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This chapter examines the effectiveness of stress inoculation training for the treatment of test anxiety in high school students. The stress inoculation training procedure facilitates the inclusion of multimodal therapeutic techniques that can help students to modify the predisposition to engage in worry cognitions and emotionality reactions and to develop coping skills, such as relaxation techniques and study habits. Stress inoculation training was selected as a treatment procedure because it provides the flexibility for the design of a multimodal treatment that includes the issues previously pointed out. The students are also provided with the opportunity to learn, practice, and use skills to cope with the stress produced by the test situation. Some of these skills were the identification, analysis, and modification of their task-irrelevant worry thoughts; muscular relaxation; and study habits, work methods, and strategies to answer tests, among others.

NOTICE TO NON-PROFESSIONALS The information contained in this newsletter is not intended as a substitute for consultation with health care professionals. Efforts to subtype ADHD began with the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM; American Psychiatric Association, 1980). In it, attention deficit disorder (ADD) was subdivided into cases with high levels of hyperactivity and those without such levels. Subsequently, the two subtypes were compared in a number of studies. The results were inconsistent in demonstrating reliable or useful differences (Carlson, 1986). Consequently, this subtyping scheme was jettisoned in the next revision of the DSM (American Psychiatric Association, 1987). ADHD replaced ADD as the term for the entire disorder, and ADD without hyperactivity was relegated to the back of the manual, called undifferentiated ADHD, with a call for more research on the nature of this group. In DSM-IV (American Psychiatric Association, 1994), the subtyping of ADHD returned but under different labels. The manual set forth two related symptom dimensions (inattention, hyperactivity-impulsivity) and used them to assign cases to subtypes based on 6 or more symptoms on either or both dimensions (American Psychiatric Association, 2000): the Predominantly Inattentive (IN) Type, the Predominantly Hyperactive-Impulsive Type (HI), and the Combined (C) Type. A few initial studies of these subtypes implied that the HI-Type might be a milder or earlier stage of the C-Type. That led to little further research on the validity of that group. It has largely been ignored or in some studies collapsed in with cases of C-Type (Nigg, Tannock, & Rohde, 2010).

This study examined the latent structure and validity of inattention, hyperactivity-impulsivity, and sluggish cognitive tempo (SCT) symptomatology. We evaluated mother and teacher ratings of ADHD and SCT symptoms in 140 Puerto Rican children (55.7% males), ages 6 to 11 years, via factor and regression analyses. A three-factor model (inattention, hyperactivity-impulsivity, and SCT) provided the best fit for both sets of ratings. Inattention was the strongest correlate of lower scores on neuropsychological, achievement, and psychosocial measures. Externalizing problems were most strongly associated with hyperactivity-impulsivity, and internalizing problems were most strongly associated with parent-rated SCT and teacher-rated Inattention. SCT was not associated with executive function but was negatively associated with math. Inattention accounted for a disproportionate amount of ADHD-related impairment, which may explain the restricted discriminant validity of DSM-IV types. The distinct factors of hyperactivity-impulsivity and SCT had unique associations with impairing comorbidities and are roughly equivalent in predicting external correlates of ADHD-related impairment.

We examined the phenotypic expression of attention-deficit/hyperactivity disorder (ADHD) across cultures by assessing the factor/latent class structure of its core symptoms. We conducted a systematic review of the literature published from January 1987 to November 2008 using Medline and PsycINFO. We systematically reviewed 2,511 article abstracts, and 48 of these abstracts were included in this review. Research with school-age children from 15 countries including different samples, informants, and rating instruments supported a two-factor ADHD model consisting of inattention and combined hyperactivity and impulsivity. This model was not supported for preschool children. Cross-cultural equivalence for the two-factor model was suggested in some studies. Latent class analyses using parental data and more recent approaches like factor mixture modeling are generally consistent with factor analyses. These findings argue in favor of a cross-cultural validity of the syndrome. The implications of these findings for further research and classificatory systems in mental health like the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) are discussed.

This study evaluates the initial efficacy of the Parent-Child Interaction Therapy (PCIT) for Puerto Rican preschool children aged 4-6 years with a diagnosis of attention-deficit/hyperactivity disorder (ADHD), combined or predominantly hyperactive type, and significant behavior problems. Thirty-two families were randomly assigned to PCIT (n = 20) or a 3.5-month waiting-list condition (WL; n = 12). Participants from both groups completed pretreatment and posttreatment assessments. Outcome measures included child's ADHD symptoms and behavior problems, parent or family functioning, and parents' satisfaction with treatment. ANCOVAs with pretreatment measures entered as covariates were significant for all posttreatment outcomes, except mother's depression, and in the expected direction (p < .01). Mothers reported a highly significant reduction in pretreatment hyperactivity and inattention and less aggressive and oppositional-defiant behaviors, conduct problems assessed as problematic, parenting stress associated with their child's behavior, and an increase in the use of adequate parenting practices. For the WL group, there were no clinically significant changes in any measure. Treatment gains obtained after treatment were maintained at a 3.5-month follow-up assessment. PCIT seems to be an efficacious intervention for Puerto Rican families who have young children with significant behavior problems.

