Faculty Bibliography

BACKGROUND: Identify a group of adults with 'undiagnosed' attention deficit hyperactivity disorder (ADHD) and compare their personal and family medical histories, psychosocial profiles, functional impairment and quality of life with non-ADHD controls. Additionally, compare adults with undiagnosed and diagnosed ADHD to investigate possible reasons why the undiagnosed avoid clinical detection. METHOD: ICD-9 codes for ADHD in administrative claims records and responses to a telephone-administered adult ADHD screener [the Adult ADHD Self-Report Scale (ASRS)] were used to classify approximately 21000 members of two large managed health-care plans as 'undiagnosed' (no coded diagnosis; ASRS positive) or 'non-ADHD' controls (no coded diagnosis; ASRS negative). Patients identified as 'undiagnosed' ADHD were compared with samples of non-ADHD controls and 'diagnosed' ADHD patients (ICD-9 coded ADHD diagnoses) on the basis of demographics, socio-economic status, past and present mental health conditions, and self-reported functional and psychosocial impairment and quality of life. RESULTS: A total of 752 'undiagnosed' ADHD subjects, 199 'non-ADHD' controls and 198 'diagnosed' ADHD subjects completed a telephone interview. Overall, the 'undiagnosed' ADHD cohort demonstrated higher rates of co-morbid illness and greater functional impairment than 'non-ADHD' controls, including significantly higher rates of current depression, and problem drinking, lower educational attainment, and greater emotional and interpersonal difficulties. 'Undiagnosed' ADHD subjects reported a different racial composition and lower educational attainment than 'diagnosed' ADHD subjects. CONCLUSION: Individuals with 'undiagnosed' ADHD manifest significantly greater functional and psychosocial impairment than those screening negative for the disorder, suggesting that ADHD poses a serious burden to adults even when clinically unrecognized

OBJECTIVE: Conduct a randomized trial to test whether a cognitive behavioral intervention designed to decrease depressive symptoms produces subsequent decreases in bulimic and substance use symptoms. METHOD: Female participants (N = 145) with elevated depressive symptoms were randomly assigned to a 4-session depression intervention or a measurement-only condition and assessed through 6-month follow-up. RESULTS: Relative to control participants, intervention participants showed decreases in depressive symptoms. Intervention participants also showed significantly greater reductions in bulimic symptoms, but not substance use, and change in depressive symptoms mediated this effect for bulimic symptoms. CONCLUSION: The results provide experimental support for the theory that affect disturbances contribute to bulimic pathology, but do not support the affect regulation theory of substance use.

Much of the research on long-term potentiation (LTP) is motivated by the question of whether changes in synaptic strength similar to LTP underlie learning and memory. Here we discuss findings from studies on fear conditioning, a form of associative learning whose neural circuitry is relatively well understood, that may be particularly suited for addressing this question. We first review the evidence suggesting that fear conditioning is mediated by changes in synaptic strength at sensory inputs to the lateral nucleus of the amygdala. We then discuss several outstanding questions that will be important for future research on the role of synaptic plasticity in fear learning. The results gained from these studies may shed light not only on fear conditioning, but may also help unravel more general cellular mechanisms of learning and memory

Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's services often with no readily identifiable adult service to support them, which presents problems as local pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs). In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry services requesting assessment and treatment. For these reasons, the British Association for Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion derived from childhood evidence. We hope that, by the time these guidelines are updated, much evidence will be available to address the many directions for future research that are detailed here

Three experiments investigated visual search for targets that differed from distractors in colour, size, or orientation. In one condition the target was defined by a conjunction of these features, while in the other condition the target was the odd one out. In all experiments, 6-7- and 9-10-year-old children were compared with young adults. Experiment 1 showed that children's search differed from adults' search in two ways. In conjunction searches children searched more slowly and took longer to reject trials when no target was present. In the odd-one-out experiments, 6-7-year-old children were slower to respond to size targets than to orientation targets, and slower for orientation targets than for colour targets. Both the other groups showed no difference in their rate of responding to colour and orientation. Experiments 2 and 3 highlighted that these results were not a function of either differential density across set sizes (Experiment 2) or discriminability of orientation and colour (Experiment 3). Across all three experiments, the results of both conjunction and odd-one-out searches highlighted a development in visual search from middle to late childhood

BACKGROUND: Disinhibited attachment is an important sequel of an institutional rearing, but questions remain regarding its measurement, its persistence, the specificity of the association with institutional rearing and on whether or not it constitutes a meaningful disorder. METHOD: Children initially reared in profoundly depriving institutions in Romania and subsequently adopted into UK families were compared with respect to findings at 11 years with children who had not experienced institutional deprivation and who had been adopted within the UK before the age of 6 months. Measures included parental reports, a Strange Situation procedure modified for use in the home and systematic standardised investigator ratings of the children's behaviour. RESULTS: Disinhibited attachment, as reported by parents, showed a high degree of persistence from 6 to 11, but also a reduction over time in its frequency. Investigator ratings validated the parental reports but suggested that much of the fall in rate of disinhibited attachment was a function of the parental measure being less developmentally appropriate at 11 than it had been at 6. Disinhibited attachment was strongly associated with institutional rearing but there was not a significant increase in relation to duration of institutional deprivation beyond the age of 6 months. Mild, but not marked, disinhibited attachment was quite frequent in non-institutionalised adopted children but both the course and correlates indicated that its meaning was probably quite different. In the institution-reared children, disinhibited attachment was associated with a marked increase in service usage and associations with other forms of psychopathology. CONCLUSIONS: Disinhibited attachment constitutes a valid, and handicapping, clinical pattern that is strongly associated with an institutional rearing

