Journal of the American Academy of Child and Adolescent Psychiatry

Theory and research on self-control were reviewed. Selected research is summarized along with some conclusions from clinical practice. Self-control difficulties are of central importance for many psychiatric disorders. Self-control is also a crucial, and often missing, ingredient for success in most treatment programs. It is stable enough to be considered an enduring trait or skill, but not immutable. Performance tests provide ingenious methods of measuring it, and they have some advantages over questionnaires. Biological research is under way: the prefrontal cortex is heavily involved; alcohol reduces self-control; serotonin may increase it. Self-control is correlated with, but not identical with, capacity for focused attention. Self-control is subject to "momentum effects": the more it is successfully practiced in a given arena, the easier subsequent practice usually becomes, and vice versa. Like a muscle, it appears to be fatigued in the short run and strengthened in the long run by exercise.

This case report describes two children who developed hyperammonemia together with frank manic behavior during treatment with a combination of valproic acid and risperidone. One child had been maintained on valproic acid for years and risperidone was added. In the second case, valproic acid was introduced to a child who had been treated with risperidone for years. In both cases, discontinuing the valproic acid resulted in normalization of ammonia levels and cessation of the manic behavior. This case report alerts physicians to the importance of obtaining serum ammonia levels in children treated with valproic acid and risperidone who present with manic behavior.

To assess the safety and efficacy of ABT-089, a novel α(4)β(2) neuronal nicotinic receptor partial agonist, vs. placebo in children with attention-deficit/hyperactivity disorder (ADHD). Two multicenter, randomized, double-blind, placebo-controlled, parallel-group studies of children 6 through 12 years of age were conducted. Study 1 (n = 274) assessed six treatment groups over 8 weeks: 4 once-daily (QD) ABT-089 doses (0.085-0.700 mg/kg), QD atomoxetine, and placebo. Study 2 (n = 119) assessed three treatment groups over 6 weeks: 2 QD ABT-089 doses (0.7 mg/kg, 1.4 mg/kg) and placebo. The primary efficacy variable was the investigator-administered Attention-Deficit/Hyperactivity Disorder Rating Scale-IV: Home Version (ADHD-RS-IV [HV]) Total Score. Safety was assessed by adverse event (AE) monitoring, laboratory tests, vital signs, physical examinations, and electrocardiogram measures. There was no statistically significant difference between ABT-089 and placebo in mean change from baseline to final evaluation of ADHD-RS-IV (HV) Total Score or other outcome measures at any dose in either study. In Study 1, atomoxetine showed statistically significant improvement for the primary and most secondary endpoints. ABT-089 was generally safe and well tolerated, with no statistically significant difference between any ABT-089 dose and placebo in the overall incidence of any specific AE, and no clinically significant changes in other safety measures. ABT-089 did not show efficacy on the primary efficacy variable, the ADHD-RS-IV (HV) Total Score, or other measures of ADHD symptomatology in children with ADHD, and had a safety profile similar to placebo. These results contrast with published reports of efficacy of nicotinic modulators in adults with ADHD.

Objective: Frontline health professionals need a "red flag" tool to aid their decision making about whether to make a referral for a full diagnostic assessment for an autism spectrum condition (ASC) in children and adults. The aim was to identify 10 items on the Autism Spectrum Quotient (AQ) (Adult, Adolescent, and Child versions) and on the Quantitative Checklist for Autism in Toddlers (Q-CHAT) with good test accuracy. Method: A case sample of more than 1,000 individuals with ASC (449 adults, 162 adolescents, 432 children and 126 toddlers) and a control sample of 3,000 controls (838 adults, 475 adolescents, 940 children, and 754 toddlers) with no ASC diagnosis participated. Case participants were recruited from the Autism Research Centre's database of volunteers. The control samples were recruited through a variety of sources. Participants completed full-length versions of the measures. The 10 best items were selected on each instrument to produce short versions. Results: At a cut-point of 6 on the AQ-10 adult, sensitivity was 0.88, specificity was 0.91, and positive predictive value (PPV) was 0.85. At a cut-point of 6 on the AQ-10 adolescent, sensitivity was 0.93, specificity was 0.95, and PPV was 0.86. At a cut-point of 6 on the AQ-10 child, sensitivity was 0.95, specificity was 0.97, and PPV was 0.94. At a cut-point of 3 on the Q-CHAT-10, sensitivity was 0.91, specificity was 0.89, and PPV was 0.58. Internal consistency was >0.85 on all measures. Conclusions: The short measures have potential to aid referral decision making for specialist assessment and should be further evaluated.

To test the fit of a seven-syndrome model to ratings of preschoolers' problems by parents in very diverse societies. Parents of 19,106 children 18 to 71 months of age from 23 societies in Asia, Australasia, Europe, the Middle East, and South America completed the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5). Confirmatory factor analyses were used to test the seven-syndrome model separately for each society. The primary model fit index, the root mean square error of approximation (RMSEA), indicated acceptable to good fit for each society. Although a six-syndrome model combining the Emotionally Reactive and Anxious/Depressed syndromes also fit the data for nine societies, it fit less well than the seven-syndrome model for seven of the nine societies. Other fit indices yielded less consistent results than the RMSEA. The seven-syndrome model provides one way to capture patterns of children's problems that are manifested in ratings by parents from many societies. Clinicians working with preschoolers from these societies can thus assess and describe parents' ratings of behavioral, emotional, and social problems in terms of the seven syndromes. The results illustrate possibilities for culture-general taxonomic constructs of preschool psychopathology. Problems not captured by the CBCL/1.5-5 may form additional syndromes, and other syndrome models may also fit the data.

