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PubMedDate not supplied

The term comorbidity is of questionable value in reference to developmental disorders: data and theory.

Over the last decade, there has been an enormous increase in the number of studies evaluating the overlap of developmental syndromes or disorders in both children and adults. This overlap of symptoms is often referred to as comorbidity, a term we criticize in this article because of its unsubstantiated presumption of independent etiologies. The premise of this article is that discrete categories do not exist in real life, and that it is misleading to refer to overlapping categories or symptoms as "comorbidities." We illustrate our point by presenting data from 179 school-age children evaluated with rigorous research criteria for seven disorders: reading disability (RD), attention-deficit/hyperactivity disorder (ADHD), developmental coordination disorder (DCD), oppositional defiant disorder (ODD), conduct disorder (CD), depression, and anxiety. Fully 50% of this sample met the criteria for at least two diagnoses. The children with ADHD were at higher risk of having at least a second disorder compared to the children with RD. Overall, the high rates of overlap of these behavioral, emotional, and educational deficits in this broadly ascertained sample support the idea that the concept of comorbidity is inadequate. We discuss the concept of atypical brain development as an explanatory idea to interpret the high rate of overlap of developmental disorders.

Adolescent↗

PubMed2000

Do executive function deficits differentiate between adolescents with ADHD and oppositional defiant/conduct disorder? A neuropsychological study using the Six Elements Test and Hayling Sentence Completion Test.

Two neuropsychological measures of executive functions--Six Elements Tests (SET) and Hayling Sentence Completion Test (HSCT)--were administered to 110 adolescents, aged 12-15 years. Participants comprised four groups: Attention Deficit Hyperactivity Disorder (ADHD) only (n = 35). ADHD and Oppositional Defiant Disorder/Conduct Disorder (ODD/CD) (n = 38), ODD/CD only (n = 11), and a normal community control group (n = 26). Results indicated that adolescents with ADHD performed significantly worse on both the SET and HSCT than those without ADHD, whether or not they also had ODD/CD. The adolescents with ADHD and with comorbid ADHD and ODD/CD were significantly more impaired in their ability to generate strategies and to monitor their ongoing behavior compared with age-matched controls and adolescents with ODD/CD only. It is argued that among adolescents with clinically significant levels of externalizing behavior problems, executive function deficits are specific to those with ADHD. The findings support the sensitivity of these two relatively new tests of executive functions and their ecological validity in tapping into everyday situations, which are potentially problematic for individuals with ADHD.

Adolescent↗

PubMed1998

Factors influencing elementary school teachers' ratings of ADHD and ODD behaviors.

Examined factors that influence teachers' ratings of children with either attention deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD). 105 teachers watched 2 videotapes--1 depicting a normal child and the other a child with either ADHD or ODD--and rated each child using 2 different questionnaires. Results indicated that teachers accurately rated the child on the ADHD versus ODD tape as having significantly more inattention and hyperactivity but significantly less oppositionality. However, effect sizes indicated the presence of a unidirectional, negative halo effect of oppositional behaviors on ratings of hyperactivity and inattention. Teachers appeared less biased in their judgments when using a well-operationalized rating scale. Finally, knowledge, education, and experience with children with ADHD generally had no effect on the accuracy of teachers' ratings.

Adult↗

PubMed2006

Divalproex sodium reduces overall aggression in youth at high risk for bipolar disorder.

INTRODUCTION: The psychopharmacology of aggression in youth is relatively unexplored, even though such maladaptive aggression manifests across many different diagnoses. METHODS: This study was a 12-week, open-label trial with divalproex sodium (DVPX) in 24 bipolar offspring 6-18 years of age (mean age = 11.3 years; 17 boys) with mixed diagnoses of major depression, cyclothymia, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). The Overt Aggression Scale (OAS) was used to measure aggression in 4-week intervals. We measured serum gamma-butyric acid (GABA) and glutamate levels at baseline and week 12. RESULTS: Seventy-one percent of evaluable subjects were considered responders to DVPX treatment by the OAS. There was a significant correlation between the Young Mania Rating Scale (YMRS) and OAS scores at week 0 (p = 0.036) and week 12 (p = 0.025). Serum DVPX level did not correlate with treatment response. CONCLUSIONS: These youths who are at high risk for bipolar disorder experienced an overall decrease in aggressive behavior in response to DVPX. Age or gender did not predict a positive response to DVPX. This study is the first report of treatment efficacy of a mood stabilizer for aggression in youth at high risk for bipolar disorder.

Adolescent↗

PubMed1998

Is a mild deficit in executive functions in boys related to childhood ADHD or to parental multigenerational alcoholism?

