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Objective To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA). Method Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments. Results Three patterns of functional outcomes emerged. Post−secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG. Conclusion Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.

The fields of child psychology and psychiatry have not yet established the clinical presentation in school of children and adolescents who have been diagnosed as having a depressive disorder. To address this issue, the authors used teacher ratings on scale oriented to the third, revised edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-III-R). Based on DSM-III- R diagnoses generated from interviews—using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiological Version (K-SADS-E)—of parents and children ages 6 to 18 years old ( N = 153), the authors formed three groups of children: Depressed, Attention-Deficit/ Hyperactivity Disorder, and Control. They then used the DSM-oriented scales of Achenbach's Teacher's Report Form and the Child Behavior Checklist, the latter completed by parents, to compare the children in each group.Teacher— parent agreement on the scales was consistent with the results from past studies.Teacher ratings distinguished among the groups almost identically to parent ratings; in particular, the Affective Problems scales significantly differentiated the Depressed group from the other two groups. Furthermore, teachers rated substantial numbers of members of the Depressed group with serious levels of both affective and anxious symptoms. Overall, teacher accuracy in identifying children with depression was 66% on the Affective Problems scales. In addition, the ratings identified two subgroups of the Depressed group: Parent-Identified Only and Teacher/Parent-Identified. Consequently, teachers appear to make clinically relevant ratings of depression in children that may enhance the diagnosis and treatment monitoring of depressive disorders in children and adolescents.

Objective: Family studies of youth with depression are reviewed and new data presented. Past studies suggest strong familiality of youth depression. However, few studies included direct interviews with fathers and both psychiatric and normal control groups. In this study, lifetime prevalences of parental Major Depressive Disorder (MDD), Recurrent Depression, Dysthymic Disorder (DD), Double Depression (MDD/DD) and Bipolar Disorder were compared for 6-18 year old youth with depression (n = 127), youth with ADHD without a depression history (n = 116), and community control youth (n = 78). Method: Parental diagnoses were made by diagnosticians blind to child diagnostic status using best estimate procedures based on the parent-interview SADS and the Family History Interview of Psychiatric Status from the other parent. Child diagnoses were based on K-SADS interviews conducted with both parent and child separately. Results: Both mothers and fathers of depressed probands were significantly more likely than mothers and fathers of the other proband groups to have a history of MDD and DD. Mothers of probands with MDD/DD had higher rates of MDD compared to mothers of other depressed probands. There were few cases of parental Bipolar Disorder and most occurred in parents of probands with depression. Conclusion: The current findings provide further evidence of the strong familiality of youth depression and highlight the need to evaluate parents when treating depressed youth. A comprehensive treatment approach may need to include a focus on obtaining treatment for and enhancing coping with parental depression.

Attention deficit/hyperactivity disorder (ADHD) is a common heritable disorder with a childhood onset. Molecular genetic studies of ADHD have previously focused on examining the roles of specific candidate genes, primarily those involved in dopaminergic pathways. We have performed the first systematic genomewide linkage scan for loci influencing ADHD in 126 affected sib pairs, using a approximately 10-cM grid of microsatellite markers. Allele-sharing linkage methods enabled us to exclude any loci with a lambda(s) of > or =3 from 96% of the genome and those with a lambda(s) of > or =2.5 from 91%, indicating that there is unlikely to be a major gene involved in ADHD susceptibility in our sample. Under a strict diagnostic scheme we could exclude all screened regions of the X chromosome for a locus-specific lambda(s) of >/=2 in brother-brother pairs, demonstrating that the excess of affected males with ADHD is probably not attributable to a major X-linked effect. Qualitative trait maximum LOD score analyses pointed to a number of chromosomal sites that may contain genetic risk factors of moderate effect. None exceeded genomewide significance thresholds, but LOD scores were >1.5 for regions on 5p12, 10q26, 12q23, and 16p13. Quantitative-trait analysis of ADHD symptom counts implicated a region on 12p13 (maximum LOD 2.6) that also yielded a LOD >1 when qualitative methods were used. A survey of regions containing 36 genes that have been proposed as candidates for ADHD indicated that 29 of these genes, including DRD4 and DAT1, could be excluded for a lambda(s) of 2. Only three of the candidates-DRD5, 5HTT, and CALCYON-coincided with sites of positive linkage identified by our screen. Two of the regions highlighted in the present study, 2q24 and 16p13, coincided with the top linkage peaks reported by a recent genome-scan study of autistic sib pairs.