In a recent study, Thapar and colleagues reported that COMT "gene variant and birth weight predict early-onset antisocial behavior in children" with attention-deficit/hyperactivity disorder. We have attempted to replicate these findings in a group of ADHD children using a similar research design. Children (n=191) between 6 and 12 years of age who were diagnosed with ADHD were included in the study. Conduct disorder was diagnosed according to DSM-IV criteria based on clinical evaluation and a structured interview (Diagnostic Interview Schedule for Children-IV). The mother's report on the child's birth weight was used in the analysis. Logistic regression analysis, with genotype and birth weight as independent variables and DSM-IV conduct disorder as the dependent variable, was conducted. No significant main effects of genotype and birth weight or interaction effects on conduct disorder were observed. In this sample of children diagnosed with ADHD, we find no association between the COMT ValMet gene variant, birth weight, and conduct disorder. Further investigations are required before using birth weight and COMT genotype as predictors of conduct disorder in children with attention-deficit/hyperactivity disorder, especially given the societal and legal ramifications of conduct disorder.

There are few well-evaluated uncomplicated community-based interventions for childhood aggression. The authors assess the impact of a community-based anger management group on child aggressive behaviors, using a randomized, controlled trial (RCT). Families with children 7 to 11 years old were recruited through advertisements and randomized (N = 123). Inclusion required parent concern about anger/aggressive behavior, RCT agreement, and a telephone behavior screen. Intervention participants were offered three parent education/skill-building group sessions, 10 weekly child group sessions, and three in-home family practice sessions. Nine groups ran from August 2002 to August 2004. Interviewers naïve to randomization collected data on all participants pre- and postgroup. Outcomes included child-rated anger and parent-rated child aggressive behavior, externalizing behavior and hostility, parent-child relationship, and parenting stress. Intent-to-treat analyses were done. Pre/postoutcome comparisons indicated no significant differences between intervention versus control, with small effect sizes for most outcomes (0.27-0.29). Although not significant, the magnitude of improvement favored intervention families on all parent-rated measures. Overall, there was no differential impact of participating in a community-based anger management group versus control on child aggressive behaviors and other associated measures. The impact of regression to the mean, effect, and sample size estimates; child comorbidity; and programmatic and methodological issues are discussed.

Although research into the continuity of disorder from childhood to adolescence is sparse, results from both longitudinal and cross sectional studies suggest that the prevalence of disorder increases for girls but may remain more stable for boys. In this paper, the methodologies of two assessment phases of the Dunedin longitudinal study have been equated to estimate the continuity of DSM-III disorder from ages 11 to 15. Although the overall prevalence of disorder doubled between the ages, this was primarily because of an increase in nonaggressive conduct disorder and major depressive episode. The sex ratios in disorder had largely reversed from a male predominance at 11 to a female predominance at 15. In terms of persistence, over 40% of those with disorder at age 11 were also identified at age 15. However, over 80% of those identified with disorder at 15 did not have a history of disorder at 11. Significant sex differences were also found in the continuity of internalizing and externalizing disorders, with externalizing disorders showing more continuity for boys, and internalizing for girls. Logistic regression models were employed to evaluate the roles family background, academic and social competence, and early histories of behavior problems may play in the determination of disorder continuity.

To examine the prevalence and risk factors of behavioral and emotional problems in Chinese children. A sample of 2,940 children aged 6 through 11 years was randomly drawn from household registers in Shandong Province of China. Parents completed the Child Behavior Checklist (CBCL) and a structured self-rating questionnaire. The mean CBCL Total Problems score was 16.1 (SD = 14.0). There was no significant age effect on the Total Problems score; boys scored significantly higher than girls (17.2 versus 15.0; F = 24.94, p < .01). The overall prevalence rates of behavioral problems were 12.5% for boys and 8.3% for girls (chi 2 = 14.23, p < .01). Logistic regression analysis showed that a number of parental, prenatal, perinatal, and postnatal factors were significantly associated with increased risk of children's behavioral problems. The prevalence of parent-reported behavioral problems in Chinese children is lower than those found in other countries. Of multiple psychosocial and biological factors associated with children's behavioral problems, separation or divorce of parents is the most significant factor.

To assess the understanding of Diagnostic Interview Schedule for Children-Version 2.25 (DISC-2.25) questions by children aged 9 through 11 years. Two hundred forty children were recruited from four public schools. The cognitive appraisal of 280 questions from the most prevalent DSM-III-R diagnoses was evaluated. The collaboration of four children was necessary to cover one DISC. Sixty DISCs, evenly distributed according to age and sex, were completed. Two child psychiatrists evaluated the children's answers. Nonparametric tests were used to assess understanding of questions as a whole, of time concepts (overall, categories, number), and of questions based on the number of words. Children aged 9, 10, and 11 years understood 38%, 38%, and 42% of the questions as a whole, respectively, and 26%, 24%, and 30% of the overall time concepts, respectively. The understanding rates of questions as a whole were significantly higher than those of overall time concepts. Durations were significantly better understood than periods and frequencies, and questions having one time component were significantly better grasped than those with two or more. Shorter questions were significantly better understood than longer ones. Although the DISC has been greatly improved since the initial version, the results suggest that additional revision is needed before clinicians or researchers use the DISC with younger children.

AbstractBehavioral and emotional problems of childhood may reflect the influence of culture: prevailing values and socialization practices may suppress development of some problems while fostering others. The authors explored this possibility, comparing 360 6‐to 11‐year‐olds in the Buddhist‐oriented, emotionally controlled culture of Thailand with 600 American 6‐ to 11‐year‐olds. Standardized parent reports on 118 child problems revealed 54 Thai‐U.S. differences (p < 0.01), generally modest in magnitude. Thai children were rated higher than Americans on 32 problems, particularly those involving Overcontrolled behavior (e.g., shyness, anxiety, depression). Across cultures, boys showed more fighting, impulsivity, and other Undercontrolled behavior than girls, and several age effects emerged. The findings provide epidemiological comparisons for two distinctly different cultures and contribute to a theoretical model of cultural influence.

