Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000.

BACKGROUND: A generation has passed since the literature on the conceptualisation, assessment and treatment of school refusal was reviewed in this journal (Elliott, ). In the light of considerable gaps in the literature, identified at that time, and growing international interest, the current paper sought to identify progress subsequently made this century. METHODS: We open with discussion of continuing conceptual uncertainty as to whether school refusal should incorporate both truancy and absenteeism marked by anxiety and distress. We then consider progress in treatment, and conclude by examining prognosis and subsequent adult functioning. In selecting intervention studies for review, our primary focus has been upon RCTS, systematic reviews and meta-analyses. RESULTS: The literature review indicates that, since the turn of the century, there has been little substantial advance in knowledge that can guide practitioners. Many of the issues raised in the 1999 paper, in particular, conceptual confusion over this heterogeneous condition, a dearth of rigorous RCT designs, limited knowledge of underlying mechanisms and uncertainty as to the long-term effects of specific forms of intervention, are little clearer than before. CONCLUSIONS: While several sound publications are available to guide intervention for school refusal, there is a continuing need for rigorous studies that can provide evidence to support individualised and tailored responses to an incapacitating problem with many causes and manifestations. While a multisystemic response to intervention approach is considered attractive, the practicalities of operating this across disparate professional borders are likely to present a long-term challenge.

Brief report: Development of the family perceptions scale; a novel instrument for evaluating subjective functioning in the families of adolescents.

A pool of 75 items relating to family functioning was created and piloted in a sample of 12-18 year olds (N = 673). The responses were subjected to an exploratory factor analysis which indicated the presence of three significant latent traits. The results were then used to inform the development of a rating instrument with five subscales labelled Nurture, Problem Solving, Expressed Emotion, Behavioural Boundaries and Responsibility. These demonstrated high levels of internal consistency (Cronbach's alphas .70-.81), high test-retest reliability (rho = .70-.82), varying degrees of intercorrelation (rho = .18-.75) and significant associations with family functioning as defined by the McMaster Family Assessment Device (p < 0.0001 in all cases). This novel instrument is a promising tool for use in both clinical practice and research.

The Diagnostic Utility of Executive Function Assessments in the Identification of ADHD in Children.

BACKGROUND: Deficits in executive functions have been widely reported to characterise individuals with ADHD. The aim of this study was to evaluate the utility of a range of executive function measures for identifying children with ADHD. METHOD: Eighty-three children with ADHD and 50 normally-developing children without ADHD were assessed on measures of inhibition, set-shifting, planning, problem-solving, response inhibition, sustained attention and working memory. Measures of sensitivity, specificity, likelihood ratios and diagnostic odds ratios were calculated. RESULTS: Executive function tasks effectively discriminated between children with and without ADHD. Measures of response inhibition and working memory contributed the most to the discriminant function. CONCLUSIONS: Cognitive measures of executive function can be used to help identify children with ADHD and could be useful as additional diagnostic tools for clinical practitioners.

The diagnostic utility of behavioral checklists in identifying children with ADHD and children with working memory deficits.

The present study investigated whether children with ADHD and those with working memory impairments have a common behavioral profile in the classroom. Three teacher checklists were used: the Conners' teacher rating scale (CTRS), the behavior rating inventory of executive function (BRIEF), and the working memory rating scale. The Conners' continuous performance test (CPT) was also included to determine whether there is a correspondence between performance on this widely used cognitive measure of attention deficits and teacher ratings of classroom behavior. All three behavior scales, but not the CPT, were able to successfully discriminate children with ADHD and those with working memory deficits from typically-developing children. Both the CTRS and the BRIEF discriminated a significant proportion of the children with ADHD from those with working memory deficits, indicating that while both groups exhibit behavioral problems in the classroom, they are characterized by differential attention profiles. The children with ADHD were identified on the basis of oppositional and hyperactive behavior, while those with working memory deficits were more inattentive.

The Impact of a Computer-Based Activity Program on the Social Functioning of Children with Autistic Spectrum Disorder.

BACKGROUND: Problems with social functioning are a major area of difficulty for children with autism. Such problems have the potential to exert a negative influence on several aspects of the children's functioning, including their ability to access education. This study looked to examine if a computer-based activity program could improve the social functioning of these children. MATERIALS AND METHODS: Using a pooled subject design, 100 children with autistic spectrum disorder were randomly allocated, controlling where possible for age and gender, to either an intervention or a control group. The children in the intervention group were encouraged to use the Nintendo (Kyoto, Japan) Wii™ and the software package "Mario & Sonic at the Olympics" in addition to their routine school physical education classes over a 9-month period. The control group attended only the routine physical education classes. RESULTS: After 1 year, analysis of the changes in the scores of teacher-completed measures of social functioning showed that boys in the intervention group had made statistically significant improvement in their functioning when compared with controls. The number of girls in the study was too small for any change to reach statistical significance. CONCLUSIONS: This type of intervention appears to have potential as a mechanism to produce improvement in the social functioning, at least of boys, as part of a physical education program.