Treatment studies in child and adolescent psychiatry are increasingly characterized by long-term, multisite, randomized clinical trials (RCTs). During the course of these RCTs it is common for clinical exigencies to emerge that require rapid, direct intervention. The challenge is to provide clinically appropriate responses that do not contaminate the delivery, distinctness, and interpretation of the treatments under investigation. In multisite studies, the problem is compounded by the need to minimize cross-site differences in the delivery of adjunct treatments. Such minimization requires fully operationalized and manual-based procedures for clinically mandated intervention. The NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (ADHD)--"the MTA"--is a long-term multisite collaborative study in which children with ADHD were randomly assigned to either medication management, behavioral treatment, the combination, or community-comparison assessment and referral. In designing its study, the MTA developed a manual-based set of procedures (the MTA Adjunct Services and Attrition Prevention [ASAP] Manual) for situations not covered by the protocol treatments. The majority of cases requiring adjunct services fell into two major categories: (1) crisis/emergent situations and (2) imminent risk of attrition. This report describes the ASAP guidelines for dealing with cases that required adjunct services that the MTA Steering Committee adopted before initiating the trial. Although the manual-based guidelines are especially applicable to multisite RCTs, many of the procedures in the ASAP Manual can apply to any treatment study in children.

Examined hypothesized gender and comorbidity differences in the observed classroom behavior of children with attention deficit hyperactivity disorder (ADHD). The behavior of 403 boys and 99 girls with ADHD, ages 7-10, was compared (a) to observed, sex-specific classroom behavior norms, (b) by sex, and (c) by comorbid subgroups. Boys and girls with ADHD deviated significantly from classroom norms on 15/16 and 13/16 categories, respectively. Compared to comparison girls, girls with ADHD had relatively high rates of verbal aggression to children. Boys with ADHD engaged in more rule-breaking and externalizing behaviors than did girls with ADHD, but the sexes did not differ on more "neutral," unobtrusive behaviors. The sex differences are consistent with notions of why girls with ADHD are identified and referred later than boys. Contrary to hypothesis, the presence of comorbid anxiety disorder (ANX) was not associated with behavioral suppression; yet, as hypothesized, children with a comorbid disruptive behavior disorder (DBD) had higher rates of rule-breaking, and impulsive and aggressive behavior, than did children with ADHD alone and those with ADHD+ANX. Elevated rates of ADHD behaviors were also observed in children with comorbid DBD, indicating that these behaviors are truly present and suggesting that reports of higher ADHD ratings in this subgroup are not simply a consequence of negative halo effects and rater biases.

Objective Recent results from the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD; MTA) have demonstrated impairments in several functioning domains in adults with childhood ADHD. The childhood predictors of these adult functional outcomes are not adequately understood. The objective of the present study was to determine the effects of childhood demographic, clinical, and family factors on adult functional outcomes in individuals with and without childhood ADHD from the MTA cohort. Method Regressions were used to determine associations of childhood factors (age range 7–10 years) of family income, IQ, comorbidity (internalizing, externalizing, and total number of non-ADHD diagnoses), parenting styles, parental education, number of household members, parental marital problems, parent–child relationships, and ADHD symptom severity with adult outcomes (mean age 25 years) of occupational functioning, educational attainment, emotional functioning, sexual behavior, and justice involvement in participants with (n = 579) and without (n = 258) ADHD. Results Predictors of adult functional outcomes in ADHD included clinical factors such as baseline ADHD severity, IQ, and comorbidity; demographic factors such as family income, number of household members and parental education; and family factors such as parental monitoring and parental marital problems. Predictors of adult outcomes were generally comparable for children with and without ADHD. Conclusion Childhood ADHD symptoms, IQ, and household income levels are important predictors of adult functional outcomes. Management of these areas early on, through timely treatments for ADHD symptoms, and providing additional support to children with lower IQ and from households with low incomes, could assist in improving adult functioning.