Objective The study describes prevalence and rates of services and medication use and associated factors over time among Puerto Rican youths with attention-deficit/hyperactivity disorder (ADHD). Method Longitudinal data are obtained on Puerto Rican children ages 5 through 13 years in the south Bronx in New York ( n = 1,138) and two metropolitan areas in Puerto Rico ( n = 1,353). The Diagnostic Interview Schedule for Children-IV is the diagnostic tool. Five composite measures of risk factors: negative family influences, ineffective structuring, environmental risks, child risks, and maternal acceptance are constructed to relate services and medication use to risk variables. Results ADHD prevalence is similar in Puerto Rico and the south Bronx. Overall mental health services, medication, and psychostimulant use is lower in Puerto Rico across three time points. Most participants never received treatment at any time point. More environmental risks, negative child traits, and low maternal warmth are associated with more services, even after adjusting for comorbidity. When risk variables are controlled, the effects of ADHD on services use decrease. Previous treatment is a strong predictor of subsequent treatment. Conclusions Rates of services and medication use are lower in Puerto Rico. Context seems to be more important than ethnicity in predicting mental health services and medication use among Puerto Rican children with ADHD. Other psychiatric diagnoses and general risk variables are important correlates of services and medication use. J. Am. Acad. Child Adolesc. Psychiatry , 2008;47(8):879-889.

Background: Research comparing treatment-referred boys and girls with attention-deficit/hyperactivity disorder (ADHD) has yielded equivocal results. Contradictory findings may be associated with differential referral practices or unexplored interactions of gender with ADHD subtypes. Method: We examined possible gender differences in ADHD and its subtypes among children aged 4 to 17 in a representative community sample (N ¼ 1896) in Puerto Rico. Caretakers provided information through the Diagnostic Interview Schedule for Children (version IV) and a battery of impairment, family relations, child problems, comorbidity and treatment measures. Results: ADHD was 2.3 times more common in boys than girls, but with one exception there was little evidence that the patterns of associations of ADHD with correlates were different for boys and girls. The exception was school suspension, which was more common among ADHD boys than girls. Additional gender interactions were found when ADHD subtypes were considered. Among those with combined type (n ¼ 50), boys were more likely to be comorbid with mood disorders than girls. For those with the inattentive type (n ¼ 47), girls were more likely to be comorbid with anxiety disorders than boys. Conclusions: Our findings lend cross-cultural generalizability to recent reports that gender does not interact with correlates for ADHD overall, but that it may play a role in subtypes. Keywords: Attention deficit/hyperactivity impulsivity disorder, gender differences, Latino/Hispanics, ADHD subtypes. Abbreviations: CT: combined type; HIT: hyperactiveimpulsive type; IT: predominantly inattentive type; ICC: intraclass correlation coefficient. The research literature on attention-deficit/hyperactivity disorder (ADHD) reports that individuals with this disorder present diverse family backgrounds, patterns of comorbidity, and impairment profiles. The heterogeneous nature of ADHD has led to its subdivision into more homogeneous subtypes based on the predominance of symptoms of inattention (predominantly inattentive subtype or IT), of hyperactivity-impulsivity symptoms (hyperactiveimpulsive subtype or HIT) or on both sets of symptoms (combined subtype or CT) (American Psychiatric Association, 1994). Research has generally supported the validity of the DSM-IV subtypes (e.g., Carlson, Shin, & Booth, 1999; Bauermeister et al., 2005; Graetz, Sawyer, Hazell, Arney, & Baghurst, 2001). The CT and IT may be stable enough over time to segregate groups for research (Lahey, Pelham, Loney, Lee, & Willcutt, 2005).

