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PubMed2005

Sources of covariation among the child-externalizing disorders: informant effects and the shared environment.

BACKGROUND: Research has documented high levels of co-morbidity among childhood externalizing disorders, but its etiology remains in dispute. Specifically, although all behavior genetic studies of the etiology of the co-occurrence of attention deficit-hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) agree that genetic factors are important, differences exist across studies in the relative weight assigned to genetic, shared environmental factors (i.e. factors that increase similarity among family members), and non-shared environmental factors (i.e. factors that decrease similarity among family members). Because heritability estimates can vary across informants, we used a biometric informant-effects model to determine whether these discrepancies were a function of systematic differences in maternal and child informant reports of ADHD, CD, and ODD. METHOD: We studied 1782 11-year-old twins from the Minnesota Twin Family Study. Symptom counts for each disorder were obtained from interviews administered to twins and their mothers. We fit a model that allowed us to examine, both across and within informants, the genetic and environmental contributions to the co-occurrence among ADHD, CD, and ODD. RESULTS: The results revealed that the co-occurrence among the disorders common to maternal and child informant reports was influenced largely by shared environmental forces. Genetic factors also contributed, though their impact was only marginally significant. In contrast, the co-occurrence unique to each informant was influenced exclusively by either genetic or non-shared environmental factors. CONCLUSIONS: Such findings offer additional evidence that shared environmental factors are important to the co-morbidity among ADHD, CD, and ODD, and highlight the necessity of considering informant effects when drawing conclusions about the origins of co-morbidity from analyses of genetically informative data.

Attention Deficit Disorder with Hyperactivity↗
PubMed2003

Attention-deficit-hyperactivity disorder with and without oppositional defiant disorder in 3- to 7-year-old children.

Attention-deficit-hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a high degree of associated behavioural problems. In order to study characteristics of ADHD with and without oppositional defiant disorder (ODD) in a representative group of young children with clinical impairment in Sweden, 131 children (101 males, 30 females) with ADHD (mean age 5 years, SD 1 year 5 months; range 3 to 7 years) were clinically examined, and their parents interviewed. Independent questionnaire data (Child Behavior Checklist, ADHD Rating Scale-IV, ODD Rating Scale-IV, Conners Hyperactivity Index) were collected. For comparison 131 children without ADHD were matched for sex, age, marital status, and socioeconomic status (115 males, 16 females; mean age 4 years 10 months, SD 1 year 5 months; range 3 to 7 years). Sixty percent of those with ADHD met full DSM-IV criteria for ODD. Only 10 of the 131 children with ADHD had no symptoms of ODD at all. The rate of children meeting full diagnostic criteria for ODD was similar across all age cohorts. Males were overrepresented in ODD, as were children of divorced parents and of mothers with low socioeconomic status. ADHD combined subtype was a stable independent factor influencing the diagnosis of ODD, regardless of psychosocial factors. Those with ADHD with ODD consistently showed higher rates of ADHD symptoms than did those with ADHD without ODD. The prevalent comorbidity of ADHD with ODD indicates that all children presenting with ADHD or ODD symptoms need to be assessed with a view to exploring both types of problem behaviours. The link between ODD and some psychosocial variables indicates the need to address these, possibly by measures such as parent training and network support.

Attention Deficit Disorder with Hyperactivity↗
PubMed2006

[Oppositional behavior in children and adolescents].

Opposition is a natural and beneficial process for children to shape their personality, it is a necessary step in their own and parents' life. It challenges the five rules governing children's life: parents' educational principles, school constraints, social rules, rules with "peers" and children's own rules. However, opposition can become pathological: symptoms of oppositional behaviors include defying requests, psychosomatic disorders in infants, offending behavior and oppositional defiant disorder. It is essential to identify them, encourage active family participation and look for a coexisting psychological condition. Oppositional disorders should be managed rapidly to prevent them from becoming chronic or evolving towards oppositional defiant or conduct disorders.