In a collaborative research program on attention-deficit hyperactivity disorder (ADHD) initiated 20 years ago at UC Irvine, we adopted Cantwell's (1994) approach to define a refined phenotype for use in studies of the biological bases of this disorder. We have used this refined phenotype (ADHD-Combined Type without internalizing comorbidities) in our molecular genetic studies of ADHD, which have paralleled the emerging literature in this new field. In our research program, we used the candidate gene approach, with hypotheses derived from the dopamine theory of ADHD and Posner and Raichle's (1994) theory of attention. We proposed a candidate dopamine gene (DRD4) and discovered an association with ADHD due to an increase prevalence of the ‘7-repeat’ allele defined by a 48-base-pair variable number of tandem repeats in exon III. The DRD4–ADHD association has now been confirmed by multiple groups around the world. In the next steps of our research program, we are evaluating the impact of a putative DRD4 risk allele on cognition, initiating an investigation of DNA sequence variation in DRD4 alleles, and investigating the association of ADHD with other candidate genes. Using our collaborative research program as an example, we will review the history and current status of molecular genetic studies of ADHD.

Objectives To examine the trajectory of methylphenidate (MPH) dosage over time, following a controlled titration, and to ascertain how accurately the titration was able to predict effective long-term treatment in children with attention-deficit/ hyperactivity disorder (ADHD). Method Using the 14-month-treatment database of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), the outcome of the initial placebo-controlled, double-blind, randomized daily switch titration of MPH was compared with the subsequent maintenance pharmacotherapy. Children received monthly monitoring visits and, when needed, medication adjustments. Results Of the 198 children for whom MPH was the optimal treatment at titration (mean ± SD dose: 30.5 ± 14.2 mg/day), 88% were still taking MPH at the end of maintenance (mean dose 34.4 ± 13.3 mg/day). Titration-determined dose and end-of-maintenance dose were significantly correlated ( r = 0.52–0.68). Children receiving combined pharmacotherapy and behavioral treatment ended maintenance on a lower dose (31.1 ± 11.7 mg/day) than did children receiving pharmacotherapy only (38.1 ± 14.2 mg/day). Of the 230 children for whom titration identified an optimal treatment, 17% continued both the assigned medication and dosage throughout maintenance. The mean number of pharmacological changes per child was 2.8 ± 1.8 (SD), and time to first change was 4.7 months ± 0.3 (SE). Conclusions For most children, initial titration found a dose of MPH in the general range of the effective maintenance dose, but did not prevent the need for subsequent maintenance adjustments. For optimal pharmacological treatment of ADHD, both careful initial titration and ongoing medication management are needed.

Five Minute Speech Sample Expressed Emotion (FMSS-EE) was examined in families of youth with depressive disorders, nondepressed youth with attention deficit/hyperactivity disorder (ADHD), and community controls screened for the absence of depression and ADHD. Consistent with the hypothesis that FMSS-EE shows some specificity as a risk factor for depression, rates of critical EE were significantly higher among mothers of youth with depression as compared to mothers of nondepressed youth with ADHD, or mothers of controls. When both mothers' and fathers' scores were used to generate family EE ratings, rates of overall EE and critical EE were significantly higher for the depressed group than the control group, but the nondepressed ADHD group did not differ significantly from the other groups. Results support the hypothesis that critical EE in mothers shows some specificity as a risk factor or correlate of depression in youth.

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7-9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.

