Benjamin B. Lahey

The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, Acceptability, Prevalence Rates, and Performance in the MECA Study

OBJECTIVE To describe the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 and to provide data on its performance characteristics in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. METHOD Data were collected on the DISC-2.3 at four sites on 1,285 randomly selected children, aged 9 through 17 years, and their parents. Two hundred forty-seven of these child-parent pairs were reassessed on the DISC-2.3 by a clinician interviewer, 1 to 3 weeks later. RESULTS Administration time was approximately 1 hour and the interview was acceptable to more than 90% of subjects. The reliability of questions to parents assessing impairment and age of onset was generally good to acceptable for most diagnoses but was less satisfactory for the child interview. Using information from parent and child, the prevalence for any diagnosis ranged from 50.6 if no impairment criteria were required to 5.4 if a Global Assessment Scale score of 50 or less was necessary. The prevalence of anxiety disorders and enuresis was markedly reduced by requiring attributable impairment. CONCLUSIONS The DISC-2 is a reliable and economical tool for assessing child psychopathology. Reliability of the DISC-P-2.3 is superior to that of the child DISC for most diagnoses but is least good for anxiety disorders. The 2.3 version of the instrument provides a significant improvement over earlier versions.

Oppositional Defiant and Conduct Disorder: A Review of the Past 10 Years, Part I

OBJECTIVE To review empirical findings on oppositional defiant disorder (ODD) and conduct disorder (CD). METHOD Selected summaries of the literature over the past decade are presented. RESULTS Evidence supports a distinction between the symptoms of ODD and many symptoms of CD, but there is controversy about whether aggressive symptoms should be considered to be part of ODD or CD. CD is clearly heterogenous, but further research is needed regarding the most useful subtypes. Some progress has been made in documenting sex differences. Symptoms that are more serious, more atypical for the childs sex, or more age-atypical appear to be prognostic of serious dysfunction. Progress has been made in the methods for assessment of ODD and CD, but some critical issues, such as combined information from different informants, remains to be addressed. A proportion of children with ODD later develop CD, and a proportion of those with CD later meet criteria for antisocial personality disorder. ODD and CD frequently co-occur with other psychiatric conditions. CONCLUSIONS Although major advances in the study of the prevalence and course of ODD and CD have occurred in the past decade, some key issues remain unanswered.

Public health significance of neuroticism.

The personality trait of neuroticism refers to relatively stable tendencies to respond with negative emotions to threat, frustration, or loss. Individuals in the population vary markedly on this trait, ranging from frequent and intense emotional reactions to minor challenges to little emotional reaction even in the face of significant difficulties. Although not widely appreciated, there is growing evidence that neuroticism is a psychological trait of profound public health significance. Neuroticism is a robust correlate and predictor of many different mental and physical disorders, comorbidity among them, and the frequency of mental and general health service use. Indeed, neuroticism apparently is a predictor of the quality and longevity of our lives. Achieving a full understanding of the nature and origins of neuroticism, and the mechanisms through which neuroticism is linked to mental and physical disorders, should be a top priority for research. Knowing why neuroticism predicts such a wide variety of seemingly diverse outcomes should lead to improved understanding of commonalities among those outcomes and improved strategies for preventing them.

Developmental change in attention-deficit hyperactivity disorder in boys: A four-year longitudinal study

One hundred six clinic-referred boys meeting criteria for DSM-III-R attention-deficit hyperactivity disorder (ADHD) (mean age 9.4 years) were assessed annually for 4 years using structured interviews of multiple informants. Hyperactivity—impulsivity symptoms declined with increasing age, but inattention symptoms did not. Rather, inattention declined only from the first to the second assessment and remained stable thereafter in boys of all ages. The rate of decline in hyperactivity—impulsivity symptoms was independent of the amount and type of treatment received. Boys who still met criteria for ADHD in Years 3 and 4 were significantly younger, more hyperactive—impulsive, and more likely to exhibit conduct disorder in Year 1 than boys who no longer met criteria in Years 3 and 4.

Validity of DSM-IV attention deficit/hyperactivity disorder symptom dimensions and subtypes.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for attention deficit/hyperactivity disorder (ADHD) specify two dimensions of inattention and hyperactivity-impulsivity symptoms that are used to define three nominal subtypes: predominantly hyperactive-impulsive type (ADHD-H), predominantly inattentive type (ADHD-I), and combined type (ADHD-C). To aid decision making for DSM-5 and other future diagnostic systems, a comprehensive literature review and meta-analysis of 546 studies was completed to evaluate the validity of the DSM-IV model of ADHD. Results indicated that DSM-IV criteria identify individuals with significant and persistent impairment in social, academic, occupational, and adaptive functioning when intelligence, demographic factors, and concurrent psychopathology are controlled. Available data overwhelmingly support the concurrent, predictive, and discriminant validity of the distinction between inattention and hyperactivity-impulsivity symptoms, and indicate that nearly all differences among the nominal subtypes are consistent with the relative levels of inattention and hyperactivity-impulsivity symptoms that define the subtypes. In contrast, the DSM-IV subtype model is compromised by weak evidence for the validity of ADHD-H after first grade, minimal support for the distinction between ADHD-I and ADHD-C in studies of etiological influences, academic and cognitive functioning, and treatment response, and the marked longitudinal instability of all three subtypes. Overall, we conclude that the DSM-IV ADHD subtypes provide a convenient clinical shorthand to describe the functional and behavioral correlates of current levels of inattention and hyperactivity-impulsivity symptoms, but do not identify discrete subgroups with sufficient long-term stability to justify the classification of distinct forms of the disorder. Empirical support is stronger for an alternative model that would replace the subtypes with dimensional modifiers that reflect the number of inattention and hyperactivity-impulsivity symptoms at the time of assessment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