Adolescent↗
PubMed2006

Effect of comorbid symptoms of oppositional defiant disorder on responses to atomoxetine in children with ADHD: a meta-analysis of controlled clinical trial data.

RATIONALE: Up to 60% of children with attention-deficit/hyperactivity disorder (ADHD) suffer from comorbid affective or behavioral impairments, the most common condition being oppositional defiant disorder (ODD), which occurs in 40-60% of children with ADHD. OBJECTIVES: This post hoc meta-analysis was performed to determine the effect of the presence of comorbid ODD symptoms on clinical outcomes among pediatric and adolescent subjects being treated for ADHD. METHODS: Acute-phase data were analyzed from three randomized, double-blind, placebo-controlled studies in outpatients aged 6-16 and meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for ADHD. Subjects received placebo or atomoxetine (max 1.8 mg/kg/day, daily) for 6-8 weeks. Patients were diagnosed with comorbid ODD on structured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime Versions). RESULTS: Of the 512 subjects studied, 158 were diagnosed with comorbid ODD. Relative to placebo, atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects irrespective of the comorbidity with ODD. ADHD subjects also showed significant improvements from baseline on most of the psychosocial measures of the child health questionnaire irrespective of the comorbidity with ODD. Reduction in ODD symptoms was highly related to the magnitude of ADHD response. CONCLUSIONS: Atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects to similar extents, indicating that the presence of comorbid symptoms of oppositionality does not affect clinical outcomes of treatment of ADHD with atomoxetine.

Adolescent↗
PubMed2001

Origins and consequences of age at first drink. II. Familial risk and heritability.

BACKGROUND: The association of age at first drink (AFD) and alcoholism may reflect a common inherited vulnerability to disinhibitory behavior and psychopathology rather than a direct influence of the former on the latter. We tested the common-inherited-vulnerability hypothesis by determining whether AFD is familial and heritable. METHODS: A sample of 1,232 14-year-old twins was classified according to their biological parents' AFD. RESULTS: Lifetime symptoms of externalizing disorders (i.e., conduct disorder and oppositional defiant disorder) were significantly higher in the sons but not the daughters of parents whose AFD came before age 15 years. Offspring symptoms of internalizing disorders (i.e., major depressive disorder, separation anxiety disorder, and overanxious disorder) were not significantly associated with parental early use of alcohol in either sons or daughters. Early use of alcohol in mothers but not fathers was associated with a significant increase in both sons' and daughters' risk of alcohol use by age 14. The contribution of genetic and environmental factors to risk of early alcohol use was investigated in a sample of 416 monozygotic (MZ) and 225 like-sex dizygotic (DZ) 14-year-old twin pairs. Twin similarity for early alcohol use was substantially greater in MZ than DZ twins in boys but about equally similar in MZ and DZ twins in girls. Estimated heritability of early alcohol use was significantly greater in boys (55%) than girls (11%), in part because the genetic factors underlying symptoms of disinhibitory psychopathology contributed more to risk of early alcohol use in boys than girls. CONCLUSIONS: Early use of alcohol is familial and, at least in males, heritable. The familial transmission of early alcohol use is caused in part by genetic risk for disinhibitory psychopathology in males and to shared environmental factors in girls. These results provide some support for a common-inherited-vulnerability hypothesis, and suggest that the processes underlying early alcohol use may differ in boys and girls.

Adolescent↗
PubMed2004

Nine months of multicomponent behavioral treatment for ADHD and effectiveness of MTA fading procedures.