Objective To examine risk and protective processes for posttraumatic stress reactions and negative sequelae following the Northridge earthquake (EQ) among youths diagnosed for pre-EQ psychopathology. Method Symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety, and social Impairment were evaluated using telephone interviews among 66 children participating in a family-genetic study of childhood-onset depression at the time of the EQ. Results Significant predictors of PTSD symptoms 1 year after the EQ included perceived stress and resource loss associated with the EQ, a pre-EQ anxiety disorder, and more frequent use of cognitive and avoidance coping strategies. PTSD symptoms were associated with high rates of concurrent general anxiety symptoms, depressive symptoms, and social adjustment problems with friends. The only significant correlation between sibling scores was on measures of sibling reports of objective exposure. Conclusions Preexisting anxiety disorders represent a risk factor for postdisaster PTSD reactions. Postdlsaster services need to attend to the needs of these youths as well as those of youths experiencing high levels of subjective stress, resource loss, and/or high exposure. That children within families show significant variation in postdisaster reactions underscores the need for attention to individual child characteristics and unshared environmental attributes. J. Am. Acad. Child Adolesc. Psychiatry , 1999, 38(8):1016–1023.

Evidence that the dopamine D4 receptor is a susceptibility gene in attention deficit hyperactivity disorder

Objective Since the introduction of DSM-III/III-R , clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research, and future classification approaches. Method The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment, and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria. Results The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless, available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD, aggressive subtype, and (2) ADHD, anxious subtype. Conclusions Additional studies of the frequency of comorbidity and associated factors are greatly needed, to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors. J. Am. Acad. Child Adolesc. Psychiatry , 1997, 36(8):1065–1079.

Objective Previous research has demonstrated that peer rejection is a significant part of the clinical presentation of many children with attention-deficit hyperactivity disorder (ADHD). Outcome studies of treatment interventions have typically failed to show generalization of treatment gains to the home and classroom. This has been especially true for children who have comorbid oppositional defiant disorder (ODD). The present study was intended to demonstrate generalization of an outpatient social skills training program when parents were trained in skills training program when parents were trained in skills relevant to their child's social adjustment. Method Thirty-five children with ADHD and 14 children without ADHD were given 12 sessions of treatment (treatment group). Outcome was compared with 12 children with ADHD and 12 children without ADHD who were on a waitlist for treatment (waitlist group). Nineteen children with ODD were in the treatment group and five in the waitlist. Stimulant medication was prescribed for all children with ADHD. Results Subjects with ADHD showed improvement comparable with that of subjects without ADHD on all teacher-and parent-reported measures of peer adjustment and social skills, except teacher-reported withdrawal. Children with ODD had outcome comparable with that of children without ODD. Effect sizes ranged from 0.93 to 1.34, indicating that the average treatment group subject was better off than 83.4% of waitlist subjects on outcome measures. Conclusions The present results suggest that children with ADHD are best helped by a combination of social skills training for themselves, collateral training for their parents, and stimulant medication. J. Am. Acad. Child Adolesc. Psychiatry , 1997, 36(8):1056–1064.

A standardized 12-week cognitive-behavioral social skills package in which parents assisted children with socialization homework assignments, was presented to 52 nonpsychotic outpatient boys, many of whom were diagnosed with DSM-III-R Attention Deficit-Hyperactivity Disorder and Oppositional Defiant Disorder. Results demonstrated that the Thought Problems factor of the mother-completed Child Behavior Checklist aided in predicting changes in teacher-rated aggression. DSM-III-R diagnosis of Oppositional Defiant Disorder predicted changes in teacher-rated withdrawal subsequent to treatment. The need for research to determine which children benefit from which treatment was discussed.

The use of clonidine alone and in combination to treat a variety of problems has increased in child and adolescent patients. Four cases of adverse experiences with clonidine are described. Clinical guidelines for the use of clonidine in particular and the use of polypharmacy in general are presented.

(1995). Training outpatient boys to conform with social ecology of popular peers: Effects on parent and teacher ratings. Journal of Clinical Child Psychology: Vol. 24, No. 3, pp. 300-310.

Whole-blood serotonin (5-HT) concentration was assessed in 15 children and adolescents with obsessive–compulsive disorder (OCD) before and during treatment with clomipramine (CMI). Pretrea...

