Cynthia R. Pfeffer

Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation

Current knowledge about early plasticity and childrens responsiveness to environmental modifications as well as the atheoretical nature of current nosological systems necessitate alternative models to explain the phenomena of childhood behavioral and emotional disturbances. Evolutionary biology provides one such framework. It organizes data from the behavioral and cognitive sciences and parallels similar efforts in other areas of medicine and biology. Through an evolutionary biological lens, some mental disorders are better viewed as an adaptive response to early pathogenic environments and/or reflect the optimization of brain function to some environments at the cost of poorer response to the demands of other environments. As an example, the authors examine attention-deficit/hyperactivity disorder (ADHD) in relation to evolutionary theories of psychology and biology and clarify the potentially adaptive nature of characteristics of inattention, impulsivity, and motoric hyperactivity, depending on the nature of childs environments. Reframing ADHD characteristics according to evolutionary theory has important treatment implications for clinicians and offers researchers opportunities for novel scientific discoveries.

Suicidal children grow up : rates and psychosocial risk factors for suicide attempts during follow-up

OBJECTIVE Rates and psychosocial risk factors for suicide attempts during a 6 to 8-year follow-up period were compared for 25 predominantly prepubertal inpatient suicide attempters, 28 inpatient suicidal ideators, 16 nonsuicidal inpatients, and 64 nonpatients. METHOD Standard research instruments were used to interview subjects and parents. Cox proportional hazard regression analyses were used to identify risk factors for a suicide attempt in the follow-up. RESULTS No deaths occurred during follow-up. Suicide attempters were six times and suicidal ideators were three times more likely than were nonpatients to attempt suicide during follow-up. Poor social adjustment and mood disorder close to a recurrent suicide attempt were the strongest risk factors. CONCLUSIONS Risk assessment should focus on identifying symptoms of mood disorders and impaired social adjustment in children with histories of suicide attempts and psychiatric hospitalization.

Suicidal Children Grow Up: Demographic and Clinical Risk Factors for Adolescent Suicide Attempts

This longitudinal study reports rates and demographic and clinical risk factors for adolescent suicide attempts during a 6- to 8-year follow-up period of an initial sample of 106 preadolescent and young adolescent psychiatric inpatients and 101 preadolescent and young adolescent nonpatients. Survival analysis was used to evaluate risk for a first suicide attempt in the follow-up period for 133 subjects who were interviewed. No deaths occurred. Suicidal inpatients, compared with nonpatients, had earlier first suicide attempts in the follow-up period. Adolescents who attempted suicide in the follow-up period were seven times more likely to have a mood disorder during the follow-up period than those who did not attempt suicide. Implications for clinical practice and research are discussed.

Suicidal Children Grow Up: Suicidal Behavior and Psychiatric Disorders among Relatives

OBJECTIVE This paper reports comprehensive data on psychiatric symptoms and disorders and medical problems of first- and second-degree biological relatives of prepubertal children who have contemplated or attempted suicide. METHOD Standard family study and family history interview techniques were used to obtain information about psychopathology and medical illness in 488 first- and 1,062 second-degree relatives of 25 child psychiatric inpatients who reported suicide attempts, 28 child psychiatric inpatients who contemplated suicide, 16 nonsuicidal child inpatients, and 54 normal children. RESULTS Suicidal behavior in children was associated with suicidal behavior in their families, although no first-degree relatives committed suicide. More first-degree relatives of child suicide attempters, compared to first-degree relatives of normal children, had antisocial personality disorder, assaultive behavior, and substance abuse. Mood disorders in first-degree relatives were not associated with child suicidal behavior. No significant associations were identified for psychopathology of second-degree relatives and child suicidal behavior. CONCLUSIONS The results suggest the importance of evaluating familial psychopathology during assessments of suicidal children. Self-directed and externally directed violence, antisocial personality disorder, and substance abuse of relatives of suicidal children should be studied to elucidate the etiology of youth suicidal behavior.

Salivary cortisol and psychopathology in children bereaved by the september 11, 2001 terror attacks

BACKGROUND Studies suggest that stressful events increase risk for childhood anxiety and depression and hypothalamic-pituitary-adrenal (HPA) axis dysregulation. This prospective longitudinal study evaluated relationships among severe psychosocial stress, psychiatric morbidity, and HPA axis function in children. METHODS Forty-five children (mean age: 8.9 +/- 2.9 years) suffering parent death from September 11, 2001 terror attacks and 34 nonbereaved children (mean age: 9.3 +/- 2.5 years) were evaluated prospectively at 6-month intervals in this 2-year study. Assessments involved diagnostic interviews (Child Schedule for Affective Disorders and Schizophrenia [K-SADS]) for psychopathology and 3 days of baseline salivary cortisol and a salivary dexamethasone suppression test for HPA axis function. RESULTS Bereaved children, but not nonbereaved children, had significantly increased rates of psychiatric disorders involving anxiety disorders, especially posttraumatic stress disorder (PTSD), after September 11, 2001 compared with retrospective assessments before September 11, 2001. Morning (AM) and 4:00 pm baseline cortisol were significantly and persistently higher for bereaved than nonbereaved children. Compared with bereaved children without psychopathology, bereaved children with PTSD had significantly lower 4:00 pm baseline cortisol and significantly greater 4:00 pm cortisol suppression. Children with generalized anxiety disorder had significantly less AM cortisol suppression than children without psychopathology. CONCLUSIONS Children bereaved by sudden, unexpected parent death had persistent psychological dysfunction and HPA axis dysregulation in this study.