The purpose of this study was to test the cross-national applicability of a standardized procedure for obtaining teachers' reports of children's behavioral/emotional problems. The Teacher's Report Form of the Child Behavior Checklist was completed by teachers of 600 American and 748 Dutch nonreferred children randomly selected from regular school classes. Analyses controlling for sex, age, and socioeconomic status showed no significant difference between the total problem scores for American versus Dutch children, nor between the number of specific problems scored higher for one nationality than the other, nor between the proportion of internalizing versus externalizing problems scored higher for either nationality. Parent and teacher reports were compared to identify problems on which there were consistent nationality, sex, and socioeconomic differences. The findings support standardized cross-national assessment of teacher-reported behavioral/emotional problems. J. Amer. Acad. Child Adol.

To examine gender and age differences in attention-deficit/hyperactivity disorder (ADHD) symptom endorsement in a large community-based sample. Families with four or more full siblings ascertained from Missouri birth records completed telephone interviews regarding lifetime DSM-IV ADHD symptoms and the Strengths and Weaknesses of ADHD-Symptoms and Normal-behavior (SWAN) questionnaire for current ADHD symptoms. Complete data were available for 9,380 subjects aged 7 through 29 years. Lifetime and current DSM-IV-like ADHD diagnoses were assigned by the DSM-IV symptom criteria. Linear regression was used to examine sex and age effects on SWAN ADHD symptom scores. Logistic regression was used to examine sex and age effects on specific ADHD diagnoses. Fractional polynomial graphs were used to examine ADHD symptom count variations across age. Overall prevalence of current DSM-IV-like ADHD was 9.2% with a male:female ratio of 2.28:1. The prevalence of DSM-IV-like ADHD was highest in children. Gender differences in DSM-IV-like ADHD subtype prevalences were highest in adolescents. On average, individuals with lifetime DSM-IV-like ADHD diagnoses had elevated current ADHD symptoms even as adolescents or adults. Lower male:female ratios than reported in some clinic-based studies suggest that females are underdiagnosed in the community. Although they may no longer meet the full symptom criteria, young adults with a history of lifetime DSM-IV-like ADHD maintain higher levels of ADHD symptoms compared with the general population. The use of age-specific diagnostic criteria should be considered for DSM-V and ICD-11.

Previous studies indicate that low resting heart rate is probably the best-replicated biological correlate of childhood antisocial and aggressive behavior. Nevertheless, there have been few longitudinal tests of this relationship, little control over potential confounds and mediators, and no test of its cross-cultural generalizability. This study tests the hypothesis that low resting heart rate at age 3 years predicts aggression at age 11 years. Resting heart rate at age 3 years was assessed in 1,795 male and female children from Mauritius. Aggressive and nonaggressive forms of antisocial behavior were assessed at age 11 years using the Child Behavior Checklist. Aggressive children had lower heart rates than nonaggressive children (p < .001). Conversely, those with low heart rates were more aggressive than those with high heart rates (p < .003). There were no interactions with gender or ethnicity. Evidence was found for specificity of low heart rate to aggressive forms of antisocial behavior. Group differences in heart rate were not attributable to 11 biological, psychological, and psychiatric mediators and confounds. It is concluded that low resting heart rate, a partly heritable trait reflecting fearlessness and stimulation-seeking, is an important, diagnostically specific, well-replicated, early biological marker for later aggressive behavior.

The aims of the present study were to survey the Child Behavior Checklist (CBCL) scores (behavioral section) in a nonclinical population of US urban children from low-income families and to compare the distribution and pattern of scores with the normative data in the CBCL manual (1991). The sample consisted of 890 low-income children and a mother or female guardian selected randomly from among Seattle public school students aged 5 to 11 years. In this sample the total CBCL score as well as all subscale scores were significantly higher than the norms. The proportion of children who scored in the clinical/borderline range was also higher than the norm. These findings support previous work showing that poverty is a risk factor for mental distress in children. They also raise questions about the validity of the CBCL norms for screening or research purpose for low-income families.

Childhood gender nonconformity has been associated with increased risk of caregiver abuse and bullying victimization outside the home, but it is unknown whether as a consequence children who are nonconforming are at higher risk of depressive symptoms. Using data from a large national cohort (N = 10,655), we examined differences in depressive symptoms from ages 12 through 30 years by gender nonconformity before age 11 years. We examined the prevalence of bullying victimization by gender nonconformity, then ascertained whether increased exposure to abuse and bullying accounted for possible increased risk of depressive symptoms. We further compared results stratified by sexual orientation. Participants in the top decile of childhood gender nonconformity were at elevated risk of depressive symptoms at ages 12 through 30 years (for females, 0.19 standard deviations more depressive symptoms than conforming females; for males, 0.34 standard deviations more symptoms than conforming males). By ages 23 to 30 years, 26% of participants in the top decile of childhood nonconformity had probable mild or moderate depression versus 18% of participants who were conforming (p<.001). Abuse and bullying victimization accounted for approximately half the increased prevalence of depressive symptoms in youth who were nonconforming versus conforming. Gender-nonconforming heterosexuals and males were at particularly elevated risk for depressive symptoms. Gender nonconformity was a strong predictor of depressive symptoms beginning in adolescence, particularly among males and heterosexuals. Physical and emotional bullying and abuse, both inside and outside the home, accounted for much of this increased risk.

