David C. Rettew

Obsessions and Compulsions across Time in 79 Children and Adolescents with Obsessive-Compulsive Disorder

Individual symptoms of 79 children and adolescents with severe obsessive-compulsive disorder were obtained from chart review of at least two in-persons evaluations and recorded across an average of 7.9 years (range, 2 to 16). Symptoms were grouped according to the categories of the Yale-Brown Symptom Checklist. No significant age related trends were found with any one type of symptom, although patients with a very early onset of illness (less than 6 years old) were more likely to have compulsions than obsessions. Across the study period, patients reported symptoms from many different symptom categories, with 47% of the patients displaying both washing and checking compulsions at some time during their illness. No patient maintained the same constellation of symptoms from presentation to follow-up. These data support the concept of obsessive-compulsive disorder as an illness with varied clinical manifestations that individually change over time.

Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews.

Standardized diagnostic interviews (SDIs) have become de facto gold standards for clinical research. However, because clinical practitioners seldom use SDIs, it is essential to determine how well SDIs agree with clinical diagnoses. In meta‐analyses of 38 articles published from 1995 to 2006 (N = 15,967 probands), mean kappas (z‐transformed) between diagnoses from clinical evaluations versus SDIs were 0.27 for a broad category of all disorders, 0.29 for externalizing disorders, and 0.28 for internalizing disorders. Kappas for specific disorders ranged from 0.19 for generalized anxiety disorder to 0.86 for anorexia nervosa (median = 0.48). For diagnostic clusters (e.g. psychotic disorders), kappas ranged from 0.14 for affective disorders (including bipolar) to 0.70 for eating disorders (median = 0.43). Kappas were significantly higher for outpatients than inpatients and for children than adults. However, these effects were not significant in meta‐regressions. Conclusions: Diagnostic agreement between SDIs and clinical evaluations varied widely by disorder and was low to moderate for most disorders. Thus, findings from SDIs may not fully apply to diagnoses based on clinical evaluations of the sort used in the published studies. Rather than implying that SDIs or clinical evaluations are inferior, characteristics of both may limit agreement and generalizability from SDI findings to clinical practice. Copyright

Adult Outcomes of Childhood Dysregulation: A 14-Year Follow-up Study.

OBJECTIVE Using a general population sample, the adult outcomes of children who presented with severe problems with self-regulation defined as being concurrently rated highly on attention problems, aggressive behavior, and anxious-depression on the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) were examined. METHOD Two thousand seventy-six children from 13 birth cohorts 4 to 16 years of age were drawn from Dutch birth registries in 1983. CBCLs were completed by parents at baseline when children from the different cohorts were 4 to 16 years of age and sampled every 2 years for the next 14 years. At year 14 the CBCL and DSM interview data were collected. Logistic regression was used to compare and contrast outcomes for children with and without dysregulation, as measured by the latent-class-defined CBCL-DP. Sex and age were covaried and concurrent DSM diagnoses were included in regression models. RESULTS Presence of childhood CBCL-DP at wave 1 was associated with increased rates of adult anxiety disorders, mood disorders, disruptive behavior disorders, and drug abuse 14 years later. After controlling for co-occurring disorders in adulthood, associations with anxiety and disruptive behavior disorders with the CBCL-DP remained, whereas the others were not significant. CONCLUSIONS A child reported to be in the CBCL-DP class is at increased risk for problems with regulating affect, behavior, and cognition in adulthood.

Individual Differences in Aggression: Genetic Analyses by age, gender, and informant in 3-, 7-, and 10-year-old Dutch Twins

Aggression in humans is associated with substantial morbidity and mortality. In this study we report on the aggressive behavior syndrome (AGG) in young children as defined by the Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF). We assessed aggression in a large sample of Dutch twins at ages 3, 7, and 10 years. The purpose of this study was three-fold. First, we determined the number of children who are “clinically deviant” on the AGG scale. Second, we assessed the genetic and environmental contributions to AGG for the maternal, paternal, and teacher ratings at each age, for boys and girls. Third, we explored issues of rater bias by analyzing parental and teacher data simultaneously. CBCL data were available from mothers on 6436 three-year-old, 5451 seven-year-old, and 2972 ten-year-old twin pairs and CBCL data from fathers on 4207 three-year-old, 4269 seven-year-old, and 2295 ten-year-old twin pairs. Teacher report data from the TRF were collected for 1036 seven-year-old and 903 ten-year-old twin pairs from the Netherlands Twin Registry. Structural equation modeling was employed to obtain genetic and environmental estimates at each age. Analyses were conducted separately by age and informant, as well as simultaneously, for all informants. Differences in raw scores across gender were found, with boys being rated as more aggressive than girls by all informants. Mothers reported more symptoms than fathers, who reported more symptoms than teachers. Evidence for moderate to high genetic influence (51%–72%) was seen for AGG by all three informants at all ages with only small sex differences in heritability estimates. Best fitting models for AGG by parent reports also included a small contribution of common environment. The largest sex differences in heritabilities were seen at age 10. Contributions of common (13%–27%) and unique (16%–31%) environment were small to moderate. There was some evidence of genetic dominance by teacher report for 10-year-old girls.