CONTEXT: Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians. OBJECTIVES: The purpose of this work was to determine whether (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers. METHODS: We conducted a cross-sectional survey of the 50,818 US nonretired members of the American Academy of Pediatrics. Of a random sample of 1600 members, 832 (745 nontrainee members) responded. This was a mailed 8-page survey with no patients and no intervention. We measured physician assessment of barriers to providing psychosocial care for children's psychosocial problems and maternal depression. RESULTS: Pediatricians frequently endorse the lack of time to treat mental health problems (77.0%) and long waiting periods to see mental health providers (74.0%) as the most important barriers to the identification and treatment of children's psychosocial problems. For maternal depression, pediatricians most often endorsed lack of training in treatment (74.5%) and lack of time to treat (64.3%) as important barriers. Pediatricians' reports of barriers clustered into physician and organizational domains. Physician domains were distinct for children and mothers, but organizational domains were not. Several physician and practice characteristics are significantly associated with the 4 barrier scales, and different characteristics (eg, sociodemographic, attitudinal, and practice features) were related to each barrier area. CONCLUSIONS: Pediatricians endorse a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require a multifaceted approach that spans organizational, physician, and patient issues. In addition, comprehensive interventions will likely require social marketing approaches designed to engage diverse audiences of clinicians and their patients to participate.

Objectives. In 2 studies, we aimed to describe the content of mothers' verbal warnings to their young children and to investigate whether mothers modify their warnings based on the type of dangerous situation and children's age. Study 1. Mothers of 12-, 18-, and 24-month-olds reported in a telephone interview the words and phrases they would use to prevent their children from falling, touching dangerous objects, ingesting poisonous substances, and running away. The words "no," "don't," and "stop" were the most frequent warnings across ages. Mothers also used warnings to elicit their children's attention, regulate children's location, modify children's actions, and to highlight the properties and consequences of specific dangers. The content, diversity and complexity of mothers' warnings varied with children's age and the type of dangerous situation. Study 2. We observed mothers in the laboratory as they warned their 12- and 18-month-old children not to walk down 50 degrees slopes. As in Study 1, mothers primarily relied on the words "no," "don't," and "stop," but again used warnings to elicit attention, regulate location, modify actions, and describe the danger. Mothers used more complex and diverse warnings with older versus younger children. Conclusions. Although simple warnings, such as 'no," "don't," and "stop" hold privileged status at all ages, mothers express a rich array of warnings that are attuned to children's age and the dangers of the situation.

BACKGROUND: There is uncertainty about the extent to which language skills are part of general intelligence and even more uncertainty on whether deprivation has differential effects on language and non-language skills. METHODS: Language and cognitive outcomes at 6 and 11 years of age were compared between a sample of 132 institution-reared Romanian children adopted into UK families under the age of 42 months, and a sample of 49 children adopted within the UK under the age of 6 months who had not experienced either institutional rearing or profound deprivation. RESULTS: The effects of institutional deprivation were basically similar for language and cognitive outcomes at age 6; in both there were few negative effects of deprivation if it ended before the age of 6 months and there was no linear association with duration of deprivation within the 6 to 42 month range. For the children over 18 months on arrival (range 18-42 months), the presence of even very minimal language skills (imitation of speech sounds) at the time of arrival was a strong beneficial prognostic factor for language and cognitive outcomes, but not for social/emotional/behavioural outcomes. Individual variations in adoptive parent characteristics were unrelated to differences in language or cognitive outcomes, possibly as a consequence of the limited variability in the adoptive family group. CONCLUSIONS: Minimal language probably indexes some form of cognitive reserve that, in turn, indexes the degree of institutional deprivation

Transient reductions in serotonin levels during tryptophan depletion (TD) are thought to impair reward processing in healthy volunteers, while another facet of the serotonergic system, the serotonin transporter (5-HTTLPR) short allele polymorphism, is implicated in augmented processing of aversive stimuli. We examined the impact and interactions of TD and the serotonin promoter polymorphism genotype on reward and punishment via two forms of instrumental learning: passive avoidance and response reversal. In this study, healthy volunteers (n=35) underwent rapid TD or control procedures and genotyping (n=26) of the 5-HTTLPR for long and short allele variants. In the passive avoidance task, tryptophan-depleted volunteers failed to respond sufficiently to rewarded stimuli compared to the control group. Additionally, long allele homozygous individuals (n=11) were slower to learn to avoid punished stimuli compared to short allele carriers (n=15). TD alone did not produce measurable deficits in probabilistic response reversal errors. However, a significant drug group by genotype interaction was found indicating that in comparison to short allele carriers, tryptophan-depleted individuals homozygous for the long allele failed to appropriately use punishment information to guide responding. These findings extend prior reports of impaired reward processing in TD to include instrumental learning. Furthermore, they demonstrate behavioral differences in responses to punishing stimuli between long allele homozygotes and short allele carriers when serotonin levels are acutely reduced.