To study the prospective link between involvement in bullying (bully, victim, bully/victim), and subsequent suicide ideation and suicidal/self-injurious behavior, in preadolescent children in the United Kingdom. A total of 6,043 children in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort were assessed to ascertain involvement in bullying between 4 and 10 years and suicide related behavior at 11.7 years. Peer victimization (victim, bully/victim) was significantly associated with suicide ideation and suicidal/self-injurious behavior after adjusting for confounders. Bully/victims were at heightened risk for suicide ideation (odds ratio [OR]; 95% confidence interval [CI]): child report at 8 years (OR = 2.84; CI = 1.81-4.45); child report at 10 years (OR = 3.20; CI = 2.07-4.95); mother report (OR = 2.71; CI = 1.81-4.05); teacher report (OR = 2.79; CI = 1.62-4.81), as were chronic victims: child report (OR = 3.26; CI = 2.24-4.75); mother report (OR = 2.49; CI = 1.64-3.79); teacher report (OR = 5.99; CI = 2.79-12.88). Similarly, bully/victims were at heightened risk for suicidal/self-injurious behavior: child report at 8 years (OR = 2.67; CI = 1.66-4.29); child report at 10 years (OR = 3.34; CI = 2.17-5.15); mother report (OR = 2.09; CI = CI = 1.36-3.20); teacher report (OR = 2.44, CI = 1.39-4.30); as were chronic victims: child report (OR = 4.10; CI = 2.76-6.08); mother report (OR = 1.91; 1.22-2.99); teacher report (OR = 3.26; CI = 1.38-7.68). Pure bullies had increased risk of suicide ideation according to child report at age 8 years (OR = 3.60; CI = 1.46-8.84), suicidal/self-injurious behavior according to child report at age 8 years (OR = 3.02; CI = 1.14-8.02), and teacher report (OR = 1.84; CI = 1.09-3.10). Children involved in bullying, in any role, and especially bully/victims and chronic victims, are at increased risk for suicide ideation and suicidal/self-injurious behavior in preadolescence.

An 11-year-old boy who initially received a DSM-III diagnosis of schizophrenia was found on further evaluation to have multiple personality disorder. Factors important in the differential diagnosis were differentiation of personalities from auditory hallucinations, a history of multiple personality disorder in the mother, and recognition of the special features of the disorder when it occurs in childhood. J. Amer. Acad. Child Adol. Psychiat., 1987, 26, 3:436–439.

In a national probability sample of 6- through 11-year-old children, the relationship between the children's cognitive development and three teacher rated attributes, low attentiveness, hyperactivity, and aggressivity, was examined. Family context as defined by parental education and family income per individual under 21 years of age in the household were controlled. Analyses of covariance revealed that the attribute of below average attentiveness was associated with significantly lower performance on tests of intelligene (WISC Vocabulary and Block Design) and on tests of achievement (Reasing and Arithmetic subtests of the Wide Range Achievement Test). Hyperactivity alone was not associated with differences in cognitive development, whereas aggressivity in boys but not in girls was associated with lower performance on Block Design.

To review the response of 11 adolescents with childhood-onset schizophrenia to a 6-week open clozapine trial. Eleven children meeting DSM-III-R criteria for schizophrenia had a 6-week open trial of clozapine (mean sixth week daily dose 370 mg). Behavioral ratings included the Brief Psychiatric Rating Scale and Children's Global Assessment Scale. More than half showed marked improvement in Brief Psychiatric Rating Scale ratings by 6 weeks of clozapine therapy compared to admission drug rating and compared to a systematic 6-week trial of haloperidol. This open trial indicates that clozapine may be a promising treatment for children and adolescents with schizophrenia who do not respond well to typical neuroleptics. A double-blind placebo-controlled study is ongoing.

To review the Dominic-R and the Terry questionnaires, respectively, for white and African-American children, both DSM-III-R-based, and more recent DSM-IV-based computerized versions. Five papers describing the development, content, validation studies, and establishment of the diagnostic cutpoints of these instruments are reviewed. The instruments are pictorial, fully structured, and designed to assess mental disorders in children 6 to 11 years of age. Symptom descriptions complement the visual stimulus, providing better information-processing than visual or auditory stimuli alone. Cognitive immaturity of young children bars frequency, duration, and age-of-onset measurements, restricting correspondence with DSM criteria. DSM-IV (computerized versions) and DSM-III-R (paper versions) disorders being assessed include specific (simple) phobias, separation anxiety, generalized anxiety (overanxious), depression/dysthymia, attention-deficit hyperactivity, oppositional defiant, and conduct disorder. Test-retest reliability of symptoms and symptom scores and criterion validity against clinical judgment support the visual-auditory combination of stimuli to assess child mental health. Intended for clinical, epidemiological, and screening purposes, these instruments are short and simple. Although it only approximates DSM-III-R and DSM-IV criteria, the pictorial format permits young children to be reliable informants about their mental health.

To investigate the prevalence and risk factors for psychiatric disorders in extremely preterm children. All babies born <26 weeks gestation in the United Kingdom and Ireland from March through December 1995 were recruited to the EPICure Study. Of 307 survivors at 11 years of age, 219 (71%) were assessed alongside 153 term-born classmates. Parents completed a structured psychiatric interview about their child, and teachers completed a corresponding questionnaire from which DSM-IV diagnoses were assigned for 219 (100%) extremely preterm children and 152 (99%) classmates. An IQ test and a physical evaluation were also administered. Longitudinal data were available for extremely preterm children. Extremely preterm children were more than three times more likely to have a psychiatric disorder than classmates (23% vs. 9%; odds ratio [OR] = 3.2; 95% confidence interval [CI] = 1.7, 6.2). Risk was significantly increased for: attention-deficit/hyperactivity disorder (ADHD; 11.5% vs. 2.9%; OR = 4.3; CI = 1.5 to 13.0), with increased risk for ADHD inattentive subtype (OR = 10.5; CI = 1.4 to 81.1) but not ADHD combined subtype (OR = 2.1; CI = 0.5 to 7.9); emotional disorders (9.0% vs. 2.1%; OR = 4.6; CI = 1.3 to 15.9), with increased risk for anxiety disorders (OR = 3.5; CI = 1.0 to 12.4); and autism spectrum disorders (8.0% vs. 0%; p = .000). Psychiatric disorders were significantly associated with cognitive impairment (OR = 3.5; CI = 1.8 to 6.4). Parent-reported behavioral problems at 2.5 and 6 years were independent predictors of psychiatric disorders at 11 years. Extremely preterm children are at increased risk for ADHD, emotional disorders, and autism spectrum disorders at 11 years of age. The mechanism of association with psychiatric disorder may include both cognitive impairment and early traumatic experiences that have an impact on both child and parent. Early screening for cognitive and behavioral problems may identify those at greatest risk.

