart reviews of seven adolescent and young adults with autistic disorder treated with fluoxetine alone or in combination with other medications were performed. Patient's ages varied from 9-20 years (M +/- SD, = 16 +/- 3.87). Fluoxetine doses ranged from 20-80 mg per day (M +/- SD of final doses 37.14 +/- 21). Duration of treatment ranged from 1.3-32 months (M 18.04 +/- 10.39). Patients' symptoms were monitored using the Aberrant Behavior Checklist (ABC) rating scale during every visit. Side effects included initial appetite suppression, vivid dreams, and hyperactivity. Improvement from baseline was seen in four subscales: irritability (21%), lethargy (37%), stereotype (27%), and inappropriate speech (21%). Lethargy subscales improved significantly during treatment (p < .029). Hyperactivity subscale increased by 14% but did not attain statistical significance. Fluoxetine appears to have important behavioral effects in treatment of clinic-referred autistic children. Future double-blind placebo controlled studies evaluating core and associated symptom response with fluoxetine are warranted.

School-based secondary prevention for children with disruptive behavior: initial outcomes.

First through fourth graders from 22 suburban elementary schools were screened for cross-setting disruptive behavior as eligibility criteria for participation in a longitudinal secondary prevention study aimed at reducing the risk for serious externalizing behavioral disorders. Three hundred nine subjects participated in either a multicomponent competence enhancement intervention (MCEI) or an information/attention control (IAC) condition over a 2-year period. Following baseline requirements, initial intervention effects were assessed at the end of intervention Year 1, at the beginning of intervention Year 2 (fall of the next school year), and at the end of intervention Year 2. Multisource assessments were not supportive of the efficacy of the MCEI over the IAC condition. Children in both groups rated themselves as improved over time in terms of increased adaptive skills and decreased school problems and internalizing symptoms. Teacher and parent ratings of externalizing behavior did not yield evidence of positive change, but teachers noted improved problem solving and observers noted a decrease in behavioral interference in both groups over time, possibly as a result of maturation.

Peer assessment of social reputation in community samples of disruptive and nondisruptive children: utility of the revised class play method.

Examined the psychometric properties of the Revised Class Play (RCP), a peer assessment measure of social reputation, in epidemiological samples of disruptive (n = 220) and nondisruptive (n = 104) children in Grades 2 through 5. Principal components analyses yielded a four-factor solution that was similar for disruptive and nondisruptive children and to previous research with this instrument. Discriminative function analyses demonstrated that the four RCP dimensions were each successful in predicting group membership, with the leadership and social etiquette dimensions best able to differentiate disruptive and nondisruptive groups. Regression modeling showed that the variance accounted for by the four RCP dimensions was large and varied for specific dimensions based on the criterion variable chosen. The advantages of the RCP as a devise for tracking social competence and peer reputation in high-risk disruptive children are discussed.

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior.

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.

Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma.

OBJECTIVE: This study examines posttraumatic stress disorder (PTSD) symptoms, trauma exposure, gender, and diagnostic comorbidity in a sample of 59 Cambodian young adults (29 male and 30 female) who survived massive trauma as children. METHOD: Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-III-R-Non-Patient version, a structured diagnostic interview, and trauma exposure was measured with a Traumatic Life Events Questionnaire. RESULTS: A significant number of those with PTSD (59%) had one or more additional DSM-III-R Axis I disorders. Major depression and generalized anxiety disorder were the most common comorbid disorders. Somatoform pain disorder was also found to coexist with PTSD but only among females. Women were also found to have higher levels of both current and lifetime PTSD symptoms. CONCLUSION: Trauma symptoms were related to exposure and exposure was related to age, but age was not related to symptoms. The findings suggest that the significant levels of comorbid diagnoses previously found to exist with PTSD in people traumatized as adults can be found among survivors of massive childhood trauma. Also, the rate of PTSD diagnoses found in this sample 15 years after the trauma of Pol Pot is comparable to findings previously reported in studies of Cambodian youths and shows that the effects of trauma experienced in childhood persist into early adulthood.

Community-based multiple-gate screening of children at risk for conduct disorder.

The present study employed a multiple-gate screening procedure to identify children at risk for the development of conduct disorder. Measures of cross-setting disruptive behavior and parent discipline practices were administered in sequential fashion to screen a population of 7,231 children attending suburban elementary schools. Convergent validity of the respective gating measures was confirmed by significant correlations with adjustment constructs. Analyses of covariance performed between positive screens, negative screens, and low-risk comparison children on adjustment constructs at each gate supported the discriminative validity of the gating procedure. Hierarchical regression analyses demonstrated that the gating measures were predictive of diagnostic ratings of attention deficit hyperactivity disorder and oppositional defiant disorder that were obtained 18 months following the screening. A stepwise logistic regression analysis indicated that the best predictors of high-risk group membership were variables related to family process, including poor family communication and involvement, poor maternal coping skills, and an external parent locus of control.

Event-related potential evidence of dysfunction in automatic processing in abstinent alcoholics.

The preattentive automatic processing of 63 alcoholics and 27 controls was evaluated with an auditory inattentive event-related oddball paradigm. We examined the mismatch negativity and the N2-P3 complex. Results showed significantly greater amplitude for N2, P3 and the N2-P3 complex for controls but no individual lead (Fz, Cz, Pz) differences by group. A group-by-lead interaction was found for N2 and for the N2-P3 complex. There were no significant latency differences between groups; however, a significant age-by-group interaction effect on latency was greatest at the Cz electrode. Results reflect a possible aberration of automatic processing in alcoholics because of a defect in the mnemonic template necessary to match with an infrequent deviant stimuli. We also found suggestive evidence of a relative weakness of frontal cortical organization in alcoholics. Future studies are suggested that would help clarify these differences in alcoholics.