Background: Differences in service utilization indicating that boys use more mental health servicesthan girls were analyzed to see if they could be explained by known correlates of service use. Thesecorrelates were arranged into individual (severe emotional disturbance, level of impairment and exter-nalizing disorders), family (parental education, psychopathology and parental concern) and schoolfactors (difficulties with school work). The objectives were to understand and identify the factorsaccounting for gender differences in mental health service utilization in order to develop alternatives topromote equity in service delivery. Methods: A representative sample of 1,896 children 4 to 17 years ofage and their primary caretakers were interviewed for this study. Reports of service use were obtainedusing the Service Assessment for Children and Adolescents. Logistic regression was used to assess therelationship between gender and service use, adjusting for known correlates. Results: Our resultsshowed that, except for impairment, other individual, family and school factors did not explain genderdifferences in service utilization. Males with impairment were 2.87 times more likely to receive servicesthan impaired females (p £ .01), and this result continued to hold true for impaired undiagnosed boyscompared to impaired diagnoses-free girls (p £ .001). Conclusions: Our findings showed a servicedisparity between impaired boys and girls who did not meet criteria for a DSM IV diagnosis, but noobserved differences in service use between boys and girls who met criteria for severe emotional dis-turbance (SED). Continued investigations are necessary to analyze, assess and understand the differentcircumstances that bring boys and girls into treatment, followed by the development of appropriateintervention programs at the school and community levels. Keywords: Service development, publichealth, disruptive behavior, internalizing disorder. Abbreviations: DISC-IV: Diagnostic InterviewSchedule for Children; MECA: Methods for the epidemiology of child and adolescent mental disorder;PIC-GAS: Parent Interviewer Children’s Global Assessment Scale; SACA: Service Assessment for Chil-dren and Adolescents; SED: severe emotional disturbance.Several studies have identified gender differences inmental health service utilization by children andadolescents, with most indicating greater utilizationby boys than girls (e.g., Alegri´a, Canino, Ramirez,Chavez, & Rusch, 2004; Barber, Rosenblatt, & Har-ris, 1992; Burns et al., 1995; Cohen & Hesselbart,1993; Cuffee, Waller, & Cuccaro, 1995; Verhulst V Kataoka, Zhang, & Wells, 2002;Wu, Hoven, & Bird, 1999; Zwaanswijk, Van derEnde, Verhaak, Bensing, & Verhulst, 2003). Under-standing and identifying the factors accounting forobserved gender differences in mental health serviceutilization is important for promoting equity in ser-vice delivery. Identifying these factors can providethe information necessary to improve access to carefor underserved children and to prevent health dis-parities.Gender differences in service use may be the resultof methodological artifacts such as sample com-position (Kataoka et al., 2002; Wu et al., 1999), agerange of the study population (Pumariega, Glover, H Verhulst & Van der Ende, 1997; Wuet al., 1999). Furthermore, these gender differencesin service use may be related to actual differences inneed of mental health services. Need for services asdefined by meeting criteria for a severe emotionaldisturbance (SED) (i.e., meeting criteria for a psy-chiatric disorder and substantial impairment infunctioning (Federal Register, 1993)) is one of thebest predictors of mental health utilization in chil-dren (Canino et al., 2004; Burns et al., 1995; Cos-tello, Angold, & Burns, 1996a, 1996b). Nevertheless,comparisons of four communities including one inPuerto Rico, as part of the MECA study (Lahey et al.,1996), found that in spite of similarities between

This article investigates geographic variation in stimulant medication use by youth with attention-deficit/hyperactivity disorder (ADHD) served by public mental health and/or drug and alcohol programs in San Diego ( n = 790) during 1997—1998 and in Puerto Rico ( n = 726) during 1998.Youth were stratified into four groups: (a) ADHD, (b) ADHD—not otherwise specified (ADHD-NOS), (c) other DSM-IV diagnoses, (d) no diagnosis. Reported rates of stimulant use were as follows: ADHD, 32.9% (Puerto Rico) and 38.8% (San Diego), and ADHD-NOS, 20.2% (Puerto Rico) and 17.8% (San Diego).Youth in San Diego were more likely to use other psychotropics and to have experienced residential or inpatient care compared with youth in Puerto Rico. A regression model indicated that predictors of stimulant use at both sites included ADHD, ADHD-NOS, male gender, and younger age. Despite sociodemographic and cultural differences, both settings demonstrated similar patterns of stimulant use, suggesting these medications are not over-used in public sectors.

Donnelly CR (2003). Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder. Child Adolesc Psychiatric Clin N Am 12: 251–269. Pitman RK, Delahanty DL (2005). Conceptually driven pharmacologic approaches to acute trauma. CNS Spectrums 10 (2): 99–106. Perrin S, Smith P, Yule W (2000). Practitioners review: The assessment and treatment of posttraumatic stress disorder in children and adolescents. J Child Psychol Psychiat 41 (3): 277–289. Scheeringa MS, Peebles CD, Cook CA, Zeanah CH (2001). Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, King D, King L (2001). Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad child Adolesc Psychiatry 40 (8): 915–921.

This study compared Hispanic children (ages 7 to 11) with combined type (CT, n=33) and inattentive type (IT, n=21) attention deficit hyperactivity disorder (ADHD) and a control group (n=25) on time-estimation and time-reproduction tasks. The ADHD groups showed larger errors in time reproduction but not in time estimation than the control group, and the groups did not differ from each other on their performance on this task. Individual differences could not be accounted for by oppositional-defiance ratings and low math or reading scores. Although various measures of executive functioning did not make significant unique contributions to time estimation performance, those of interference control and nonverbal working memory did so to the time-reproduction task. Findings suggest that ADHD is associated with a specific impairment in the capacity to reproduce rather than estimate time durations and that this may be related to the children's deficits in inhibition and working memory.