A Practical Measure of Impairment: Psychometric Properties of the Impairment Rating Scale in Samples of Children With Attention Deficit Hyperactivity Disorder and Two School-Based Samples

Assessing impairment is an explicit component of current psychiatric diagnostic systems. A brief parent and teacher rating scale for assessing impairment was developed and studied using attention deficit hyperactivity disorder (ADHD) as an exemplar disorder. The psychometric properties of the Impairment Rating Scale (IRS) were measured in 4 samples. Two included ADHD and matched comparison children and the other 2 a school sample. Overall, IRS ratings exhibited very good temporal stability. They correlated with other impairment ratings and behavioral measures and displayed evidence of convergent and discriminant validity. The IRS was highly effective in discriminating between children with and without ADHD. Evidence that the parent and teacher IRS accounted for unique variance beyond ratings of ADHD symptoms is also presented. The scale is brief, practical, and in the public domain. The results of the studies and implications for the assessment of impairment are discussed.

Oppositional defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample

Abstract This study is a meta-analytic summary of 60 factor analyses from 44 published studies of 28,401 children and adolescents. The results suggested that, strictly in terms of behavioral covariation, conduct problems in children may best be conceptualized in terms of two orthogonal dimensions of behavior: (1) an overt/covert dimension and (2) a destructive/nondestructive dimension. The four quadrants created by the intersection of these two bipolar dimensions corresponded well to distinctions among norm-violating behaviors made by legal systems and previous diagnostic conceptualizations: oppositional, aggressive, property violations, and status offenses. The results of this meta-analysis were cross-validated in a clinic sample of 177 boys age 7–12. One major finding from the validation sample was a strong correspondence between empirically derived syndromes based on the meta-analysis and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev., American Psychiatric Association, 1987) (DSM-III-R) definitions of conduct disorder and oppositional defiant disorder. A second major finding from the validation study was that age of onset may be a critical variable in explaining the results of the meta-analysis.

Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children.

OBJECTIVE Little is known about the validity of the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children. Moreover, the results of the DSM-IV field trials raised concerns that inclusion of the new predominantly hyperactive-impulsive type of ADHD in DSM-IV might increase the likelihood of the diagnosis being given to active but unimpaired preschool and primary school children. METHOD The validity of DSM-IV criteria for each subtype of ADHD was evaluated in 126 children, aged 4 through 6 years, and 126 matched comparison children. Probands and controls were classified by using structured diagnostic interviews of the parent and a DSM-IV checklist completed by the teacher. RESULTS Children who met DSM-IV criteria for each subtype of ADHD according to parent and teacher reports differed consistently from controls on a wide range of measures of social and academic impairment, even when other types of psychopathology and other potential confounds were controlled. CONCLUSIONS When diagnosed by means of a structured diagnostic protocol, all three DSM-IV subtypes of ADHD are valid for 4- through 6-year-old children in the sense of identifying children with lower mean scores on measures of adaptive functioning that are independently associated with ADHD.

Criterion Validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3)

OBJECTIVE To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings. METHOD Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses. RESULTS In general, the DISC showed moderate to good validity across a number of diagnoses. CONCLUSIONS Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.

Issues of taxonomy and comorbidity in the development of conduct disorder

A developmental approach to the classification of antisocial behavior is necessary for two reasons. First, although the continuity of antisocial behavior is strong for many individuals, the topography of antisocial behavior changes during the course of development. Second, antisocial behavior apparently develops in at least two separate pathways — child-onset versus adolescent-onset — that differ markedly regarding types of antisocial behavior displayed, persistence, and perhaps etiology. The development of antisocial behavior must also be understood within the context of co-occurring disorders and conditions. Comorbid attention-deficit hyperactivity disorder appears to be associated with greater aggression and a worse prognosis, and comorbid academic underachievement is also associated with a negative course. Emerging evidence also suggests that comorbid anxiety disorder is associated with level of aggression, but the direction of the correlation appears to differ at different ages. In all, full understanding of conduct disorder requires developmentally sensitive classification as well as consideration of comorbid conditions.