We examined 9-month data from the 14-month NIMH Multimodal Treatment Study of Children with ADHD (the MTA) as a further check on the relative effect of medication (MedMgt) and behavioral treatment (Beh) for attention-deficit/hyperactivity disorder (ADHD) while Beh was still being delivered at greater intensity than at 14-month endpoint, and conversely as a check on the efficacy of the MTA behavioral generalization/maintenance procedures. Intention-to-treat analysis at 9 months showed essentially the same results as at 14 months, after Beh had been completely faded; MedMgt and the combination (Comb) of medication and Beh were significantly superior to Beh and community care (CC) for ADHD and oppositional-defiant (ODD) symptoms, with mixed results for social skills and internalizing symptoms. All treatment-group differences examined as changes in slopes from 9 to 14 months were nonsignificant (we found general improvement for all groups). Slopes from baseline to 9 months correlated highly (r > .74, p < .0001) with slopes from baseline to 14 months for all groups. The time function from baseline to 14 months showed a significant linear, but not quadratic, trend for the main outcome measure (a composite of parent- and teacher-rated ADHD and ODD symptoms) for all groups. Findings suggest that in contrast to the hypothesized deterioration in the relative benefit of Beh between 9 and 14 months (after completion of fading), the MTA Beh generalization and maintenance procedures implemented through 9 months apparently yielded continuing improvement through 14 months, with preservation of the relative position of Beh compared to other treatment strategies.

Analysis of Variance↗
PubMed2003

Alterations in stress cortisol reactivity in depressed preschoolers relative to psychiatric and no-disorder comparison groups.

BACKGROUND: Despite the robust and widely replicated finding of elevated hypothalamic-pituitary-adrenal (HPA) axis reactivity in depressed adults, studies of depressed children have yielded ambiguous findings. Animal models of early depression and studies of children experiencing early psychosocial deprivation have suggested that alterations in HPA axis reactivity are evident in early "depressive-like" conditions. The current study is, to our knowledge, the first investigation of HPA axis reactivity in very young children with a clinical depressive syndrome for which content validity has been established. METHODS: Depressed, psychiatric, and no-disorder comparison children aged 3 through 5.6 years were studied for HPA axis reactivity in response to experimental psychosocial stressors. The children were diagnosed using a developmentally appropriate, structured psychiatric interview. Salivary cortisol was obtained at 3 time points during a laboratory assessment before and after stressors involving separation from the parent and frustrating tasks. RESULTS: Repeated measures of multivariate analysis of variance revealed a significant interaction between the diagnostic group and 2 cortisol percent change scores. Depressed preschoolers displayed a pattern of increasing cortisol levels throughout the assessment in response to both separation and frustration stressors. In contrast, both comparison groups showed decreasing cortisol levels in response to the separation stressor. All groups displayed increasing cortisol levels in response to frustrating tasks. Preschoolers with a presumptive melancholic depressive subtype displayed these alterations at a greater magnitude relative to comparison groups. CONCLUSIONS: To our knowledge, these findings are the first to demonstrate altered HPA axis reactivity in depressed preschoolers. These alterations are consistent with those described in depressed adults and in animal models of early depression. These findings provide evidence for possible continuity of HPA axis alterations in depressive disorders across the lifespan and are discussed in the context of prior studies of HPA axis reactivity in clinically depressed children and adolescents, suggesting that younger age and inpatient status are features associated with altered HPA axis reactivity.

Arousal↗
PubMed2003

Parent-child conflict and the comorbidity among childhood externalizing disorders.

BACKGROUND: Previous research has suggested that substantial comorbidity exists among childhood externalizing disorders, specifically attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Moreover, parent-child conflict predicts each of these disorders. Our goals were to determine whether parent-child conflict was associated with the comorbidity among ADHD, CD, and ODD, and to explicitly examine the etiology of this association via a genetically informative design. METHODS: We compared the fit of the following 2 biometric models: the 2-factor common-pathway model, which examined genetic and environmental contributions to the relationship between conflict and the covariation among the 3 disorders, and the Cholesky model, which examined the relationship between conflict and each disorder individually. The sample consisted of 808 same-sex 11-year-old twin pairs from the Minnesota Twin Family Study, a population-based sample of Minnesota twins and their families. Main outcome measures included symptom counts for ADHD, CD, and ODD, obtained from structured interviews administered to twins and their mothers. Parent-child conflict was assessed via mother and twin reports of the Parental Environment Questionnaire. RESULTS: The 2-factor model provided a better fit to the data. These results indicated that conflict accounted for 33% of the covariation among the disorders, via genetic and environmental factors. CONCLUSIONS: Parent-child conflict appears to act as a common vulnerability that increases risk for multiple childhood disorders. Furthermore, this association is mediated via common genetic and environmental factors. These findings support the idea that the comorbidity among these disorders partially reflects core psychopathological processes in the family environment that link putatively separate psychiatric disorders.