To determine whether individual differences in emotional reactivity predicted high levels of conduct problems and/or emotional (depressive and anxiety) symptoms at 1-year follow-up in a community sample of 7- to 11-year-old children (N = 659). The study used a prospective design with picture perception methodology at baseline to elicit emotional responses from children. Conduct problems and symptoms of anxiety and depression were evaluated using repeated measures from self-, teacher, and parent report questionnaires completed at baseline and 1 year. Children who reported decreased emotional arousal to unpleasant (B = -0.069; p = .011) and pleasant (B = -0.134; p = .036) pictures showed higher levels of self-reported and teacher-reported conduct problems at 1-year follow-up, respectively. Conversely, children who reported increased emotional arousal to neutral pictures (B = 0.661; p = .030) at baseline showed higher levels of anxiety symptoms at follow-up. These findings held when baseline level of problems and symptoms, sex, age, socioeconomic status, and IQ were taken into account. Findings were nonsignificant for symptoms of depression at the multivariate level of analyses. Although findings showed that symptom level at baseline remains the best predictor of symptom level at follow-up, these prospective findings extend previous reports in children and adults and provide predictive validity for decreased arousal correlating with high levels of subsequent conduct problems and increased arousal correlating with high levels of subsequent anxiety symptoms. Differences in emotional processing may constitute a risk process for the subsequent onset of conduct and anxiety disorder in middle childhood.

Adolescence is a developmental period that entails substantial changes in risk-taking behavior and experimentation with alcohol and drugs. Understanding how the brain is changing during this period relative to childhood and adulthood and how these changes vary across individuals are key in predicting risk for later substance abuse and dependence. This review discusses recent human imaging and animal work in the context of an emerging view of adolescence as characterized by a tension between early emerging "bottom-up" systems that express exaggerated reactivity to motivational stimuli and later maturing "top-down" cognitive control regions. Behavioral, clinical, and neurobiological evidences are reported for dissociating these two systems developmentally. The literature on the effects of alcohol and its rewarding properties in the brain is discussed in the context of these two systems. Collectively, these studies show curvilinear development of motivational behavior and the underlying subcortical brain regions, with a peak inflection from 13 to 17 years. In contrast, prefrontal regions, important in top-down regulation of behavior, show a linear pattern of development well into young adulthood that parallels that seen in behavioral studies of impulsivity. The tension or imbalance between these developing systems during adolescence may lead to cognitive control processes being more vulnerable to incentive-based modulation and increased susceptibility to the motivational properties of alcohol and drugs. As such, behavior challenges that require cognitive control in the face of appetitive cues may serve as useful biobehavioral markers for predicting which teens may be at greater risk for alcohol and substance dependence.

Precipitating factors and life events associated with medically serious suicide attempts were examined in young people making serious suicide attempts and control subjects. Using a case-control design, the authors contrasted 129 young people making serious suicide attempts with 153 randomly selected community controls on a series of life event occurrences within the preceding year. Precipitating factors for serious suicide attempts were also examined. The most common precipitants of serious suicide attempts were relationship breakdowns, other interpersonal problems, and financial difficulties. However, one third of those attempting suicide were unable to describe any precipitating factor. Individuals who made serious suicide attempts had elevated rates of life events which were associated principally with interpersonal difficulties, work issues, financial difficulties, and legal problems. When due allowance was made for intercorrelations between life event measures and antecedent social, family, and personality factors, interpersonal losses and conflicts and legal problems remained significant risk factors for serious suicide attempts. Important proximal occurrences for serious suicide attempts among young people include a series of life events associated principally with interpersonal conflicts, relationship difficulties, and legal problems.

To compare the history of psychiatric contacts among young people who have made medically serious suicide attempts and control subjects. Using a case-control design, the authors contrasted 129 young people who made serious suicide attempts with 153 randomly selected community controls on a series of measures of lifetime, prior year, and prior month contacts with psychiatric services. Of those who made serious suicide attempts, 78.3% had a lifetime history of contact with health services for psychiatric reasons, 72.1% reported contact within the year preceding the suicide attempt 58.9% reported contact within the month preceding the suicide attempt, and 29.5% had a lifetime history of psychiatric hospital admission. Within the year preceding the suicide attempt, 21.7% had been admitted to a psychiatric hospital and 67.4% had outpatient consultations for psychiatric problems. Multiple logistic regression suggested that the best psychiatric service predictors of risk of serious suicide attempt were admission within the preceding year (p < .005) and outpatient consultation within the preceding month (p < .0001). Young people making serious suicide attempts had vastly elevated rates of a range of psychiatric contacts including hospital admissions and outpatient consultations. These findings imply that the development of improved treatment and management strategies for young people with psychiatric morbidity may be a very effective approach to reducing youthful suicidal behaviors.