A mild deficit in executive functions has been hypothesized to be associated with attention deficit hyperactivity disorder (ADHD), with externalizing problem behaviors such as conduct disorder (CD) and with the vulnerability to alcoholism in sons of multi-generational alcoholics (SOMGAs). These three categories overlap, which raises concerns about the specificity of the hypothesized associations. In the present study, measures of executive functions (EFs) were tested in seventy-six 7- to 11-year-old boys: boys with ADHD but without a family history of addiction, SOMGAs, and controls. Specific deficits in EFs were found for boys with ADHD but not for SOMGAs. The association between a deficit in EFs and attention problems remained after controlling for externalizing problem behaviors, but not for the reverse. These results suggest that a mild deficit in EFs is specifically related to ADHD and that the deficits reported in boys with CD and in SOMGAs are due to relatively high attentional problems in these groups or due to other factors such as motivation.

Alcoholism↗

PubMed2000

The problems of internal validation without a theoretical context: the different conceptual underpinnings of psychopathy and the disruptive behavior disorder criteria.

G. L. Burns (2000) has concluded that the Psychopathy Screening Device's content is limited because it contains items that overlap with criteria for several disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The problem with G. L. Burns's analysis is that it was conducted without an adequate understanding or specification of the conceptual underpinnings of either the construct of psychopathy or the constructs assessed by the DSM criteria. This reply attempts to clarify these conceptual frameworks to illustrate that to judge the adequacy of the content of a measure of psychopathy by comparing it with DSM criteria is inconsistent with the differing theoretical frameworks underlying these classification systems. Forcing measures of psychopathy to be designed around DSM criteria leads to inadequate measures of psychopathy and can limit advances both in our understanding of developmental precursors to psychopathy and in the classification of DSM disorders.

Antisocial Personality Disorder↗

PubMed2003

Diagnostic utility of DSM-IV-TR symptoms in the prediction of DSM-IV-TR ADHD subtypes and ODD.

OBJECTIVE: Examined the diagnostic utility of DSM-IV-TR symptoms in the prediction of DSM-IV-TR ADHD subtypes and ODD to: (a) Assess the relative utility of parent and teacher ratings, and (b) Examine the utility of individual symptoms as inclusion and exclusion criteria. METHOD: Parent and teacher versions of the Disruptive Behavior Disorders Rating Scale were completed for 440 children (217 boys; 223 girls) ranging in age from 9 to 13 years and were used to classify children into groups. Individual symptoms were used to compute corrected conditional probability statistics. RESULTS: Corrected positive predictive power (cPPP) statistics indicated that parent and teacher ratings had similar diagnostic utility in the prediction of the presence of ADHD, Inattentive Type and ADHD, Hyperactive/Impulsive Type, and that their combination did not provide incremental utility over either informant alone. However, cPPP statistics for ADHD, Combined Type, and ODD indicated that teacher ratings, and the use of combined parent and teacher ratings, provided an advantage over parent ratings alone. Results support the use of a multi-method, multi-informant assessment approach.

Adolescent↗

PubMed2003

Possible basal ganglia pathology in children with complex symptoms.

BACKGROUND: Clinical observation of children presenting with a myriad of motor, behavioral, emotional, and sensorial symptoms who do not respond to treatment led to the hypothesis that these children may constitute a unique population, perhaps even a new clinical entity. The literature on child and adolescent psychopathology does not specifically address the phenomenological, diagnostic, and etiological factors that make these children unique. For this reason, a preliminary study was conducted to identify additional symptoms and features that make these children different. METHOD: Data were collected in 2001 on 7 children with complex symptomatology using the Behavior Assessment System for Children, the Anxiety Disorders Interview Schedule for DSM-IV, and a neurological illnesses and symptoms questionnaire designed by the authors. RESULTS: On average, these children met full DSM-IV criteria for 1 to 5 diagnoses. The most prevalent diagnoses were attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, oppositional defiant disorder, and pervasive developmental disorder. These children also exhibited a high incidence of sensory hyperarousal, aggressiveness, hypersexuality, and neuroethological behaviors. Almost all of the children also had indications of a history of bacterial or viral infection. CONCLUSION: The specific symptoms identified and the biological factors found in many of the children seem to suggest basal ganglia involvement.

Adolescent↗

PubMed1998

Psychiatric and psychological morbidity as a function of adaptive disability in preschool children with aggressive and hyperactive-impulsive-inattentive behavior.