Adult↗
PubMed2004

The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment.

BACKGROUND: Few prevalence studies in which DSM-IV criteria were used in children in representative community samples have been reported. We present prevalence data for the child and adolescent population of Puerto Rico and examine the relation of DSM-IV diagnoses to global impairment, demographic correlates, and service use in an island-wide representative sample. METHODS: We sampled 1886 child-caretaker dyads in Puerto Rico by using a multistage sampling design. Children were aged 4 to 17 years. Response rate was 90.1%. Face-to-face interviews of children and their primary caretakers were performed by trained laypersons who administered the Diagnostic Interview Schedule for Children, version IV (DISC-IV) in Spanish. Global impairment was measured by using the Children's Global Assessment Scale scored by the interviewer of the parent. Reports of service use were obtained by using the Service Assessment for Children and Adolescents. RESULTS: Although 19.8% of the sample met DSM-IV criteria without considering impairment, 16.4% of the population had 1 or more of the DSM-IV disorders when a measure of impairment specific to each diagnosis was considered. The overall prevalence was further reduced to 6.9% when a measure of global impairment was added to that definition. The most prevalent disorders were attention-deficit/hyperactivity disorder (8.0%) and oppositional defiant disorder (5.5%). Children in urban settings had higher rates than those in rural regions. Older age was related to higher rates of major depression and social phobia, and younger age was related to higher rates of attention-deficit/hyperactivity disorder. Both overall rates and rates of specific DSM-IV/DISC-IV disorders were related to service use. Children with impairment without diagnosis were more likely to use school services, whereas children with impairment with diagnosis were more likely to use the specialty mental health sector. Of those with both a diagnosis and global impairment, only half received services from any source. CONCLUSIONS: Because we used the DISC-IV to apply DSM-IV criteria, the study yielded prevalence rates that are generally comparable with those found in previous surveys. The inclusion of diagnosis-specific impairment criteria reduced rates slightly. When global impairment criteria were imposed, the rates were reduced by approximately half.

Adolescent↗
PubMed2000

Hypescheme: an operational criteria checklist and minimum data set for molecular genetic studies of attention deficit and hyperactivity disorders.

Investigators engaged in mapping the genetic basis of attention deficit hyperactivity disorder (ADHD) currently use a number of measures for the collection of clinical information. This gives rise to difficulties in comparing datasets and research communications between independent groups. This paper describes the development of Hypescheme, which is an operational criteria checklist for ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD), and is proposed as a minimum dataset for those engaged in molecular genetic studies of ADHD. Hypescheme consists of a computerised data checklist system that includes all the operational criteria required for both DSM-IV and ICD-10 diagnostic criteria and a systematic record of information about comorbid psychiatric, developmental, and neurological disorders. Using this data, an algorithm applies both DSM-IV and ICD-10 criteria to generate operational diagnostics under both these systems. Hypescheme is not designed to replace current assessment protocols but to be a final common checklist that can be completed by experienced researchers using all available data.

Attention Deficit Disorder with Hyperactivity↗
PubMed2004

Phenotype studies of the DRD4 gene polymorphisms in ADHD: association with oppositional defiant disorder and positive family history.