The aim of this study was to examine the psychometric properties of a Spanish translation of an eight-item version of the Adolescent Dissociative Experiences Scale (ADES-8). The eight items were selected to assess pathological forms of dissociative experiences. The scale was administered to a representative sample of 459 medically indigent adolescents, ages 11 to 17, who received mental health services in Puerto Rico. Results indicated that the ADES-8 demonstrated satisfactory internal consistency and test-retest reliability. As expected, most adolescents evidenced very low scores, with nearly half (46%) scoring zero. The scale showed expected patterns of convergent validity with variables that are hypothesized to be related to dissociative disorders, such as psychiatric impairment, comorbidity, and abusive experiences. Logistic regression analyses suggested that a cutoff score of three on the ADES-8 was the best screening rule for identifying persons with higher values on the convergent validity variables. The findings provide support for the clinical and research promise of the ADES-8 as a screening instrument for dissociative disorders in referred youths.

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4–17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11–17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.

The test-retest reliability of the Spanish Diagnostic Interview Schedule for Children (DISC-IV) is presented. This version was developed in Puerto Rico in consultation with an international bilingual committee, sponsored by NIMH. The sample (N = 146) consisted of children recruited from outpatient mental health clinics and a drug residential treatment facility. Two different pairs of nonclinicians administered the DISC twice to the parent and child respondents. Results indicated fair to moderate agreement for parent reports on most diagnoses. Relatively similar agreement levels were observed for last month and last year time frames. Surprisingly, the inclusion of impairment as a criterion for diagnosis did not substantially change the pattern of results for specific disorders. Parents were more reliable when reporting on diagnoses of younger (4-10) than older children. Children 11-17 years old were reliable informants on disruptive and substance abuse/dependence disorders, but unreliable for anxiety and depressive disorders. Hence, parents were more reliable when reporting about anxiety and depressive disorders whereas children were more reliable than their parents when reporting about disruptive and substance disorders.

Objective To address rising concerns about the possible overdiagnosis of attention-deficit hyperactivity disorder (ADHD) and overtreatment with stimulants. To date, almost no studies have examined ADHD in unbiased community-based studies, ascertaining both the prevalence of the diagnosis within nonreferred populations and the extent to which various treatments (i.e., stimulant medication, mental health treatments, and educational interventions) are used. Method As a part of the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, the authors examined epidemiological survey data obtained from 1,285 children and their parents across 4 U.S. communities. Analyses examined the frequency of children's ADHD diagnosis, the extent to which medications were prescribed, as well as the provision of other services (e.g., psychosocial treatments, school-based educational interventions). Results Findings indicated that 5.1% of children met full DSM-III-R ADHD criteria across the pooled sample. Only 12.5% of children meeting ADHD criteria had been treated with stimulants during the previous 12 months. Some children who had been prescribed stimulants did not meet full ADHD diagnostic criteria, but these children manifested high levels of ADHD symptoms, suggesting that the medication had been appropriately prescribed. Children with ADHD were generally more likely to receive mental health counseling and/or school-based interventions than medication. Conclusions Medication treatments are often not used in treating ADHD children identified in the community, suggesting the need for better education of parents, physicians, and mental health professionals about the effectiveness of these treatments. On the basis of these data it cannot be concluded that substantial “overtreatment” with stimulants is occurring across communities in general.

(1995). Dimensions of attention deficit hyperactivity disorder: Findings from teacher and parent reports in a community sample. Journal of Clinical Child Psychology: Vol. 24, No. 3, pp. 264-271.

Epidemiologic studies of psychiatric childhood disorders have differed broadly in the geographic areas sampled, the age ranges sampled, the assessment methods used to ascertain cases, and the correlates and potential risk factors studied. Definitive conclusions as to the prevalence of the disruptive behavior disorders are difficult to reach.

Objective Little is known about the effect of social context and gender on persistence of attention-deficit/hyperactivity disorder (ADHD) in children of early and middle school years. The study compared persistence of DSM-IV ADHD and ADHD not otherwise specified (NOS) over 2 years in two groups of Puerto Rican children. Method A three-wave study obtained data on Puerto Rican children 5 through 13 years of age at baseline. Samples were drawn in the South Bronx in New York (n = 1,138) and two metropolitan areas in Puerto Rico (n = 1,353). The Diagnostic Interview Schedule for Children Version IV was used to diagnose ADHD and ADHD-NOS. Results ADHD or ADHD-NOS diagnosis at wave 1 strongly predicted disorder at waves 2 and 3. ADHD had a significantly stronger predictive effect than ADHD-NOS consistently across site and gender. There was a significant interaction with baseline age. For those younger at baseline, the strength of the prediction of ADHD-NOS was relatively weak; for older children, the presence of ADHD-NOS at baseline predicted risk of subsequent ADHD or ADHD-NOS. Conclusions Persistence of ADHD in children of similar ethnicity does not manifest differently across context and gender. Results suggest that age-specific symptom criteria and modification of age-of-onset criteria should be considered for the diagnosis.