Children with attention deficit hyperactivity disorder display disruptive behavioral disorders that tend to interfere with academic and social progress and that may respond only partially to classroom management and motivational approaches. Although stimulant medication is seen as a necessary adjunct to treatment in many cases, measurement of response to such treatment is often quite problematic. The present study provides findings on response to treatment with methylphenidate (Ritalin) across six measures of cognitive, academic, and social functioning in 71 boys, ages 7 to 11 years, with attention deficit hyperactivity disorder. Optimal response to this drug was determined in double-blind, placebo, crossover trials, and measurement of response focused on procedures similar to those in actual practice. Response ranged from approximately 18 to 71% across the six measures, suggesting that whether a child can be considered a responder to methylphenidate depends greatly on choice of outcome measure. A clinically therapeutic dosage level for each subject was also used to examine dose effects, and factor analytic results suggest that three of the six measures appeared to tap child behaviors quite different from those measured by traditional means.

This article selectively reviews aspects of families of children with attention-deficit hyperactivity disorder (ADHD). A growing body of evidence indicates that some type, or possibly multiple types, of biologic underpinnings lead to a final common pathway of ADHD. Nevertheless, considerable information has accumulated on aspects of the families of children with ADHD as well. Some of the current areas of research include the familiality of the disorder, whether this familiality is genetic, issues regarding parent-child interaction, and involvement of parents in the treatment of children with ADHD. This article touches on current research in each of these areas.

The publication of DSM-IIΙ in 1980 seems to have reawakened interest in clinical phenomenology and nosology of child and adolescent psychopathology. The body of data is growing on mood disorders in children and adolescents who have been diagnosed by different sets of criteria. At the same time, two new sets of criteria are being developed. Much new work needs to be done on the external validation of the categories delineated by these different systems.

The other articles in this issue have attempted to present brief, up-to-date summaries of the current issues regarding mood disorders in prepubertal children and adolescents. This article concentrates on future research directions that may lead to advances in the field.

Successful treatment of children and adolescents with mood disorders requires a flexible and broad-based treatment plan. This article describes the many treatment approaches that have been found to be relevant for the treatment of youngsters with mood disorders and provides some guidelines for selection of treatments. The stages of treatment of mood disorders from initial assessment to maintenance are highlighted. Psychosocial as well as pharmacologic therapies are reviewed.

Recent proposed amendments to the federal special education law and proposed definitional changes in the seriously emotionally disturbed category suggest that attention deficit hyperactivity disorder may become an increasingly important diagnostic entity within the field of behavioral disorders. To examine the potential impact on special education programs, 30 boys with pure hyperactivity (i.e., no other associated diagnoses) and 41 boys with mixed hyperactivity (i.e., hyperactivity with conduct or oppositional defiant disorders) were examined as to their IQ and academic functioning. Academic function was measured both on psychoeducational tests and on curriculum-based probes. Findings suggest a great deal of heterogeneity on all measures along with some decrement in academic performance if conduct or oppositional disorder were also present. Decrements tended to be statistically significant, however, on only two of several measures given. Reading comprehension results are of particular interest as are the small percentage of subjects who potentially qualify as learning disabled. Implications for academic expectations and special education eligibility are discussed.

Achenbach Child Behavior Checklist ratings were collected on boys aged 6 to 11 years screened as not having significant behavior problems, as clinic-referred boys, and as boys diagnosed as having Attention Deficit-Hyperactivity Disorder alone or together with Oppositional-Defiant Disorder or Conduct Disorder. Cluster analysis resulted in a classification system related to DSM-III-R classification of the boys and parent self-report of mildly antisocial acts. Clusters also enhanced the ability of the instrument to detect Attention Deficit Hyperactivity Disorder and disruptive behavior disorders.

Children and adolescents with obsessive compulsive disorder were studied in an 8-week, multicenter, double-blind, parallel groups trial of clomipramine hydrochloride (CMI) versus placebo. Efficacy assessments included the child version of the Yale-Brown Obsessive Compulsive Scale and the National Institute of Mental Health Global rating scale. At the end of 8 weeks, CMI-treated patients showed a mean reduction in Yale-Brown Obsessive Compulsive Scale score of 37% compared to 8% in the placebo group. Side effects were typical of tricyclic antidepressants. In a 1-year open label treatment, CMI continued to be effective and well tolerated.