The objective of this study was to investigate association of DRD4 polymorphisms with ADHD subtypes for which there is evidence for increased heritability. The genetic variants tested were the 120 bp insertion/deletion, the -616, -521, -376, and the 48 bp DRD4 VNTR. The primary analyses were of association with oppositional defiant disorder (ODD), conduct disorder (CD), and diagnostic subtypes. Secondary analyses of clinical subtype were exploratory in nature and included analysis of association of DRD4 polymorphisms with family history of ADHD. We observed significant association between DRD4 7-repeat allele transmission and ADHD children with comorbid ODD (chi(2) = 6.74, df = 1, P = 0.01, OR = 2.45) The DRD4 7-repeat allele was also significantly associated with family history positive ADHD (chi(2) = 10.12, df = 1, P = 0.0021, OR = 3.57). We observed no significant distortion in the transmission of any of the tested DRD4 variants with inattentive or hyperactive-impulsive subtypes or symptom dimensions. In conclusion, our findings of increased DRD4 7-repeat allele transmission in ODD extend those reported by Holmes et al. To our knowledge, this is the first study to report association of the DRD4 7-repeat allele with ADHD children who have a positive family history of ADHD. Overall, the results from this study support the investigation of clinical subtypes in molecular genetic studies of ADHD.

Adult↗
PubMed2002

Dimensional measures of psychopathology. The probability of being classified with a psychiatric disorder using empirically derived symptom scales.

OBJECTIVES: We sought to develop a ranking scheme that assigns a probability of having one of four psychiatric disorders to children based on their scores on a symptom scale. We then estimated the impact of each scale symptom on the prevalence of the disorder in the population. METHOD: Logistic regressions were specified for ADHD, ODD, depressive, and conduct disorders using all the individual symptoms in the pertinent scale as predictors. Individual fitted values from the regression function then served as a probability scale measure. We combined the prevalence and influence of each scale symptom to calculate its overall impact on the prevalence of the disorder. RESULTS: Probability distributions had a wide range of values and discriminated between cases and non-cases. Those having a disorder were consistently associated with higher probabilities in the scale. The estimated probability corresponds to the empiric prevalence of the diagnosis in a group of persons sharing the same estimated probabilities. Symptoms varied on their impact on the prevalence of the disorder. CONCLUSIONS: We recommend the estimated probability of the disorder based on the empirically defined scales as dimensional measures that complement prevalence of the disorder. Different symptoms are identified as targets for screening when selection is based on their impact on the prevalence of the disorder than when selection is based on the strength of the association with the disorder. We recommend using a common nosology with different classification schemes; the categorical definition of the disorder, the probability of having the disorder, and the impact of each symptom in the prevalence. Different measures serve different purposes.

Adolescent↗
PubMed2003

"A school for all kinds of minds." The impact of neuropsychiatric disorders, gender and ethnicity on school-related tasks administered to 9-10-year-old children.

This cross-sectional study of reading,writing and mathematics skills in a total population of 589 children attending 4th grade in regular public schools showed that neuropsychiatric disorder was a strong predictor of poor performance, girls scored better than boys on language tests and some mathematics test, and immigrant children had similar results as native Swedish children on most tests. Sixty percent of boys with and 7% of boys without DAMP (Deficits in Attention,Motor control and Perception) or ADHD (Attention- Deficit/Hyperactivity Disorder) had substantial school difficulties. The rate of children requiring individualised special education measures was estimated at a minimum of 15%. This constitutes a major challenge to a society claiming to offer equal opportunities and participation for all children.

Attention Deficit Disorder with Hyperactivity↗
PubMed2004

The distribution of symptoms of attention-deficit/hyperactivity disorder and oppositional defiant disorder in school age children in Turkey.

OBJECTIVE: The aim of this study was to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in school age children in Sivas province centre and to examine the distribution of symptoms according to subtypes. METHOD: The study population was made up of 1425 children between the ages of 6 and 15 from eight primary schools selected by random sampling method in Sivas province centre. All students were given a questionnaire prepared according to DSMIV criteria that was completed by their parents or teachers. This form includes 18 symptoms of ADHD and eight symptoms of ODD. Student's t-test and variance analysis were used for statistical evaluation. RESULTS: A prevalence of 8.1% was found for ADHD in our study. According to subtypes, 32.2% of these were "inattentive", 40% were "hyperactive" and 27.8% were combined type. A prevalence of 11.5% was found for ODD. The boy/girl ratio was > 1 for both ADHD and ODD, and 52.2% of those with ADHD were established as having ODD at the same time. CONCLUSIONS: The prevalence of ADHD and ODD in primary school children was not considered to be small. Studies concerning the distribution of symptoms in different societies, cultures, and viewpoints and identification of children with this type of problem are beneficial for early diagnosis and prophylactic treatment.