Purpose The worldwide prevalence of conduct disorder (CD) and oppositional defiant disorder (ODD) is presented to examine the first of four criteria used in other studies to determine the validity of psychiatric disorders across cultures. Methods The authors searched Medline and PsycINFO from 1987 to 2008. Studies were included if they were representative of specific communities or countries and reported point prevalence of CD or ODD according to DSM-III-R or DSM-IV criteria for children 18 years or younger. Results Only methodological and not geographic factors were associated with variability of the prevalence estimates. Conclusions The results are discussed in terms of their significance for the classification of disorders and the need for further research to establish the validity of these two disorders across cultures.

Objective: This study examined the impact of inattention, hyperactivity, and oppositional defiant disorder (ODD) behaviors and gender on family life. Method: We created scales for the Family Experiences Inventory (FEI) in a nonclinical sample of Spaniard families with children ages 6 to 12 years ( N = 369) and analyzed the perceived impact of these three behavior dimensions on family experiences. Results: Multiple regression analyses indicated that ODD behaviors were uniquely correlated with Total FEI and its dimensions. Inattention was also uniquely related to higher negative Impact on School Relations and lower Positive Impact on Parents scales. Finally, gender—hyperactivity interactions indicated that boys with higher hyperactivity scores were more likely to score higher on the FEI Total, School Relations, and Siblings scales, and more likely to score lower on the Positive Impact on Parents scale than girls. Conclusions: These findings suggested that parents perceive greater child-related impact and place greater burden from having a male child with hyperactivity. Inattention, hyperactivity, and oppositional defiant behaviors are associated with global parent—child interactive stress but the pattern of associations will vary depending upon the behavior, child gender, and context of family life examined.

Patterns of correlates, comorbidity and impairment associated with attention-deficit hyperactivity disorder (ADHD) in children and youth were examined in representative samples from the community and from treatment facilities serving medically indigent youth in Puerto Rico. Information from caretakers and youths was obtained using the Diagnostic Interview Schedule for Children, (version IV), measures of global impairment, and a battery of potential correlates. In the community (N = 1,896) and the treated samples (N = 763), 7.5 and 26.2% of the children, respectively, met criteria for DSM-IV ADHD in the previous year. Although the prevalence rates and degree of impairment differed, the general patterns of correlates, comorbidity and impairment were similar in both populations. The exceptions were associated with conduct disorder, anxiety, impairment in the ADHD comorbid group, and age factors that appeared to be related to selection into treatment.

Differences in service utilization indicating that boys use more mental health services than girls were analyzed to see if they could be explained by known correlates of service use. These correlates were arranged into individual (severe emotional disturbance, level of impairment and externalizing disorders), family (parental education, psychopathology and parental concern) and school factors (difficulties with school work). The objectives were to understand and identify the factors accounting for gender differences in mental health service utilization in order to develop alternatives to promote equity in service delivery.A representative sample of 1,896 children 4 to 17 years of age and their primary caretakers were interviewed for this study. Reports of service use were obtained using the Service Assessment for Children and Adolescents. Logistic regression was used to assess the relationship between gender and service use, adjusting for known correlates.Our results showed that, except for impairment, other individual, family and school factors did not explain gender differences in service utilization. Males with impairment were 2.87 times more likely to receive services than impaired females (por= .01), and this result continued to hold true for impaired undiagnosed boys compared to impaired diagnoses-free girls (por= .001).Our findings showed a service disparity between impaired boys and girls who did not meet criteria for a DSM IV diagnosis, but no observed differences in service use between boys and girls who met criteria for severe emotional disturbance (SED). Continued investigations are necessary to analyze, assess and understand the different circumstances that bring boys and girls into treatment, followed by the development of appropriate intervention programs at the school and community levels.