Suicidal behavior in normal school children: a comparison with child psychiatric inpatients

A study of 101 randomly selected preadolescent school children, who had never been psychiatric patients, revealed 11.9% with suicidal ideas, threats, or attempts. Suicidal ideas were expressed in 8.9% of the school children. Suicidal school children differed from nonsuicidal school children in greater preoccupation with death, more recent and past depression, more suicidal impulses in the mothers, and a greater tendency to use introjection as an ego defense. These factors were similar to those found in a comparison of suicidal and nonsuicidal psychiatric inpatients. Factors that contribute to the risk of suicidal behavior in children are described.

Child survivors of parental death from cancer or suicide: depressive and behavioral outcomes

Depressive symptoms, social competence, and behavior problems of prepubescent children bereaved within 18 months of parental death from cancer (57 families, 64 children) or suicide (11 families, 16 children) were compared. Most children reported normative levels of depressive symptoms. Children whose parents died from suicide, compared with those whose parents died from cancer, reported significantly more depressive symptoms, involving negative mood, interpersonal problems, ineffectiveness, and anhedonia. Parental reports of childrens competence and behavior were similar to a normative sample of children and did not differ between the children bereaved by parental cancer or suicide. Additional research should focus on other factors, such as family psychopathology, stresses, and impact of stigma, which may influence the course of bereaved children. Copyright

Childhood suicidal behavior. a developmental perspective

This article provides an overview of the sociocultural and psychosocial features and implications for treatment of prepubertal suicidal children. It provides cross-sectional and longitudinal information about specific risk factors of prepubertal suicidal behavior with a focus on how these factors also predict future suicidal behavior. A developmental focus addresses issues of cognitive and emotional immaturity as related to early onset suicidal behavior.

Child-Adolescent Suicidal Potential Index (CASPI): a screen for risk for early onset suicidal behavior

This studys purpose was to develop a reliable and valid self-report questionnaire, the Child-Adolescent Suicidal Potential Index (CASPI), to screen for risk for suicidal behavior in children and adolescents. Four hundred twenty-five child and adolescent psychiatric patients and nonpatients completed the CASPI and other research instruments to rate suicidal and assaultive behavior and symptoms of depression, anxiety, and hopelessness. The 30-item CASPI involves 3 factors (anxious-impulsive depression, suicidal ideation or acts, family distress) that contributed to a unidimensional 2nd-order factor accounting for 59% of the total variance. Internal consistency (alpha) for the total score was .90, and test-retest reliability (ICC) for the total score was .76. Total score distinguished between children and adolescents with different severity of psychopathology and different levels of suicidal and assaultive behavior. Each of the 3 factors had different contributions to discriminating between levels of suicidal status. CASPI total score of 11 distinguished suicidal ideation or acts from nonsuicidal behavior, with sensitivity 70% and specificity 65%. CASPI total score positively correlated with symptom severity of depression, anxiety, and hopelessness.

Peripheral serotonin measures in prepubertal psychiatric inpatients and normal children: associations with suicidal behavior and its risk factors

BACKGROUND This study reports relationships between suicidal behavior and its risk factors in prepubertal children and whole blood and platelet serotonin-related measures. METHODS Seventy-five prepubertal psychiatric inpatients including 23 (30.7%) nonsuicidal, 32 (42.7%) with suicidal ideation, and 20 (26.6%) with a suicide attempt were compared to 35 normal prepubertal controls with regard to platelet serotonin content, serotonin-amplified platelet aggregation, and whole blood tryptophan. RESULTS Mean whole blood tryptophan content was significantly lower among inpatient children with a recent suicide attempt than among normal controls or inpatients with suicidal ideation (F = 3.94, df = 3.54, p < or = .01). Inpatient children with a mood disorder had significantly higher platelet serotonin content than inpatients without a mood disorder (F = 3.86, df = 2.80, p < or = .03). Racial/ethnic differences were also observed for inpatients and normal controls, with whites having significantly lower levels of platelet serotonin (expressed as ng/mL blood or ng/10(9) platelets) than blacks or Latinos. Blacks had significantly higher levels of whole blood tryptophan than other racial/ethnic groups. CONCLUSIONS The results suggest that whole blood tryptophan and platelet serotonin content should be studied for their predictive validity as risk factors for suicidal behavior in youth while controlling for racial/ethnic differences.