Children with high levels of aggressive-hyperactive-impulsive-inattentive behavior (AHII; n = 154) were subdivided into those with (n = 38) and without (n = 116) adaptive disability (+AD/-AD) defined as a discrepancy between expected versus actual adaptive functioning. They were compared to each other and a control group of 47 normal children. Both AHII groups were more likely to have attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder than control children; more symptoms of general psychopathology; greater social skills deficits; more parental problems; and lower levels of academic achievement skills. Compared to AHII - AD children, AHII + AD children had (1) more conduct disorder; (2) greater inattention and aggression symptoms; (3) more social problems, less academic competence, and poorer self-control at school; (4) more severe and pervasive behavior problems across multiple home and school settings; and (5) parents with poorer child management practices. Thus, adaptive disability has utility as a marker for more severe and pervasive impairments in AHII children.

Achievement↗

PubMed2003

Juvenile bipolar disorder in Brazil: clinical and treatment findings.

BACKGROUND: Because few studies were conducted to evaluate bipolar disorder in children and adolescents outside North America, this investigation aims to describe clinical features, pattern of comorbidities, and response to pharmacologic treatment in a sample of youths with bipolar disorder (BD) from a pediatric psychopharmacology outpatient clinic in Brazil. METHODS: We performed a retrospective chart review of all patients under age 15 with BD diagnoses who were evaluated and treated in our clinic from 1998-2001. A comparison sample of subjects with attention-deficit/hyperactivity disorder (ADHD) without BD (n = 362) was also evaluated. RESULTS: The prevalence of juvenile BD in our sample was 7.2% (36/500) (95% confidence interval = 5.2-9.9). Irritable mood was detected in 91.7% of the bipolar patients. The main comorbidity found was ADHD (58.3%). Children with BD had significantly higher rates of abnormally elevated CBCL scores in the externalizing dimension, anxiety and depression, delinquent behavior, and aggressive behavior scales than ADHD subjects (p <.05). Most BD patients (78%) needed combination drug therapy to achieve symptomatic control. CONCLUSIONS: Our results replicate clinical and treatment findings from U.S. investigations in a different culture demonstrating that juvenile BD is not a rare disorder in clinical samples.

Adolescent↗

PubMed2003

Social skills training in children with attention deficit hyperactivity disorder: a randomized-controlled clinical trial.

Evaluated efficacy of social skills training (SST) on children with 2 subtypes of attention deficit hyperactivity disorder (ADHD). Participants were 120 children (30 girls, 90 boys), ages 8 to 12 with ADHD-Inattentive type (ADHD-I; n = 59) or Combined type (ADHD-C; n = 61). The children were randomly assigned within diagnosis subtype to the treatment condition (8 weeks of SST) or the no-intervention control condition. SST led to greater improvements in both parent- and child-perceived assertion skills in the children with ADHD, yet did not affect the other domains of social competence. Diagnostically heterogeneous groups led to greater improvements on parent-report of their child's cooperation and assertion abilities as well as children's report of their own empathy skills. Diagnostically homogeneous groups led to greater decreases in externalizing behaviors at posttreatment but not at follow-up. Children with comorbid oppositional defiant disorder (ODD) did not benefit as much from the intervention. Children with ADHD-I improved in assertion skills more than children with ADHD-C, yet the 2 diagnostic entities did not differ in improvement levels across all other social skills.

Attention Deficit Disorder with Hyperactivity↗

PubMed2001

Behavioral and neural consequences of prenatal exposure to nicotine.

OBJECTIVE: To review evidence for the neurodevelopmental effects of in utero exposure to nicotine. Concerns about long-term cognitive and behavioral effects of prenatal exposure to nicotine arise from reports of increased rates of disruptive behavioral disorders in children whose mothers smoked during pregnancy. The relatively high rate of tobacco smoking among pregnant women (25% of all pregnancies in the U.S.) underlines the seriousness of these concerns. METHOD: This review examines the largest and most recent epidemiological and clinical studies that investigated the association of prenatal nicotine exposure with health, behavioral, and cognitive problems. Because of the numerous potential confounding variables in human research, findings from animal studies, in which environmental factors are strictly controlled, are also discussed. Finally, neural and molecular mechanisms that are likely to underlie neurodevelopmental disruptions produced by prenatal nicotine exposure are outlined. RESULTS: A dose-response relationship between maternal smoking rates and low birth weight (potentially associated with lower cognitive ability) and spontaneous abortion is consistently found, whereas long-term developmental and behavioral effects in the offspring are still controversial, perhaps because of the difficulty of separating them from other genetic and environmental factors. Despite the wide variability of experimental paradigms used in animal studies, common physical and behavioral effects of prenatal exposure to nicotine have been observed, including low birth weight, enhanced locomotor activity, and cognitive impairment. Finally, disturbances in neuronal pathfinding, abnormalities in cell proliferation and differentiation, and disruptions in the development of the cholinergic and catecholaminergic systems all have been reported in molecular animal studies of in utero exposure to nicotine. CONCLUSIONS: Prenatal exposure to nicotine may lead to dysregulation in neurodevelopment and can indicate higher risk for psychiatric problems, including substance abuse. Knowledge of prenatal exposure to nicotine should prompt child psychiatrists to closely monitor at-risk patients.