In this paper we describe the process used to develop treatment manuals for internalizing and externalizing disorders in children and adolescents. These manuals were developed to offer health care providers and others working in child mental health a flexible intervention that could be adapted to different countries and localities based on: 1) the amount of health care and school resources that are available; 2) the nature and severity of the types of problems children have; and 3) the preferences and cultural factors that are important within these communities. We also discuss the experiences and cultural issues faced by sites in Egypt, Lebanon, Israel, and Brazil who volunteered to implement the manualized treatment programs. The feedback received from these sites indicates that the manuals can be implemented to help children with internalizing and externalizing problems. Neste artigo, descrevemos o processo utilizado para elaborar manuais de tratamento para transtornos de externalização e intrnalização em crianças e adolescentes. Esses manuais foram elaborados para oferecer uma intervenção flexível para provedores de atenção à saúde e demais profissionais que trabalham com a saúde mental da criança, podendo ser adaptados a diferentes países e localidades, com base: 1) no nível de atenção médica e de recursos educacionais disponíveis; 2) na natureza e na gravidade dos tipos de problemas que as crianças apresentam; e 3) nas preferências e fatores culturais que são importantes nessas comunidades. Discutimos, também, as experiências e os problemas culturais enfrentados pelas localidades no Egito, Líbano, Israel e Brasil que foram voluntárias em implementar os programas de tratamento especificados nos manuais. O retorno recebido dessas localidades indica que os manuais podem ser implementados para auxiliar as crianças com problemas de externalização e internalização.

Dissemination of evidence-based assessment and intervention approaches for child and adolescent with behavioral and/or emotional problems is now a priority in the field worldwide. However, developing staff competence in evidence-based assessment and intervention approaches in different countries is complicated by some environmental and economic constraints. In this paper a distance training/supervision model is discussed. We describe seven specific challenges encountered and solutions used for overcoming the obstacles in order to implement evidence-based assessment and intervention approaches in different sites in Brazil, Egypt, Israel, and Lebanon. A disseminação de estratégias de intervenção e avaliação baseadas em evidências para crianças e adolescentes com problemas comportamentais e/ou emocionais é hoje uma prioridade mundial. No entanto, o desenvolvimento de equipes capacitadas para implementação de estratégias de intervenção e avaliação baseadas em evidências nos diferentes países é limitado por restrições ambientais e econômicas. Neste artigo, discute-se um modelo de treinamento/supervisão à distância. Em seguida, são descritos sete desafios específicos encontrados e as soluções utilizadas para superar os obstáculos para implementação de estratégias de intervenção e avaliação baseadas em evidências em diferentes localidades no Brasil, Egito, Israel e Líbano.

Background: Research has shown that a large proportion of adolescents with symptoms of depression and substantial distress or impairment fail to meet the diagnostic criteria for a major depressive disorder (MDD). However, many of these undiagnosed adolescents may meet criteria for a residual category of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revised (DSM-IV-TR), Depressive Disorder Not Otherwise Specified. Minor Depression (mDEP), an example of one of these categories, allows the inclusion of sub-threshold cases that fall below the diagnostic criteria of the five symptoms required for MDD. Minor depression in adolescence is important because it is significantly related to MDD in adulthood. The present study examines a number of risk factors, functional impairment, comorbidity and service utilization patterns associated with depression in community adolescents who met the DSM-IV criteria for mDEP and compares their profile to adolescents who met the criteria for MDD. Method: Puerto Rican adolescents 11 to 17 years old were selected from an island-wide probability household sample of children ranging in age from 4 to 17. The Diagnostic Interview Schedule in Spanish (DISC IV), together with a structured protocol of risks and protective factors, and service utilization questionnaires were administered to primary caretakers and their children. Results: Our findings indicate that youngsters with mDEP had significant impairment and used more mental health services than those with major depression. In addition, adolescents with mDEP had similar outcomes when compared to those meeting full criteria for MDD in terms of psychosocial correlates and comorbidity. Conclusions: The results, although not definitive, suggest a need for further research in order to determine the validity of the present DSM IV diagnostic criteria for mDEP in adolescents.