To study the genetic and environmental contributions to stability and change of attention-deficit/hyperactivity disorder (ADHD) symptoms between 8 and 9 and 13 and 14 years of age. The sample included 1,480 twin pairs born in Sweden between May 1985 and December 1986. At wave 1 in 1994, when twins were 8-9 years old, 1,106 (75%) of the parents responded to a mailed questionnaire, and at wave 2 when the twins were 13-14 years old, 1,063 (73%) responded. A checklist with 14 items based on the 14 DSM-III-R symptoms for ADHD was completed. Structural equation modeling was used to analyze the data. A relatively high stability of ADHD symptoms over this 5-year period was found. This continuity was mainly due to the same genetic effects operating at both points in time. Change in symptoms between childhood and early adolescence was to a large extent due to new genetic effects in early adolescence but also due to new nonshared environmental effects that became important during adolescence. The genetic stability highlights the importance of the continuing search for genes and endophenotypes of ADHD.

Eighteen children who had been hyperactive in at least three different assessment settings at age 7 years were followed up at ages 10 and 13; they were compared with 29 children who were hyperactive in two assessment situations and 51 children who were not judged to be hyperactive. All the children were recruited from a population-based screening study of deficits in attention, motor control, and perception performed in Goteborg public preschools when the children were 6 years old. The results of the follow-up studies indicate that generalized hyperkinesis carries a poor prognosis in relation to persistence of hyperactivity in the 3-year perspective but a somewhat better prognosis in the 6-year perspective. School achievement was problematic throughout the follow- up period. Children with generalized hyperkinesis have a very early onset of problems. Except for the possible influence of male gender and low birth weight, it has not appeared that background factors such as social class, heredity, or IQ in the child have good predictive power. Children with cross-situational, but not generalized, hyperkinesis have a much better outlook even though they fare somewhat worse than children who were not hyperactive at all in the preschool years. © 1988 by the American Academy of Child and Adolescent Psychiatry.

To determine whether the prevalence of children's behavioral/emotional problems changed significantly over a 13-year period. Problems and competencies reported by parents and teachers for a random sample of 7 to 16 years old assessed in 1989 were compared with those reported by parents for a 1976 sample and by teachers for a 1981 to 1982 sample. Parent reports were obtained with the Child Behavior Checklist; teacher reports were obtained with the Teacher's Report Form. Problem scores were higher and competence scores were lower in 1989 than in the earlier assessments. The secular changes were small but included diverse problems, syndromes, and competencies. Changes did not differ significantly by age, gender, socioeconomic status, nor black/white ethnicity. Correlations of 0.97 to 0.99 between rankings of item scores across 7.5- and 13-year intervals support the stability of the assessment procedures. Despite increases in problem scores, the 1989 U.S. scores were not higher than those in several other cultures. Viewed categorically in terms of caseness, more untreated children in the 1989 than the 1976 sample would be considered to need help. Multicohort longitudinal studies now in progress will test predictors of within- and between-cohort change.

Protective processes in at-risk children between 4 and 13 years of age were examined in a longitudinal study. A multiple risk index was used at 4 years to identify 50 high-risk children and 102 who were at low risk. Cognitive and social-emotional status were measured at each time point. The following indicators of protective processes were related to positive change in cognitive and/or social-emotional function in the high-risk children between 4 and 13 years: mother-child interaction; child perceived competence, locus of control, life events, and social support; and maternal parenting values, social support, depression, and expressed emotion. Many of these factors were also related to improvement in the low-risk children. Some variables showed an interaction effect, where impact was substantially higher in the high-risk group compared with the low-risk group. The utility of multiple risk constructs and process oriented approaches to protective factors are discussed.

To test the developmental continuity, interrelationships, and predictive associations of the oppositional defiant disorder (ODD) subdimensions of irritable, headstrong, and hurtful. Data were collected from 6,328 mother-child pairs participating in the Avon Longitudinal Study of Parents and Children (United Kingdom). Developmental continuity for each subdimension was strong and interrelationships indicated that headstrong was associated mainly with irritable, whereas irritable did not cross associate with other ODD subdimensions; and hurtful was associated with lower levels of headstrong. With regard to associations at age 16 years, irritable at age 13 years was associated with depression, whereas headstrong at 13 was associated with delinquency and callous attitude; at age 13, hurtful failed to associate with any of the 3 age 16 outcomes. The results suggest that the ODD headstrong and irritable subdimensions are developmentally distinct, with small cross-over (i.e., headstrong to irritable), and are associated with unique outcomes. Hurtful does not appear to be associated with future maladjustment in children.

To study the associations between sleep quality/quantity and performance in auditory/visual working memory tasks of different load levels. Sixty schoolchildren aged 6 to 13 years from normal school classes voluntarily participated. Actigraphy measurement was done during a typical school week for 72 consecutive hours. It was timed together with the working memory experiments to obtain information on children's sleep during that period. The n-back task paradigm was used to examine auditory and visual working memory functions. Lower sleep efficiency and longer sleep latency were associated with a higher percentage of incorrect responses in working memory tasks at all memory load levels (partial correlations, controlling for age, all p values < .05, except in visual 0-back and auditive 2-back tasks); shorter sleep duration was associated with performing tasks at the highest load level only (partial correlations, controlling for age,p < .05). Also in general linear models (controlling for age, gender, and socioeconomic status), sleep efficiency (F = 11.706, p = .050) and latency (F = 3.588, p = .034) were significantly associated with the mean incorrect response rate in auditory working memory tasks. Sleep quality and quantity affect performance of working memory tasks in school-age children. In children with learning difficulties the possibility of underlying sleep problems should be excluded.