Controversy surrounding stimulant medication, particularly its effects on reading performance, continues to obscure the issue of the use of this drug in classroom situations. The present study emphasized careful differential diagnosis, double-blind and placebo approaches, and curriculum-based dependent measures to address these concerns. Methylphenidate was administered to two groups of boys, ages 8 through 11. The two groups included 27 subjects meeting criteria for attention deficit-hyperactivity disorder but not conduct disorder, known as hyperactive disorder (HD), and 28 subjects meeting criteria for both diagnostic categories, known as hyperactive-aggressive (HA). Only four subjects in each group met a discrepancy criterion for learning disabilities (LD). Methylphenidate was administered to both groups at three levels of dosage, along with baseline and placebo conditions. Dependent measures involved both reading recognition and reading comprehension, equivalent across all conditions. No significant results were found for the group with HD in either reading recognition or comprehension, due largely to unusual placebo reactions. Results were generally in the direction predicted for the group with HA, but only significantly so in reading comprehension, and no dose effect was found on this variable. Implications for reading as a dependent measure of medication effects are discussed.

Whole blood serotonin (5-HT) concentration was assessed in 16 children and adolescents with severe obsessive-compulsive disorder (OCD) and in 14 normal adolescent controls. There was no difference in blood 5-HT content between the OCD patients and the normal controls. However, the OCD patients with a family history of OCD had significantly higher blood 5-HT levels than did either the OCD patients without a family history of OCD or the normal controls. Blood 5-HT content was not associated with a history of major depressive disorder or chronic tic disorder. These preliminary results suggest that studies of serotonergic functioning in OCD may need to control for family history of OCD and that blood 5-HT may be a useful biochemical measure in family-genetic studies of OCD.

This paper discusses the manifestations and correlates of depressive affect disorders in adolescents. It begins with some definitions and a discussion of the concept (from adult psychiatry) of depression and depressive disorders. The clinical picture of depressive disorders in adults is described, and the interrelationship is considered between them and the depressive disorders of adolescents and prepubertal children. Data are discussed regarding the external validity of adolescent depressive disorders (including their familial and biological correlates, their course and treatment outcome). Finally, the relevance of these data is summarized with regard to the process of establishing a diagnosis of a depressive disorder in adolescents.

It is well established that stimulant medication improves classroom manageability and attention in terms of time on task, but does stimulant medication improve learning or long-term academic achievement in children with ADHD? There is no clear evidence that it does, but there are at least two reasons why beneficial effects may be obscured in research studies and clinical practice: (1) Higher-than-optimal doses may be prescribed if behavioral response (rather than cognitive response) is used to titrate the dose, and (2) treatment may be overinclusive if diagnostic groups are targeted in which a significant proportion of cases do not have favorable cognitive responses to medication. This article addresses these two issues and describes a large clinical series of patients who were evaluated using a double-blind medication assessment protocol designed to overcome some of the theoretical deficiencies suggested by these issues.

Objective. In the Multimodal Treatment Study of ADHD (MTA), the effects of medication management (MedMgt) and behavior modification therapy (Beh) and their combination (Comb) and usual community comparison (CC) in the treatment of attention-deficit/hyperactivity disorder (ADHD) differed at the 14-month assessment as a result of superiority of the MTA MedMgt strategy (Comb or MedMgt) over Beh and CC and modest additional benefits of Comb over MedMgt alone. Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention. Methods. Of 579 children who entered the study, 540 (93%) participated in the first follow-up 10 months after the end of treatment. Mixed-effects regression models explored possible persisting effects of the MTA medication strategy, the incremental benefits of Comb over MedMgt alone, and the possible superiority of Beh over CC on 5 effectiveness and 4 service use domains. Results. The MTA medication strategy showed persisting significant superiority over Beh and CC for ADHD and oppositional-defiant symptoms at 24 months, although not as great as at 14 months. Significant additional benefits of Comb over MedMgt and of Beh over CC were not found. The groups differed significantly in mean dose (methylphenidate equivalents 30.4, 37.5, 25.7, and 24.0 mg/day, respectively). Continuing medication use partly mediated the persisting superiority of Comb and MedMgt. Conclusion. The benefits of intensive MedMgt for ADHD extend 10 months beyond the intensive treatment phase only in symptom domains and diminish over time.