Background: The aim of this investigation was to examine the construct validity and distinctiveness ofthe inattentive type (IT) and combined type (CT) of Attention-Deficit/Hyperactivity Disorder (ADHD) in aLatino/Hispanic sample. Method: A comprehensive assessment was conducted with a clinicallydiagnosed school-based sample of 98 children aged 6 to 11 (CT ¼ 44; IT ¼ 25; controlgroup ¼ 29). Results: Both ADHD groups were impaired on academic achievement measures, pre-sented more ADHD-type behaviors during math and vigilance tasks, and exhibited greater internalizingsymptoms. The IT group had a later onset of inattention symptoms, presented more sluggish cognitivetempo symptoms, was less prone to initiate social interactions or to be assertive and more self-controlled in social interchanges, was less likely to have externalizing behaviors, had mothers whoreported less child-related family stress, and was less impaired in their adaptive function-ing. Conclusions: Findings supported the construct validity of ADHD in this culturally differentsample and suggested that the CT and IT represent distinct disorders. Keywords: ADHD, inattentiveand combined subtypes, Latino, Hispanic. Abbreviations: ADHD SS-SRF: ADHD Symptoms Scale –Self-Report Form; AI: Activity-Impulsivity; BDI: Beck Depression Inventory–Spanish; BGT: Bender-Gestalt Test; CGAS: Children’s Global Assessment Scale–Spanish; CPT: Conners’ ContinuousPerformance Test; DBRS: Disruptive Behavior Rating Scale; DISC-IV: Diagnostic Interview Schedule forChildren IV; DM: Distraction-Motivation; FEI: Family Experiences Inventory; HSQ: Home SituationsQuestionnaire; IATQ: It’s About Time Questionnaire; PPI: Parent Practices Inventory; SBI: SchoolBehavior Inventory; SCT: sluggish cognitive tempo; SSQ: School Situations Questionnaire; SSSQ:Spanish Social Skills Questionnaire; WPB-S: Woodcock Psychoeducational Battery–Spanish.Attention-Deficit/Hyperactivity Disorder (ADHD) is aheterogeneous disorder. This has led clinicians andresearchers to examine the usefulness of subdivid-ing the disorder into more homogenous subtypes. Inthe Diagnostic and Statistical Manual of MentalDisorders – 4th Edition (DSM-IV; American Psychi-atric Association [APA], 1994), ADHD is subtypedbased on the predominance of impairing symptomsof inattention (inattentive type [IT]), of hyperactivity-impulsivity symptoms (hyperactive-impulsive type[HIT]), or on both sets of symptoms (combined type[CT]). The validity of these subtypes has been thesubject of many studies, particularly for the CT andIT, which for many years have been viewed not assubtypes of ADHD but as different disorders (Milich,Ballentine, & Lynam, 2001).In studies with clinic-referred children, the CT hasbeen found to present earlier age of symptom onset(e.g., Faraone, Biederman, Weber, & Russell, 1998).Regarding patterns of comorbidity, the CT presentedhigher rates of oppositional defiant disorder (ODD)and conduct disorder (CD) or more externalizingproblems than the IT in both clinic and school-basedsamples (Carlson & Mann, 2000; Lahey & Willcutt,2002). The pattern of comorbidity with internalizingproblems is not as clear-cut (Milich et al., 2001). Inschool-based samples, children with the CT pre-sented higher teacher ratings of anxious-depressedand generalized anxiety behaviors (Gaub & Carlson,1997; Nolan, Gadow, & Sprafkin, 2001). In contrast,clinic-referred children with the CT and IT did notdiffer on teacher or parent ratings of anxious/de-pressed symptoms nor in their rates of internalizingdisorders (Eiraldi, Power, & Nezu, 1997; Faraoneet al.)When social functioning is examined, the CT re-ceived higher teacher ratings of social problems andpeer dislike in school-based studies. In clinicalstudies, however, this difference among subgroupsis not consistently found (Carlson & Mann, 2000).Similarly, no consistent significant differences havebeen found between clinic-referred children with theCT and IT on cognitive and academic achievementtests, although both tend to have poorer perform-ance than controls. These differences have notbeen studied in school-based samples (Carlson &Mann, 2000). When considering attentional style,studies with clinic-referred (McBurnett, Pfiffner, &Frick, 2001) and school-based (Carlson & Mann,2002) samples have indicated that inattention

Objective To examine to what extent Latino/Hispanic children with and without attention-deficit/hyperactivity disorder (ADHD) are receiving treatment and to identify variables that predict treatment with stimulant medication. Method Primary caretakers of a probability household sample ( N = 1,897) of Puerto Rican children aged 4-17 years were administered structured interviews (response rate: 90.1%) from 1999-2000 to ascertain psychiatric disorders and types of services received. Results Only 7.0% of children with ADHD received stimulant medication during the last year; moreover, only 3.6% had actually continued this treatment at the time of the interview. One fourth or less of those with ADHD received school-based services or psychosocial treatment. The male-female ratio in stimulant medication use was 10 to 1. In addition, only 0.2% of those with no psychiatric diagnosis received this treatment. ADHD and ADHD-not otherwise specified, impairment, and being male significantly predicted stimulant treatment. Conclusions Children with ADHD in this Latino/Hispanic population are not receiving the most efficacious treatments based on scientific findings and relevant clinical consensus. This population is undertreated rather than overtreated. J. Am. Acad. Child Adolesc. Psychiatry , 2003, 42(7):851-855.

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4-17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11-17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.

The reliability across time, informants and interviewers of the Spanish translation of the DISC-2.1 was tested on a Puerto Rican Hispanic sample using a test-retest design. Levels of reliability between clinic ant) community samples and between younger and older children were compared to explore the sources of low reliability for certain psychiatric disorders. Parents’ reports tended to be mare reliable than those of their children, although the difference was less obvious with older children. Reliability was generally higher for the externalizing disorders and when the second interviewer was a psychiatrist rather than a lay interviewer.