The developmental, dimensional and diagnostic interview (3di): a novel computerized assessment for autism spectrum disorders.

OBJECTIVE: Autism is a diagnostic spectrum of variable severity, with significant comorbidity. No existing standardized interview measures autistic features dimensionally. The authors aimed to develop a parental autism interview that could be administered to unselected clinical and general population samples that measures both symptom intensity and comorbidity across the full range of the autistic spectrum. METHOD: A computerized procedure was devised for administration by trained interviewers that generates symptom and diagnostic profiles for both autism and non-autistic conditions. Test-retest reliability and interrater reliability were assessed in unselected clinical (n = 50) and nonclinical (n = 30) populations. Concurrent validity (n = 120), discriminant validity (n = 120), and criterion validity (n = 29) were evaluated in autistic spectrum and non-autistic patients. RESULTS: Test-retest and interrater reliabilities were excellent (most intraclass correlation coefficients > 0.9). Concurrent validity (agreement with independent clinician formulation) was very good (mean kappa = 0.74). Criterion validity, a comparison with the Autism Diagnostic Interview, was excellent. Discrimination between autistic spectrum versus non-autistic subjects was almost perfect (sensitivity 1.0; specificity > 0.97). CONCLUSIONS: The Developmental, Dimensional and Diagnostic Interview (3di) provides an efficient and accurate means of assessing, in dimensional terms, the presence of autistic symptoms in both clinical and normal populations. It offers novel opportunities for those engaged in research and clinical practice.

Developing a Resilience Package for Vulnerable Children.

In recent years great efforts have been made to clarify what factors make it more likely that a child will develop mental health problems, and what elements increase the resilience of vulnerable children, and hence protect them from becoming disturbed. With the increase in understanding about the nature of such resilience comes the possibility of developing preventative packages for at-risk groups. METHOD: Children whose parents have significant depressive illness have been offered a supportive package that seeks to increase their resilience. This focuses on the child's resources, family education and interaction, and community resources and supports for the family to access. RESULTS: Initial results show the package increases social activity, reduces emotionality and helps families become more flexible. CONCLUSION: Helping children reduce their risk of developing mental health problems is rightly an area of growing importance. This package is a potentially successful way of achieving this by promoting their resilience.

A Randomised Control Trial of the Impact of a Computer-Based Activity Programme upon the Fitness of Children with Autism.

The poor levels of fitness in children with autism are prompting concern for the children's future health. This study looked to assess if a computer-based activity programme could improve fitness levels (as reflected in cardiopulmonary function) of these children, and achieve a reduction in their body mass index. In a randomised controlled trial, 50 children with autism (of which 33 were under the age of 11 years and 39 were boys) were allocated to an intervention group which encouraged them to use the Nintendo Wii and the software package "Mario and Sonics at the Olympics" in addition to their routine physical education classes. 50 children with autism (34 under the age of 11 years and 40 being boys) acted as controls. At the end of one year, analysis of the changes in scores using analysis of covariance (ANCOVA) on the Eurofit fitness tests showed that the intervention group had made statistically significant improvement on all tests other than flexibility. These improvements were also significantly better than controls. This type of intervention appears to be an effective addition to standard fitness training in order to help children with autism improve their fitness levels.

Children with low working memory and children with ADHD: same or different?

The purpose of this study was to compare working memory (WM), executive function, academic ability, and problem classroom behaviors in children aged 8-11 years who were either identified via routine screening as having low WM, or had been diagnosed with ADHD. Standardized assessments of WM, executive function and reading and mathematics were administered to 83 children with ADHD, 50 children with low WM and 50 typically developing children. Teachers rated problem behaviors on checklists measuring attention, hyperactivity/impulsivity, oppositional behavior, and difficulties associated with executive function in the classroom. The ADHD and low WM groups had highly similar WM and executive function profiles, but were distinguished in two key respects: children with ADHD had higher levels of rated and observed impulsive behavior, and children with low WM had slower response times. Possible mechanisms for these common and distinct deficits are discussed.

Investigating the relationship between attention and working memory in clinical and community samples.

The first aim of the present study was to investigate whether differences in core deficits in ADHD subtypes lead to dissociable working memory profiles. The second aim was to compare the working memory profiles of inattentive students with those identified as having poor working memory, as they exhibit very similar behavioral profiles. Finally, the relationship between working memory and academic attainment in these groups were also of interest. Four groups of 9-year-olds were recruited: a community sample of children with inattentive symptoms, a clinically diagnosed group of children with ADHD-Combined, children with low working memory, and a healthy comparison group. They were assessed on measures of working memory, IQ, academic attainment, and sustained attention. The findings indicated that the combined and inattentive subtypes could not be distinguished on the basis of their working memory profile. In contrast, those with inattentive symptoms did better on the short-term memory tasks than the low working memory group. The majority of all three atypical groups performed very poorly in reading and math. This pattern can be interpreted as reflecting the link between working memory and academic attainment, even in those with attention problems.