Faculty Bibliography

Before assigning full etiologic validity to a psycopathologic disorder, disease theory suggests that a causal dysfunction in a mechanism within the affect individuals must be identified. Existing theories on attention-deficit/hyperactivity disorder (ADHD) suggest such dysfunctions in cognitive, neuropsychological, or motivational processes in the child. To date, researchers have tested these theories by comparing groups with DSM-defined ADHD to children without ADHD. Using executive functioning as an illustration of an issue that exists across all such theories, this article describes substantial overlaps in the group performance data. Thus only a subgroup may have executive deficits. Noted are other supportive data suggesting multiple pathways to ADHD. The article explores implications and recommends that future theory and research give more consideration to the probability that only a subset of behaviorally defined children will have a deficit in a given neurocognitive mechanism believed to contribute to the disorder. Creation of a provisional set of criteria in DSM-V for defining an 'executive deficit type' could stimulate research to validate the first etiologic subtype of ADHD and spur the development of more sophisticated causal models, which in the longer term may give clinicians ways to target and tailor treatments

Until recently, causal models of attention-deficit/hyperactivity disorder (ADHD) have tended to focus on the role of common, simple, core deficits. One such model highlights the role of executive dysfunction due to deficient inhibitory control resulting from disturbances in the frontodorsal striatal circuit and associated mesocortical dopaminergic branches. An alternative model presents ADHD as resulting from impaired signaling of delayed rewards arising from disturbances in motivational processes, involving frontoventral striatal reward circuits and mesolimbic branches terminating in the ventral striatum, particularly the nucleus accumbens. In the present article, these models are elaborated in two ways. First, they are each placed within their developmental context by consideration of the role of person x environment correlation and interaction and individual adaptation to developmental constraint. Second, their relationship to one another is reviewed in the light of recent data suggesting that delay aversion and executive functions might each make distinctive contributions to the development of the disorder. This provides an impetus for theoretical models built around the idea of multiple neurodevelopmental pathways. The possibility of neuropathologic heterogeneity in ADHD is likely to have important implications for the clinical management of the condition, potentially impacting on both diagnostic strategies and treatment options

Significant ethnic differences have been consistently documented on attention-deficit/hyperactivity disorder (ADHD) teacher rating scales. Whether these ethnic differences result from a teacher rating bias or reflect actual classroom behavior patterns is unknown. Ethnic differences between Caucasian and African American (AA) elementary schoolchildren on teacher ratings and codings of observed classroom behavior were examined with latent variables. In structural equation models, correlations between teacher ratings and observed classroom behavior suggested nonbiased teacher ratings of AA schoolchildren with diagnosed ADHD. Ethnic differences were documented for both teacher ratings of ADHD and classroom behavior. Differences in classroom behavior were attenuated when the behavior of an average child in the classroom was taken into account. Multiple explanations for this pattern of results are discussed

OBJECTIVE: The prevalence and workplace consequences of adult attention deficit/hyperactivity disorder (ADHD) are unknown. METHODS: An ADHD screen was included in a national household survey (n = 3198, ages 18-44). Clinical re-interviews calibrated the screen to diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition ADHD. Diagnoses among workers were compared with responses to the WHO Health and Work Performance Questionnaire (HPQ). RESULTS: A total of 4.2% of workers had ADHD. ADHD was associated with 35.0 days of annual lost work performance, with higher associations among blue collar (55.8 days) than professional (12.2 days), technical (19.8 days), or service (32.6 days) workers. These associations represent 120 million days of annual lost work in the U.S. labor force, equivalent to dollar 19.5 billion lost human capital. CONCLUSIONS: ADHD is a common and costly workplace condition. Effectiveness trials are needed to estimate the region of interest of workplace ADHD screening and treatment programs

OBJECTIVE: The aim of this investigation was to compare the efficacy of computer-assisted cognitive therapy against standard cognitive therapy and a control group without treatment for outpatients with nonpsychotic major depressive disorder. METHOD: Medication-free participants (N=45) with major depressive disorder were randomly assigned to cognitive therapy (N=15), computer-assisted cognitive therapy (N=15), or a wait list (N=15). Both active treatments consisted of nine sessions over 8 weeks. Therapist time was reduced after the first visit for computer-assisted cognitive therapy, with 25-minute sessions rather than 50-minute sessions. Assessments were completed pretreatment, after 4 and 8 weeks of therapy, and 3 and 6 months posttreatment. RESULTS: Computer-assisted cognitive therapy and standard cognitive therapy were superior to the wait list control group for treatment of depression and did not differ from each other on the primary outcome variables. Very large between-group effect sizes were observed. Improvement in depression for both computer-assisted cognitive therapy and standard cognitive therapy was maintained at the 3- and 6-month follow-up evaluations. Computer-assisted cognitive therapy had more robust effects, relative to being wait-listed, than standard cognitive therapy in reducing measures of cognitive distortion and in improving knowledge about cognitive therapy. CONCLUSIONS: A multimedia, computer-assisted form of cognitive therapy with reduced therapist contact was as efficacious as standard cognitive therapy. Computer-assisted therapy could decrease costs and improve access to cognitive therapy for depression

The reinforcernent/extinction disorder hypothesis (Sagvolden et al.) is an important counterweight to the executive dysfunction model of attention-deficit/hyperactivity disorder (ADHD). However, like that model, it conceptualises ADHD as pathophysiologically homogeneous, resulting from a common core dysfunction. Recent studies reporting neuropsychological heterogeneity suggest that this common core dysfunction may be the scientific equivalent of a red herring