Factor analysis on teacher ratings of symptoms in a probability community sample of children aged 6 to 16 years (N = 614) yielded two factors: Inattention and Hyperactivity-Impulsivity. Subsequent cluster analyses on the scores of factorially derived scales for a subsample of 170 children with a diagnosis of attention deficit disorder with (ADDH) and without hyperactivity (ADDWO), or normals, resulted in five clusters that accounted for 88% of the variance. The existence of these clusters was confirmed using external validating criteria. The data support a bidimensional conceptualization of attention deficit disorder with hyperactivity, one dimension consisting of symptoms of inattention and another of symptoms of hyperactivity-impulsivity. The data also suggests that a condition very similar to the DSM-III-R description of undifferentiated attention-deficit disorder also exists as a distinct entity.

The relationship between operant level (base rate) and asymptotic reinforced instrumental responding was investigated in several contingencies in which licking was contingent upon running, under different FR schedules. For Group I the relationship was examined by selecting rats who naturally differed in their running base rates and for which the licking base rates were equivalent. For Group II the relationship was examined by selecting rats with equivalent running and licking base rates, but whose running rates were eventually made to differ by manipulating wheel-torque requirements. Asymptotic reinforced instrumental responding was found to be linearly related to pre-contingent running base rates, for all FR schedules, and independent of the procedures used to obtain differing running base rates. The results support Premack's contention that asymptotic reinforced instrumental responding is a joint function of the reinforcing response and the operant level of the instrumental response.

Operant conditioning techniques were applied to a case of “elective mutism.” The child was an 8-year-old, third grade boy who refused to participate in classroom activities which required verbal communication. Outside the classroom setting, however, he was observed to communicate freely and without difficulty. The treatment was administered by classroom teachers. The child's verbal expression in the classroom was considerably increased by making social and tangible reinforcers contingent upon hand raising, answering questions, and reading aloud; completion of classroom assignments was similarly improved. At the time the study was completed his grades had improved to such a degree that his teachers recommended his promotion to the fourth grade. Follow-up observation a year later indicated that treatment gains had been maintained.

The Inventario de Comportamiento Escolar (IDCE) is a teacher rating inventory for the assessment of Puerto Rican children, particularly those with a behavior pattern indicative of attention deficit disorder, learning disabilities, or academic underachievement. Factor analysis of classroom behavior ratings of a representative sample of 961 Puerto Rican students (kindergarten to sixth grade) yielded five scales: Inattention, Hyperactivity, Inappropriate Social Behavior, Irritability-Hostility, and Anxiety. Factor analysis of school performance ratings yielded five scales: Reading-Spelling, Expressive Language, Memory, Directionality-Laterality, and Motor Skills. Alpha coefficients (mean: .90; range: .81 to .97) and item total correlations (mean: .67; range: .52 to .78) provided evidence of the internal consistency of the scales. Four-week test-retest reliability ranged from .70 to .90.

In the present experiment, rats were trained to avoid shock by crossing to the adjacent compartment in a one-way avoidance box. Extinction of this response was then carried out in the presence of: (1) three active rats, the social facilitators (SF) which had been trained not to avoid the conditional stimuli; (2) three completely anesthetized rats, the anesthetized social facilitators (ASF); (3) three objects (O); and (4) alone (C). Groups SF and ASF extinguished significantly faster than Groups O and C; however, there were no significant differences observed between Groups O and C or between Groups SF and ASF. It was concluded that anesthetized rats were as effective as the active, nonanesthetized rats in facilitating extinction of the avoidance response. *We would like to thank Joseph Ternes for his comments and suggestions, for sponsoring and for taking editorial responsibility for this paper. This study was submitted by the first author in partial fulfillment of the requirements for a degree of Master of Arts, Department of Psychology, University of Puerto Rico.

Running and licking response probabilities in rats were obtained for the first and last 13-min periods of 30-min daily test sessions. When licking was the more probable response, it reinforced running; when running was the more probable response, it reinforced licking. These data confirm the relative and reversible properties of the reinforcement relation.

For two female college Ss, different procedures were used to produce comparable probabilities of lever responding for points and music. Both of these equally probable responses then were made contingent upon responding on a third lever on CRF, FR-5, and FR-10 reinforcement schedules. For all three schedules, the two equally probable responses produced comparable reinforced response increments. In a second experiment, a sequence of procedures was used which produced equal probabilities of responding for music and points, then a higher probability of responding for music relative to responding for points, then the converse probabilities. Responding on a CRF schedule varied directly with the probability of the reinforcing response. The results of both experiments were interpreted as support for Premack’s indifference principle.