Using receiver operating characteristics, the authors examined outcome predictors (variables associated with outcome regardless of treatment) and moderators (variables identifying subgroups with differential treatment effectiveness) in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD; MTA). Treatment response was determined using parent- and teacher-reported ADHD and oppositional defiant symptoms, with levels near or within the normal range indicating excellent response. Among 9 baseline child and family characteristics, none predicted but 3 moderated treatment response. In medication management and combined treatments, parental depressive symptoms and severity of child ADHD were associated with decreased rates of excellent response; when these 2 characteristics were present, below-average child IQ was an additional moderator. No predictors or moderators emerged for behavioral and community comparison treatments. The authors discuss conceptual and clinical implications of research on treatment moderators.

The purpose of this study was to discriminate subtypes of obsessive-compulsive disorder (OCD) in a clinical sample of children and adolescents. Sixty OCD patients were assessed in two outpatient psychiatric clinics; 15 patients had a lifetime history of tics and 45 patients had no tic history. Interviews were conducted with the patients and their parents by a child psychiatrist using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The symptom checklist of the CY-BOCS was used to categorize obsessions and compulsions. Discriminant function analysis was used to compare the two groups in their symptomatology. There was no difference between the two groups in seven obsession categories. However, there was a significant difference between the two groups in seven compulsion categories. Ordering, hoarding, and washing compulsions were more common in those with no tic history. The results indicate that tic-related OCD may be differentiated from non-tic-related OCD early in life by the presence or absence of certain compulsive symptoms.

Objectives Previous research has been inconclusive whether attention-deficit/hyperactivity disorder (ADHD), when comorbid with disruptive disorders (oppositional defiant disorder [ODD] or conduct disorder [CD]), with the internalizing disorders (anxiety and/or depression), or with both, should constitute separate clinical entities. Determination of the clinical significance of potential ADHD + internalizing disorder or ADHD + ODD/CD syndromes could yield better diagnostic decision-making, treatment planning, and treatment outcomes. Method Drawing upon cross-sectional and longitudinal information from 579 children (aged 7–9.9 years) with ADHD participating in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), investigators applied validational criteria to compare ADHD subjects with and without comorbid internalizing disorders and ODD/CD. Results Substantial evidence of main effects of internalizing and externalizing comorbid disorders was found. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to the MTA behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to MTA medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. Conclusions Findings indicate that three clinical profiles, ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder (ADHD + ANX), ADHD co-occurring with ODD/CD but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes different from "pure" ADHD with neither comorbidity. Future clinical, etiological, and genetics research should explore the merits of these three ADHD classification options.

Objective To examine ratings and objective measures of attention-deficit/hyperactivity disorder (ADHD) symptoms to assess whether ADHD children with and without comorbid conditions have equally high levels of core symptoms and whether symptom profiles differ as a function of comorbidity and gender. Method Four hundred ninety-eight children from the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were divided into comorbid groups based on the parent Diagnostic Interview Schedule for Children and assessed via parents' and teachers' Swanson, Nolan, and Pelham (SNAP) ratings and a continuous performance test (CPT). Comorbidity and gender effects were examined using analyses of covariance controlled for age and site. Results CPT inattention, impulsivity, and dyscontrol errors were high in all ADHD groups. Children with ADHD + oppositional defiant or conduct disorder were rated as more impulsive than inattentive, while children with ADHD + anxiety disorders (ANX) were relatively more inattentive than impulsive. Girls were less impaired than boys on most ratings and several CPT indices, particularly impulsivity, and girls with ADHD + ANX made fewer CPT impulsivity errors than girls with ADHD-only. Conclusions Children with ADHD have high levels of core symptoms as measured by rating scales and CPT, irrespective of comorbidity. However, there are important differences in symptomatology as a function of comorbidity and gender.