Adolescent↗
PubMed2005

Prediction of adolescent outcome in children with disruptive behaviour disorders--a study of neurobiological, psychological and family factors.

In this preliminary study we explored the predictive influence of various family, psychological, demographic, and neurobiological characteristics on the persistence of antisocial behaviour in adolescence. Existing data were combined with case-records in a sample of 47 disruptive behaviour disordered (DBD) children who had been treated in in-patient and/or day-treatment units when they were between seven to 12 years old. Parent-rated and self-rated externalizing problem scores and the presence of a DBD diagnosis served as the outcome measures in adolescence. We used linear regression analyses to examine the predictors of adolescent outcome. A lower basal skin conductance level (SCL) was repeatedly found to predict poor adolescent outcome, either when rated by parents or by participants themselves. In addition, comorbid attention-deficit hyperactivity disorder, one aspect of performance on the door-opening task, and a mother of low socioeconomic status also predicted that a child would have more antisocial problems in adolescence, depending on the type of outcome measure. Results of this study support the fearlessness theory, according to which low activity of the autonomous nervous system, as manifested by low SCL, is related to the effectiveness of socializing punishment and accordingly to poor socialization and adolescent outcome.

Adolescent↗
PubMed2005

DSM-IV or ICD-10-DCR diagnoses in child and adolescent psychiatry: does it matter?

OBJECTIVE: DSM-IV is the most widely used diagnostic classification system in research, whereas ICD-10 is more widely used clinically. Knowledge of differences is essential when research findings are implemented in daily clinical practice. We examined differences between the two diagnostic systems regarding three major child psychiatric diagnostic categories. METHODS: A total of 199 consecutively referred, child psychiatric patients were interviewed with a semistructured diagnostic interview (K-SADS-PL) including questions covering specific ICD-10-DCR criteria, and diagnosed according to both diagnostic systems. RESULTS: Differences were found regarding the diagnoses major depressive disorder/depressive episode and attention deficit hyperactivity disorder/disturbance of activity and attention. In both cases, more children met DSM-IV-TR criteria than ICD-10-DCR criteria. The diagnosis, oppositional defiant disorder, proved interchangeable between the two diagnostic systems. CONCLUSION: Differences between diagnostic systems must be taken into account when research findings using one diagnostic system are implemented with children diagnosed by another diagnostic system.

Adolescent↗
PubMed2006

Comorbid oppositional defiant disorder and the risk of relapse during 9 months of atomoxetine treatment for attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine the influence of comorbid oppositional defiant disorder (ODD) on the relative risk (RR) of relapse during 9 months of treatment with atomoxetine for attention-deficit/hyperactivity disorder (ADHD). METHOD: Four hundred and sixteen children and adolescents with ADHD whose symptoms remitted during initial 10-week, open-label atomoxetine treatment were randomly assigned to continue with atomoxetine or placebo. RESULTS: In all, 43% met criteria for comorbid ODD. A total of 17% of patients with comorbid ODD relapsed (CGI-Severity score >or= 3 and ADHD Rating Scale total score of 90% or more of baseline at study entry on two consecutive visits) during atomoxetine treatment, compared with 26% of patients without comorbid ODD (RR 0.67, 95% CI 0.42-1.06). Mean time to relapse was not significantly different [mean (SE) days to relapse, ADHD/ +ODD: 215 (7.38); ADHD/-ODD: 211 (7.61); log rank p = 0.08]. This finding is placed within the context of atomoxetine affording an overall protection against relapse compared with placebo (RR 0.59, 95% CI 0.43-0.80). CONCLUSIONS: Comorbid ODD does not influence the rate of relapse of patients with ADHD during longer-term treatment with atomoxetine. Atomoxetine protects against the relapse of ADHD symptoms regardless of the presence or absence of comorbid ODD.

Adolescent↗