Faculty Bibliography

Seventeen children with attention deficit disorder (ADHD) and 10 normal controls performed two tasks while event-related potentials were recorded. ADHD subjects took part in two more sessions under methylphenidate (MP) or placebo. In the spatial orienting task, invalidly cued targets elicited a longer reaction time (RT) and a P3 that was longer in latency and greater in amplitude than did validly cued targets. Performance was similar for both groups, but the early portion of P3 (300-400 ms) was lower in amplitude for invalidly cued targets in ADHD subjects. MP increased accuracy without affecting RT and shortened P3 peak latency and increased the amplitude of its early portion. In the focused attention task, accuracy was greater for controls and MP, but there were no RT differences. Attended stimuli elicited greater amplitude P1, N1, and P3 than did nonattended stimuli, but these measures were unaffected by diagnosis or medication

OBJECTIVE: The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA. METHOD: A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA. RESULTS: Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)? CONCLUSIONS: The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA

OBJECTIVE. This study evaluated the effects on behavior and sleep of methylphenidate (MPH) administered at 4 PM to children with attention-deficit hyperactivity disorder (ADHD). METHODOLOGY. Twelve children admitted to a child psychiatric inpatient service with ADHD participated in a double-blind, crossover study in which they received a 4 PM dose of either 15 mg of MPH, 10 mg of MPH, or a placebo in random order for 12 consecutive days. Ratings of behavior, including ADHD symptoms, pertaining to the period from dose administration until sleep onset, were supplied nightly by hospital staff. Sleep latency and sleep adequacy were also assessed for each night. RESULTS. MPH resulted in markedly improved behavioral control compared with placebo; there was no difference between 15-mg and 10-mg MPH doses. MPH did not alter sleep latencies observed with the placebo. Children were more often rated as less tired on awakening after nights that they received 10 mg of MPH compared with 15 mg of MPH and the placebo. Weight loss was apparent among 83% of the patients, but dinner intake did not vary with third-dose condition. CONCLUSIONS. Morning and noon administration of stimulants to children with ADHD is a near-universal practice, but many clinicians avoid a third, late-afternoon administration for fear of inducing insomnia. This study's findings show that children with ADHD derive substantial symptom reduction from MPH administered in late afternoon, with no untoward effects on sleep. Therefore, three-times-a-day dosing should be considered for those children exhibiting ADHD symptoms in the evening. Adverse effects on sleep latency were not apparent in the sample overall. Nonetheless, monitoring for possible aggravation of sleep problems and weight loss remains sound treatment practice

OBJECTIVE: The primary purpose of this research is to investigate the criteria used by child and adolescent clinicians in determining the appropriateness of hospitalization for suicidal adolescents. METHOD: A questionnaire containing 64 vignettes describing adolescent suicide attempters was completed by a sample of 36 child and adolescent clinicians. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette. RESULTS: Hospitalization preference was found to be inversely related to professional experience and was significantly predicted by all risk factors except gender. Configural cue utilization added substantially to the efficacy of a linear model in predicting preference to hospitalize. CONCLUSIONS: Experienced clinicians use known risk factors for adolescent suicide in making recommendations to hospitalize, but results also suggest ongoing needs for education and training in adolescent suicidality

OBJECTIVE: A teacher rating scale designed to reflect current diagnostic descriptors of oppositional defiant disorder and conduct disorder was developed and standardized. METHOD: Teacher ratings were obtained for 1,258 1st-through 10th-grade children from two school districts in New York and for 81 clinically referred children with conduct disorder. RESULTS: Three factors relevant to oppositional defiant disorder and conduct disorder were generated: defiance, physical aggression, and delinquent aggression. A fourth factor reflects peer problems. Internal consistency, test-retest reliability, and interrater reliability are documented using a population and a conduct disorder sample. The validity of the factors is supported by the factors' ability to discriminate between children in the general population and those with conduct disorders, by correlations with global impairment items, and by expected sex differences. CONCLUSION: The scale has utility for assessing symptoms of conduct disorder in school settings

Behavioral patterns over time were assessed during the first 24 days of hospitalization for 98 child psychiatric inpatients. Staff completed daily behavioral monitoring and ratings. Patients were categorized as improved, unchanged or deteriorated during this time. Thirty-four percent of patients initially exhibited well-controlled behavior, but then significantly worsened after a period averaging 6.8 days. This result empirically supports the 'honeymoon' phenomenon. Other patients showed either improvement during the initial period (15%), no change (30%), or could not be reliably classified (21%). Therefore, many child inpatients show rapid symptom stabilization after admission, but a large number then worsen. Clinical, scientific and administrative implications of these results are discussed

An uncontrolled pilot study assessed the possible clinical efficacy of pemoline for treating conduct symptoms in 10 boys (aged 8-14 yrs) with conduct disorder and attention deficit hyperactivity disorder (ADHD). Ss who did not respond satisfactorily to short-term methylphenidate treatment received a 7-wk open trial of pemoline. For the 5 partial responders, pemoline was added to the methylphenidate; in the 5 remaining, pemoline was substituted for methylphenidate. Pemoline treatment appeared to reduce the various symptoms of conduct disorder. Marked behavioral improvement was observed in 4 Ss, partial improvement in 3, and little benefit in the remaining 3. Adverse effects were generally minimal and well tolerated, even when pemoline was used in combination with methylphenidate: 1 S had severe appetite loss and sleep onset delay, while 3 others had moderate sleep problems. Preliminary data suggest that pemoline might be useful for reducing symptoms of conduct disorder. (PsycIN

This study evaluated the accuracy of teachers' ratings and examined whether these ratings are influenced by halo effects. One hundred thirty-nine elementary school teachers viewed videotapes of what they believed were children in regular fourth-grade classrooms. In fact, the children were actors who followed prepared scripts that depicted a child engaging in behaviors characteristic of an attention-deficit hyperactivity disorder (ADHD), an oppositional defiant disorder or a normal youngster. The findings provide support for a bias that was unidirectional in nature. Specifically, teachers rated hyperactive behaviors accurately when the child behaved like an ADHD youngster. However, ratings of hyperactivity and of ADHD symptomatic behaviors were spuriously inflated when behaviors associated with oppositional defiant disorder occurred. In contrast, teachers rated oppositional and conduct problem behaviors accurately, regardless of the presence of hyperactive behaviors. The implications of these findings regarding diagnostic practices and rating scale formats are discussed

The distinguishing and overlapping features of attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) are discussed. Conclusions regarding comorbidity, treatment efficacy, and long-term outcome can be influenced by several factors, including diagnostic procedures and sample characteristics. The need to distinguish between referred and non-referred samples is particularly crucial when considering treatment and comorbidity issues. The efficacy of psychosocial and pharmacological treatments in ADHD and CD children is reviewed as are the few studies of psychostimulant medication in co-morbid youngsters. Suggestions regarding treatment planning and recommendations for treatment and research are described