The self-esteem of children with Attention Deficit Hyperactivity Disorder (ADHD) has been shown to be low. The effects of stimulant medication upon their self-esteem have not been systematically studied. The present study employed a reliable self-report instrument to measure the self-esteem of children with ADHD medicated with stimulants vs. those who were unmedicated. Results showed that stimulants were associated with significantly higher self-esteem. Children with ADHD prescribed stimulants reported feeling more intelligent and more popular than unmedicated children with ADHD. Children with ADHD and Oppositional Defiant Disorder (ODD) prescribed stimulants reported feeling better behaved. Significant correlations indicated that higher doses were associated with higher self-esteem. The present results suggest a need for a well-controlled study to determine if stimulants were responsible for the observed differences in self-esteem.

As discussed in Chapters 4, 5, and 13, a large body of evidence has accumulated about impairments in cognitive, social, and school functioning in children with Attention-Deficit/ Hyperactivity Disorder (ADHD)t (Cantwell, 1996), which has generated increased interest in research on risk factors for this disorder. Risk factors are defined as variables that increase the probability of any form of psychopathology. In contrast, protective factors modify an individual’s response to risk factors and thus reduce the chance of disorder or of a maladaptive outcome. Resilience is defined as successful adaptation despite exposure to risk or adversity (Masten, 1994).

These parameters describe the aims and approach to diagnosis, treatment, and monitoring of children and adolescents with language and learning disorders (LLDs). LLDs are amon the most common developmental disorders the clinician is likely to encounter. About 50% of children with an LLD also have a comorbid Axis I psychiatric disorder. The diagnosis of an LLD requires a discrepancy, based on age and intelligence, between potential and achievement. The clinician collaborates with parents and school personnel to clarify the diagnosis, implement appropriate treatment and remediation, and monitor progress. The clinician is instrumental in identifying and treating comorbid conditions, including determining the appropriateness of medication. Long-term prognosis depends on the type and severity of the LLD, the availability of remediation, and the presence of a supportive family and school environment. J. Am. Acad. Child Adolesc. Psychiatry , 1998, 37(10 Supplement):46S–62S.

Objective This was a randomized, double-blind, crossover study of 30 children with attention-deficit/hyperactivity disorder (ADHD) that evaluated the time course effects of four doses of Adderall® (5,10,15, and 20 mg), an inactive control (placebo), and a positive control (clinical dose of methylphenidate). Method For each treatment condition, a capsule was administered in the morning and assessments were performed in an analog classroom setting every 1.5 hours across the day. Subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measures were obtained for each classroom session, and these measures were used to evaluate time-response and dose- response effects of Adderall®. Results For doses of Adderall® greater than 5 mg, significant time course effects were observed. Rapid improvements on teacher ratings and math performance were observed by 1.5 hours after administration, and these effects dissipated by the end of the day. The specific pattern of time course effects depended on dose: the time of peak effects and the duration of action increased with dose of Adderall®. Conclusions This documentation of efficacy in a controlled study supports the addition of Adderall® to the armamentarium of psychotropic medications for the treatment of ADHD. The differences in time-response patterns of Adderall® and methylphenidate may help tailor treatment to meet specific clinical needs of different children with ADHD.

The Collaborative Multimodal Treatment Study of Children With Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first child multisite cooperative agreement treatment study of children conducted by the National Institute of Mental Health, Rockville, Md. It examines the long-term effectiveness of medication vs behavioral treatment vs both for treatment of ADHD and compares state-of-the-art treatment with routine community care. In a parallel-groups design, 576 children (age, 7-9 years) with ADHD (96 at each site) are thoroughly assessed and randomized to 4 conditions: (1) medication alone, (2) psychosocial treatment alone, (3) the combination of both, (4) or community comparison. The first 3 groups are treated for 14 months and all are reassessed periodically for 24 months. Designers met the following challenges: framing clinically relevant primary questions; defining the target population; choice, intensity, and integration and combination of treatments for fair comparisons; combining scientific controls and standardization with clinical flexibility; and implementing a controlled clinical trial in a nonclinical setting (school) controlled by others. Innovative solutions included extensive decision algorithms and manualized adaptations of treatments to specific needs.