Faculty Bibliography

This paper, intended to provide useful insights for the clinical management of sleep disturbances in attention-deficit/hyperactivity disorder (ADHD), presents a critical, updated overview of the most relevant studies on the prevalence, etiopathophysiology and treatment strategies of sleep problems associated with ADHD, including restless legs syndrome, periodic limb movements in sleep, sleep-onset delay, increased nocturnal motor activity, sleep-disordered breathing, deficit in alertness, and sleep alterations accounted for by comorbid psychiatric disorders or ADHD medications. We also discuss some possible avenues for future research in the field.

BACKGROUND: The differentiation hypothesis posits that the underlying liability distribution for psychopathology is of low dimensionality in young children, inflating diagnostic comorbidity rates, but increases in dimensionality with age as latent syndromes become less correlated. This hypothesis has not been adequately tested with longitudinal psychiatric symptom data. METHODS: Confirmatory factor analyses of DSM-IV symptoms from seven common Axis I syndromes--major depression, generalized anxiety, separation anxiety, social anxiety, attention deficient hyperactivity, conduct, and oppositional defiant disorders--were conducted longitudinally, from ages 9 to 16, using the general-population Great Smoky Mountains Study sample. RESULTS: An eight-syndrome model fit well at all ages, and in both genders. It included social anxiety, separation anxiety, oppositional defiant, and conduct syndromes, along with a multidimensional attention deficit-hyperactivity syndrome (i.e., inattention, hyperactivity, and impulsivity) and a unidimensional major depression/generalized anxiety syndrome. A high degree of measurement invariance across age was found for all syndromes, except for major depression/generalized anxiety. Major depression and generalized anxiety syndromes slightly diverged at age 14-16, when they also began to explain more symptom variance. Additionally, correlations between some emotional and disruptive syndromes showed slight differentiation. CONCLUSIONS: Marked developmental differentiation of psychopathology, as implied by the orthogenetic principle, is not a prominent cause of preadolescent and adolescent psychiatric comorbidity.

OBJECTIVE: The goal of our study was to investigate the impact of dysthymic disorder (DD), a form of chronic depression, on naturalistic outcome in individuals with personality disorders (PDs). METHOD: The Collaborative Longitudinal Personality Disorders Study is a cohort initially including 573 subjects with 4 targeted PDs (borderline, avoidant, schizotypal, and obsessive-compulsive) and 95 subjects with major depression but no PD. At baseline, 115 subjects were diagnosed with coexisting DD, of whom 109 (94.8%) were PD subjects. Regression analyses were performed to predict 3 classes of broad clinical outcome after 2 years of prospective follow-up. We hypothesized that DD diagnosis at baseline would be associated with worse outcome on (1) persistence of a PD diagnosis, (2) impairment in psychosocial functioning (as measured by the Longitudinal Interval Follow-up Evaluation), and (3) crisis-related treatment utilization. RESULTS: Baseline DD diagnosis was associated with persistence of PD diagnosis at 2 years, particularly for borderline and avoidant PDs. It was associated with worse outcome on global social adjustment, life satisfaction, recreation, and friendships, but not employment or relationship with spouse. Contrary to expectation, DD did not increase suicide attempts, emergency room visits, or psychiatric hospitalizations. CONCLUSIONS: Comorbidity of DD is associated with persistence of PD diagnosis and with worse outcome on many, but not all, measures of psychosocial functioning

OBJECTIVE: Population-based demands for trauma services have accelerated interest in the rapid deployment of efficacious interventions to address the diverse mental health consequences of traumatic experiences. However, optimal strategies for supporting either implementation or dissemination of trauma-focused interventions within healthcare or mental healthcare systems are underdeveloped. METHODS: This work offers suggestions for adapting treatment research parameters in order to advance the science on the implementable and practical use of trauma-focused interventions within a public health framework. To this end, we briefly examine the current status of research evidence in this area and discuss efficacy and effectiveness treatment research parameters with specific attention to the implications for developing the research base on the implementation and dissemination of effective trauma practices for children and adolescents. RESULTS: Examples from current studies are used to identify approaches for developing, testing and enhancing strategies to roll out effective treatment practices in real-world settings. CONCLUSIONS: New approaches that reflect the contexts in which these practices are implemented may enhance the feasibility, acceptability, replicability and sustainability of trauma treatments and services, and thus improve outcomes for a broader population of youth and families.

OBJECTIVE: To place imaging-genetics research in the context of child psychiatry. METHOD: A conceptual overview is provided, followed by discussion of specific research examples. RESULTS: Imaging-genetics research is described linking brain function to two specific genes, for the serotonin-reuptake-transporter protein and a monoamine oxidase enzyme. Work is then described on phenotype selection in imaging genetics. CONCLUSIONS: Child psychiatry applications of imaging genetics are only beginning to emerge. The approach holds promise for advancing understandings of pathophysiology and therapeutics.