To characterize female suicides (n = 19) in an unselected nationwide youth suicide population aged 13 to 22 years (n = 116) and to compare them with male suicides with respect to variables indicating psychopathology and psychosocial functioning. The data were collected in a psychological autopsy study of all suicides (N = 1,397) in Finland during a 12-month period. Data collection included interviews of next of kin and professionals and information from records after the suicide. Two thirds (68%) of the female victims had suffered from a mood disorder, and 73% had communicated their suicidal intent. Half (47%) of the female subjects had been in psychiatric care at some point in their lives, and 42% had been hospitalized. Compared with young male suicides, the young female victims more often had made previous suicide attempts (63% versus 30%), received more often a diagnosis of major depression (37% versus 14%), and had more often been in psychiatric care (47% versus 21%) during the year preceding the suicide. The females were more often incapable of working, and their psychosocial impairment was more severe during the final week. Alcohol abuse was almost as common among the female as the male victims (21% versus 26%). The results suggest that young females who commit suicide may have suffered from more severe psychopathology than young male victims. Substance abuse seems to be a major factor also in female suicides. Preventive efforts within psychiatric care are likely to reach a higher proportion of the young females than males at high risk for suicide.

A genetic study of behavioral deviance in 285 pairs of 13-year-old twins is described. Parents and teachers completed standardized questionnaires on the total sample. Concordance rates for monozygotic and dizygotic twins with respect to individual items of behavior, as well as antisocial and neurotic subscale scores, were calculated to produce an estimate of the genetic contribution to etiology of deviance. It is concluded that genetic influences are greatest for items relating to overactivity, inattention, and lack of concentration but are present to a less certain degree for a range of neurotic, antisocial, and psychosomatic behavior items. © 1988 by the American Academy of Child and Adolescent Psychiatry.

To examine associations between a series of sociodemographic factors, childhood experiences, and mental disorders and risk of serious suicide attempt in young people aged 13 through 24 years and to explore the joint relationship between these factors and vulnerability to serious suicide attempt. The study used a case-control design in which a sample of 129 young people who had made serious suicide attempts was contrasted with 153 randomly selected community controls. Measures included sociodemographic factors (educational qualifications, annual income, residential mobility), childhood experiences (parental relationship, parental care, childhood sexual abuse), and psychiatric morbidity. On the basis of multiple logistic regression, those making serious suicide attempts reported elevated rates of sociodemographic disadvantage (p < .0001), higher rates of disadvantageous childhood experiences (p < .05), and elevated rates of psychiatric morbidity (p < .0001). Risks of serious suicide attempt among young people increased with extent of exposure to childhood adversity, social disadvantage, and psychiatric morbidity, with each of these factors making independent contributions to risk of serious suicide attempt.

These practice parameters have been developed by the American Academy of Child and Adolescent Psychiatry as a guide for clinicians evaluating psychiatric disorders in children and adolescents. The document focuses on the assessment, diagnostic, and treatment planning process, emphasizing a developmental perspective. The assessment process is intended for all children and adolescents presenting with psychiatric disorders that impair emotional, cognitive, physical, or behavioral functioning to assist the clinician in arriving at accurate diagnoses and in appropriate treatments. Details of the parent and child interviews are presented as well as an outline of specific areas of inquiry necessary for this process. The use of standardized tests and rating scales is addressed. These parameters were previously published in J. Am. Acad. Child Adolesc. Psychiatry, 1995, 31:1386-1402.

To test the 14-year continuity and change of behavioral and emotional problems from childhood into adulthood. For 1,615 children and adolescents aged 4 to 16 years from the general population, parents completed the Child Behavior Checklist (CBCL) at initial assessment. At follow-up 14 years later, subjects completed the Young Adult Self-Report (YASR), and their parents completed the Young Adult Behavior Checklist (YABCL). Of the subjects who were initially classified as deviant, 14 years later 41% were classified as deviant according to their YABCL Total Problem score, and 29% according to their YASR Total Problem score. Intrainformant (CBCL/YABCL) Withdrawn, Social Problems, Delinquent Behavior, and Aggressive Behavior scores, and cross-informant (CBCL/YASR) Anxious/Depressed, Thought Problems, and Delinquent Behavior scores were independent predictors of general levels of problem behavior. Childhood and adolescent problems persisted to a considerable degree into adulthood, although the majority of children who were deviant at initial assessment could not be regarded as deviant 14 years later. Children who were adolescents at initial assessment (12-16 years) showed higher stability of problem behaviors than subjects who were children at initial assessment (4-11 years).

To arrive at a better estimation of informant-specific correlates of suicidal behavior in young adolescents and to see how agreements and discrepancies between child and parent informants can contribute to the development of research and interventions. The weighted sample from the Quebec Child Mental Health Survey conducted in 1992 included 825 adolescents, aged 12 to 14 years, and their parents. The adolescent and one parent were questioned by two different interviewers. The response rate was 80.3%. Three categories of independent variables were assessed: adolescent, family, and socioeconomic characteristics. Logistic regression models were based on the adolescent and parent informant reports. Parents identified 6 of the 59 adolescents having reported suicidal ideation and 2 of the 36 adolescents having reported suicide attempts. Two informant-specific models of correlates of suicidal behavior were found. The adolescent model included internalizing and externalizing mental disorders, family stressful events, and parent-adolescent relationship difficulties, while the parent model included perceiving a need for help for the adolescent, parent's depressive disorders, and parent-adolescent relationship difficulties. The study shows the relevance of considering informant-specific correlates of suicidal behavior in the development of research and interventions targeting youths suicidal behavior.

Using a general population sample, the adult outcomes of children who presented with severe problems with self-regulation defined as being concurrently rated highly on attention problems, aggressive behavior, and anxious-depression on the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) were examined. Two thousand seventy-six children from 13 birth cohorts 4 to 16 years of age were drawn from Dutch birth registries in 1983. CBCLs were completed by parents at baseline when children from the different cohorts were 4 to 16 years of age and sampled every 2 years for the next 14 years. At year 14 the CBCL and DSM interview data were collected. Logistic regression was used to compare and contrast outcomes for children with and without dysregulation, as measured by the latent-class-defined CBCL-DP. Sex and age were covaried and concurrent DSM diagnoses were included in regression models. Presence of childhood CBCL-DP at wave 1 was associated with increased rates of adult anxiety disorders, mood disorders, disruptive behavior disorders, and drug abuse 14 years later. After controlling for co-occurring disorders in adulthood, associations with anxiety and disruptive behavior disorders with the CBCL-DP remained, whereas the others were not significant. A child reported to be in the CBCL-DP class is at increased risk for problems with regulating affect, behavior, and cognition in adulthood.