OBJECTIVE: To estimate prevalence rates of antipsychotic use in children and adolescents from 1996 to 2001 in three state Medicaid programs (midwestern [MM], southern [SM], and western [WM]) and one private managed care organization (MCO). METHOD: Prescription claims were used to evaluate antipsychotic prevalence, defined as the number of children and adolescents up to the age of 19 years with at least one prescription claim for an antipsychotic per 1,000 enrolled youths. RESULTS: From 1996 to 2001, the prevalence of total antipsychotic use increased in each program (MM: 4.7 to 14.3 per 1,000; SM: 6.3 to 15.5; WM: 4.5 to 6.9; and MCO: 1.5 to 3.4). Typical antipsychotic use decreased (MM: 3.7 to 2.0 per 1,000; SM: 4.6 to 1.5; WM: 4.4 to 1.3; and MCO: 1.2 to 0.9), while atypical antipsychotic use dramatically increased (MM: 1.4 to 13.1 per 1,000; SM: 2.5 to 14.9; WM: 0.3 to 6.2; and MCO: 0.4 to 2.7). CONCLUSIONS: The increased prevalence of antipsychotic use in children and adolescents from 1996 to 2001 was attributed to increased use of atypical antipsychotics. Given the limited data with atypical antipsychotics in youths, this emphasizes the need for additional studies of these agents and other treatment modalities in this population.

OBJECTIVE: To evaluate the SAFE Homes (SH) program, a short-term group care program for children between 3 and 12 years of age who enter care for the first time. The program aims to improve case outcomes by consolidating resources to facilitate assessment and treatment planning. METHODS: The 1-year outcomes of 342 children who received SAFE Home services and 342 matched foster care (FC) control children were compared. The 684 subjects used in this report were selected from a larger pool of 909 subjects using propensity score matching to control for hidden bias in treatment group assignment. We hypothesized that SAFE Homes would result in greater continuity of care for children (e.g., fewer placements, more placements with siblings and in towns of origin), identification of more relatives for substitute care when needed, reduced use of high-cost restrictive care settings (e.g., residential, inpatient), and reduced rates of re-abuse through earlier detection and provision of services to meet child and family treatment needs. RESULTS: Prior to the initiation of the SAFE Homes program, 75% of the children who entered care in the State experienced three or more placements in the first year. The outcomes of both the SH and FC cases were significantly improved over pre-SAFE Home State statistics. The FC group, however, had comparable or better outcomes on most variables examined. In addition, the total cost for out-of-home care for the children in FC was significantly less, despite the fact that the two groups spent similar amounts of time in care (average time in care: 7 months). This finding held when the total placement cost was calculated using the State reimbursement rate of 206.00 US dollars per day for SAFE Home care (SH: 20,851 US dollars +/- 24,231 US dollars; FC: 8,441 US dollars +/- 21,126 US dollars, p < .001), and a conservative SAFE Home program fee of 85.00 US dollars per day that only considered the child care and custodial staffing costs uniquely associated with the program (SH: 13,314 US dollars +/- 21,718 US dollars; FC: 8,441 US dollars +/-21,126 US dollars, p < .001). CONCLUSION: Improvements in outcomes related to continuity of care can be attained through staff training. The SAFE Home model of care is not cost-effective for first-time placements

BACKGROUND: Few studies have compared the related diagnostic constructs of depressive personality disorder (DPD) and dysthymic disorder (DD). The authors attempted to replicate findings of Klein and Shih in longitudinally followed patients with personality disorder or major depressive disorder (MDD) in the Collaborative Longitudinal Personality Disorders Study. METHODS: Subjects (N = 665) were evaluated at baseline and over 2 years (n = 546) by reliably trained clinical interviewers using semistructured interviews and self-report personality questionnaires. RESULTS: Only 44 subjects (24.6% of 179 DPD and 49.4% of 89 early-onset dysthymic subjects) met criteria for both disorders at baseline. Depressive personality disorder was associated with increased comorbidity of some axis I anxiety disorders and other axis II diagnoses, particularly avoidant (71.5%) and borderline (55.9%) personality disorders. Depressive personality disorder was associated with low positive and high negative affectivity on dimensional measures of temperament. Depressive personality disorder subjects had lower likelihood of remission of baseline MDD at 2-year follow-up, whereas DD subjects did not. The DPD diagnosis appeared unstable over 2 years of follow-up, as only 31% (n = 47) of 154 subjects who had DPD at baseline and also had follow-up assessment met criteria on blind retesting. LIMITATIONS: Results from this sample may not generalize to other populations. CONCLUSIONS: Depressive personality disorder and dysthymic disorder appear to be related but differ in diagnostic constructs. Its moderating effect on MDD and predicted relationship to measures of temperament support the validity of DPD, but its diagnostic instability raises questions about its course, utility, and measurement

The autism spectrum disorders (ASDs) can present with symptoms commonly found in mood and anxiety disorders. The Social Communication Questionnaire (SCQ), Children's Communication Checklist (CCC-2), and the Social Reciprocity Scale (SRS) were used to screen children in a mood disorders research clinic setting for symptoms of ASD. Ninety-three patients (mean age, 12.7 +/- 2.8 years; percent male, 63%) completed at least one scale, and 50 children completed all three. The prevalence of those screening positive for a possible ASD on one instrument was 62% and on all three measures was 8%. Fifty-seven percent (n = 21/37; odds ratio, 4.59 [95% confidence interval (CI) = 1.40-15.11]) of those scoring in the "ASD-likely" range on the SRS scored in that range on the CCC-2. Only 16% (n = 6/37; odds ratio, not significant (NS)) of those scoring in the ASD-likely range on the SRS, and 14% (n = 5/37; odds ratio, NS) of those scoring in the ASD-likely range on the CCC-2, scored similarly on the SCQ. These results demonstrate a need to develop valid and reliable instruments to screen for ASDs in children presenting outside of ASD clinics.