Three experiments investigated whether 14- and 15-month-old infants use information for both friction and slant for prospective control of locomotion down slopes. In Experiment 1, high- and low-friction conditions were interleaved on a range of shallow and steep slopes. In Experiment 2, friction conditions were blocked. In Experiment 3, the low-friction surface was visually distinct from the surrounding high-friction surface. In all three experiments, infants could walk down steeper slopes in the high-friction condition than they could in the low-friction condition. Infants detected affordances for walking down slopes in the high-friction condition, but in the low-friction condition, they attempted impossibly slippery slopes and fell repeatedly. In both friction conditions, when infants paused to explore slopes, they were less likely to attempt slopes beyond their ability. Exploration was elicited by visual information for slant (Experiments 1 and 2) or by a visually distinct surface that marked the change in friction (Experiment 3).

Restricted and repetitive behaviors (RRBs) observed during the Autism Diagnostic Observation Schedule [ADOS: Lord et al., 2000] were examined in a longitudinal data set of 455 toddlers and preschoolers (age 8-56 months) with clinical diagnosis of Autism Spectrum Disorders (ASD; autism, n=121 and pervasive developmental disorders-not otherwise specified (PDD-NOS), n=71), a nonspectrum disorder (NS; n=90), or typical development (TD; n=173). Even in the relatively brief semi-structured observations, GEE analyses of the severity and prevalence of RRBs differentiated children with ASD from those with NS and TD across all ages. RRB total scores on the ADOS were stable over time for children with ASD and NS; however, typically developing preschoolers showed lower RRB scores than typically developing toddlers. Nonverbal IQ (NVIQ) was more strongly related to the prevalence of RRBs in older children with PDD-NOS, NS, and TD than younger children under 2 years and those with autism. Item analyses revealed different relationships between individual items and NVIQ, age, diagnosis, and gender. These findings are discussed in terms of their implications for the etiology and treatment of RRBs as well as for the framework of ASD diagnostic criteria in future diagnostic systems

Early-life stress (ES) has been associated with diverse forms of psychopathology. Some investigators suggest that these associations reflect the effects of stress on the neural circuits that support cognitive control. However, very few prior studies have examined the associations between ES, cognitive control, and underlying neural architecture. The present study compares adolescents with a documented history of ES to typical adolescents on a cognitive control task using functional magnetic resonance imaging (fMRI). Twelve ES adolescents who were adopted because of early caregiver deprivation (9 females, age=13 years+/-2.58) and 21 healthy control adolescents without a history of ES (10 females, age=13 years+/-1.96) who resided with their biological parents performed the change task (Nelson, Vinton et al., 2007)--a variant of the stop task--during fMRI. Behaviourally, ES adolescents took longer to switch from a prepotent response ("go") to an alternative response ("change") than control adolescents. During correct "change" responses vs. correct "go" responses, this behavioural group difference was accompanied by higher activation in ES subjects than controls. These differences were noted in regions involved in primary sensorimotor processes (pre- and postcentral gyri), conflict monitoring (dorsal anterior cingulate gyrus), inhibitory and response control (inferior prefrontal cortex and striatum), and somatic representations (posterior insula). Furthermore, correct "change" responses vs. incorrect "change" responses recruited the inferior prefrontal cortex (BA 44/46) more strongly in ES subjects than controls. These data suggest impaired cognitive control in youth who experienced ES.

OBJECTIVE: Posttraumatic stress disorder (PTSD) related to childhood abuse is associated with features of affect regulation and interpersonal disturbances that substantially contribute to impairment. Existing treatments do not address these problems or the difficulties they may pose in the exploration of trauma memories, an efficacious and frequently recommended approach to resolving PTSD. The authors evaluated the benefits and risks of a treatment combining an initial preparatory phase of skills training in affect and interpersonal regulation (STAIR) followed by exposure by comparing it against two control conditions: Supportive Counseling followed by Exposure (Support/Exposure) and skills training followed by Supportive Counseling (STAIR/Support). METHOD: Participants were women with PTSD related to childhood abuse (N=104) who were randomly assigned to the STAIR/Exposure condition, Support/Exposure condition (exposure comparator), or STAIR/Support condition (skills comparator) and assessed at posttreatment, 3 months, and 6 months. RESULTS: The STAIR/Exposure group was more likely to achieve sustained and full PTSD remission relative to the exposure comparator, while the skills comparator condition fell in the middle (27% versus 13% versus 0%). STAIR/Exposure produced greater improvements in emotion regulation than the exposure comparator and greater improvements in interpersonal problems than both conditions. The STAIR/Exposure dropout rate was lower than the rate for the exposure comparator and similar to the rate for the skills comparator. There were significantly lower session-to-session PTSD symptoms during the exposure phase in the STAIR/Exposure condition than in the Support/Exposure condition. STAIR/Exposure was associated with fewer cases of PTSD worsening relative to both of the other two conditions. CONCLUSIONS: For a PTSD population with chronic and early-life trauma, a phase-based skills-to-exposure treatment was associated with greater benefits and fewer adverse effects than treatments that excluded either skills training or exposure