Animals↗

PubMed2004

Latina mothers' stances on stimulant medication: complexity, conflict, and compromise.

This study was undertaken to understand and describe Latina mothers' cognitions and attitudes toward the use of medication for their young children's behavior problems under the premise that these factors are determinants of noncompliance and inadequate adherence to medication treatments. Quantitative and qualitative data were extracted from a multimethod study of professional help seeking. Participants were 62 mothers from Cuba, Puerto Rico, and the Dominican Republic. Findings indicated that mothers overwhelmingly preferred treatment options other than medication primarily because they understood medication to be addictive, dulling of cognitive processes, and inappropriate for behavior problems. Inadequate adherence was common and logically consistent with maternal cognitions. Maternal choices with respect to the use of medication were transactional and quite complex in nature and changed over time. The strongest agents in this process were schools and the mothers' immediate family. Implications for clinical practice are presented.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Screening for DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operating characteristic analysis.

BACKGROUND: This study examines the diagnostic accuracy of the CBCL syndrome AS scales for predicting DSM-IV Attention Deficit-Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder with or without Conduct Disorder (ODD/CD). METHODS: The sample included 370 children (187 probands and 183 siblings) participating in a family genetic study of attention and aggressive behavior problems. Univariate and stepwise logistic regression analyses were used to derive models for predicting two diagnostic conditions: ADHD and ODD/CD. RESULTS: The Attention Problems syndrome significantly predicted ADHD, and ODD/CD was significantly predicted by the Aggressive Behavior syndrome. Both scales demonstrated good diagnostic accuracy, as assessed through receiver operating characteristics analyses. Cut-point analyses confirmed the utility of low T-scores, 55 on the respective syndromes, for efficiently discriminating cases from noncases. CONCLUSIONS: CBCL syndromes display good diagnostic efficiency for assessing common externalizing disorders in children.

Adolescent↗

PubMed2001

Predictors of adolescent psychopathy: the role of impulsivity, hyperactivity, and sensation seeking.

Clinical applications to psychopathy encompass downward extensions to adolescent populations. In alliance with clinical practice, several prominent researchers have formulated prediction models for adolescent psychopathy that include various forms of behavioral dysregulation, including impulsivity, attention-deficit/hyperactivity disorder (ADHD), and sensation seeking. As a cross-sectional study, the current investigation systematically examined behavioral dysregulation in 79 male adolescents who, as a result of adjudication, were placed them in a maximum-security facility. Impulsivity appeared to be the best predictor of both psychopathy and conduct problems. In addition, conduct-disordered symptoms were predicted mostly by impulsivity, with minor contributions from sensation seeking and ADHD symptoms.

Adolescent↗

PubMed2003

Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD.

From the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder--a randomized clinical trial of 579 children ages 7-9 years receiving 14 months of medication management, behavioral treatment, combination, or community care--the authors matched each African American and Latino participant with randomly selected Caucasian participants of same sex, treatment group, and site. Although Caucasian children were significantly less symptomatic than African American and Latino children on some ratings, response to treatment did not differ significantly by ethnicity after controlling for public assistance. Ethnic minority families cooperated with and benefited significantly from combination (multimodal) treatment (d = 0.36, compared with medication). This incremental gain withstood statistical control for mother's education, single-parent status, and public assistance. Treatment for lower socioeconomic status minority children, especially if comorbid, should combine medication and behavioral treatment.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Significance of childhood conduct problems to later development of conduct disorder among children with ADHD: a prospective follow-up study.

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.

Adolescent↗

PubMed2005

Understanding the covariation among childhood externalizing symptoms: genetic and environmental influences on conduct disorder, attention deficit hyperactivity disorder, and oppositional defiant disorder symptoms.

Conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) are common childhood externalizing disorders that frequently co-occur. However, the causes of their comorbidity are not well understood. To address that question, we analyzed data from >600 Finnish twin pairs, who completed standardized interviews at age 14. Behavior genetic methods were used to examine how genetic/environmental factors contribute to each disorder's symptoms and to their covariation. We found significant genetic effects on each disorder with only modest evidence of shared environmental influences. Our data suggest the comorbidity among CD, ADHD, and ODD is primarily explained by shared genetic influences; however, each disorder was also under unique genetic influence, supporting the distinction of each disorder.

Adolescent↗