To describe the developmental course of marijuana use among a group of American Indian adolescents, aged 14 through 20 years. A group of 1,766 American Indian adolescents from 3 culture groups provided repeated measures of 30-day marijuana use twice a year across a 3-year period. Linking 5 age cohorts, hierarchical linear modeling was used to model a curvilinear trajectory of marijuana use. Gender and community differences were examined as well. Support was found for a "maturational" model of marijuana use across time: Use increased in middle adolescence, peaked in later adolescence, and began to decrease in early adulthood. Both gender and community differences in trajectories were significant as well. Marijuana use among American Indian adolescents follows a clear developmental trajectory. Growth curve analysis can provide an additional tool for studying the effects of interventions that may not be apparent in a traditional evaluation design.

To determine the contributions of genetic and environmental influences to variation in self-report of obsessive-compulsive (OC) symptoms in a population-based twin sample of adolescent boys and girls. Self-report ratings on the eight-item Youth Self-Report Obsessive-Compulsive Scale were collected in Dutch mono- and dizygotic twin pairs who participated at age 12 (N = 746 twin pairs), 14 (N = 963 pairs), or 16 years (N = 1,070 pairs). Structural equation modeling was used to break down the variation in liability to OC symptoms into genetic and environmental components. At age 12, no difference in prevalence was found for OC symptoms in boys and girls. At ages 14 and 16, the prevalence was higher in girls. At all ages, genetic factors contributed significantly to variation on OC symptom liability; 27% at the age of 12,57% at the age of 14, and 54% at the age of 16. There were no sex differences in heritability. Only at age 12, environmental factors shared by children from the same family contributed significantly (16%) to individual differences in OC symptom scores. During adolescence, OC symptoms are influenced by genetic and nonshared environmental factors. Sex differences in prevalence, but not heritability, emerge in adolescence. At age 12, shared environmental factors are of importance, but their influence disappears at later ages. This is in line with earlier research at age 12 that used parental ratings of OC symptoms. Thus, between-family factors play a significant role in explaining individual differences in OC symptoms at this age.

Few studies exist that examine continuities between child and adult psychopathology in unselected samples. This study prospectively examined the adult outcomes of psychopathology in an epidemiological sample of children and adolescents across a 14-year period. In 1983, parent ratings of behavioral and emotional problems were obtained for 1,578 children and adolescents aged 4 through 16 years from the Dutch general population. At follow-up, 14 years later, subjects were reassessed with a standardized DSM-IV interview. High levels of childhood problems predicted an approximate 2- to 6-fold increased risk for adulthood DSM-IV diagnoses. The associations between specific childhood problems and adulthood diagnoses were complex. Social Problems in girls predicted later DSM-IV disorder. Rule-breaking behavior in boys predicted both mood disorders and disruptive disorders in adulthood. High levels of childhood behavioral and emotional problems are related to DSM-IV diagnoses in adulthood. The strongest predictor of disorders in adulthood was childhood rule-breaking behavior. Attention Problems did not predict any of the DSM-IV categories when adjusted for the associations with other Child Behavior Checklist scales.

To describe the risks and risk factors for substance use initiation and progression among a large sample of American Indian (AI) adolescents. Data came from surveys completed by 2,356 AI adolescents aged 14 to 20 years who participated in two or more consecutive waves of a longitudinal study between 1993 and 1996 (response rate 74%). Discrete-time survival analysis was used to describe the risks and risk factors for substance use initiation and progression. The risk for initiating use of any substance accelerated in early adolescence and peaked at age 18. The risk for progression from use of alcohol, marijuana, and/or inhalants to the use of other illicit drugs (e.g., cocaine) increased over the first 4.5 years after initiating substance use, then diminished in subsequent years. The risk of substance use initiation and progression varied across the four participating communities and by season of the year. Compared to adolescents who initiated substance use with alcohol only, adolescents who initiated substance use with marijuana or inhalants were more likely to progress to use other illicit drugs. Prevention programs for AI communities should be designed to address these community, age, and seasonal variations in the risks for substance use initiation and progression.

Autism displays a remarkably high heritability but a complex genetic etiology. One approach to identifying susceptibility loci under these conditions is to define more homogeneous subsets of families on the basis of genetically relevant phenotypic or biological characteristics that vary from case to case. The authors performed a principal components analysis, using items from the Autism Diagnostic Interview, which resulted in six clusters of variables, five of which showed significant sib-sib correlation. The utility of these phenotypic subsets was tested in an exploratory genetic analysis of the autism candidate region on chromosome 15q11-q13. When the Collaborative Linkage Study of Autism sample was divided, on the basis of mean proband score for the "savant skills" cluster, the heterogeneity logarithm of the odds under a recessive model at D15S511, within the GABRB3 gene, increased from 0.6 to 2.6 in the subset of families in which probands had greater savant skills. These data are consistent with the genetic contribution of a 15q locus to autism susceptibility in a subset of affected individuals exhibiting savant skills. Similar types of skills have been noted in individuals with Prader-Willi syndrome, which results from deletions of this chromosomal region.

253Autism is a neuropsychiatric disorder that exhibits high heri-tability and is considered to have a complex genetic etiology. Asibling of a child with autism has a 25 to 50 times greater riskfor developing autism than someone in the general population.Autism displays both clinical and genetic heterogeneity, as reviewedin last month’s column. A different set of genes may confer riskin different families or individuals (genetic heterogeneity), anddifferent siblings in a given family may have a different clinical