Latent Class Analysis Shows Strong Heritability of the Child Behavior Checklist–Juvenile Bipolar Phenotype

BACKGROUND The Child Behavior Checklist (CBCL) has been used to provide a quantitative description of childhood bipolar disorder (BPAD). Many have reported that children in the clinical range on the Attention Problems (AP), Aggressive Behavior (AGG), and Anxious-Depressed (A/D) syndromes simultaneously are more likely to meet the criteria for childhood BPAD. The purpose of this study was to determine if Latent Class Analysis (LCA) could identify heritable phenotypes representing the CBCL-Juvenile Bipolar (CBCL-JBD) profile and whether this phenotype demonstrates increased frequency of suicidal endorsement. METHODS The CBCL data were received by survey of mothers of twins in two large twin samples, the Netherlands Twin Registry. The setting for the study was the general community twin sample. Participants included 6246 10-year-old Dutch twins from the Netherlands Twin Registry. The main outcome measure consisted of the LCA on the items comprising the AP, AGG, and A/D subscales and means from the suicidal items #18 and #91 within classes. RESULTS A 7 class model fit best for girls and an 8 class fit best for boys. The most common class for boys or girls was one with no symptoms. The CBCL-JBD phenotype was the least common--about 4%-5% of the boys and girls. This class was the only one that had significant elevations on the suicidal items of the CBCL. Gender differences were present across latent classes with girls showing no aggression without the CBCL-JBD phenotype and rarely showing attention problems in isolation. Evidence of high heritability of these latent classes was found with odds ratios. CONCLUSIONS In a general population sample, LCA identifies a CBCL-JBD phenotype latent class that is associated with high rates of suicidality, is highly heritable, and speaks to the comorbidity between attention problems, aggressive behavior, and anxious/depression in children.

Associations between temperament and DSM-IV externalizing disorders in children and adolescents.

ABSTRACT. This study investigated associations between child temperament and DSM-IV disorders in children. A total of 156 probands (97 boys, 59 girls; mean age = 10.78 years) and 154 randomly selected siblings were assessed using the Junior Temperament and Character Inventory (JTCI) and a structured DSM-IV interview. Subjects were placed in nonoverlapping groups of (1) attention-deficit hyperactivity disorder (ADHD) only, (2) disruptive behavior disorders (DBD) only, (3) DBD plus an affective and/or anxiety disorder (DBD+Int), and (4) controls with no diagnosis. Many JTCI scales were found to differ between diagnostic groups and controls. Regression analyses showed independent associations between low persistence and ADHD-only group membership, high novelty seeking (NS), and the DBD-only group and between high harm avoidance (HA) and DBD+Int group membership. The interaction NS × HA was related to the ADHD-only group. Future research is needed to determine the mechanism of these association.

Child Behavior Checklist Juvenile Bipolar Disorder (CBCL‐JBD) and CBCL Posttraumatic Stress Problems (CBCL‐PTSP) scales are measures of a single dysregulatory syndrome

BACKGROUND The Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) profile and Posttraumatic Stress Problems (CBCL-PTSP) scale have been used to assess juvenile bipolar disorder (JBD) and posttraumatic stress disorder (PTSD), respectively. However, their validity is questionable according to previous research. Both measures are associated with severe psychopathology often encompassing multiple DSM-IV diagnoses. Further, children who score highly on one of these scales often have elevated scores on the other, independent of PTSD or JBD diagnoses. We hypothesized that the two scales may be indicators of a single syndrome related to dysregulated mood, attention, and behavior. We aimed to describe and identify the overlap between the CBCL-JBD profile and CBCL-PTSP scales. METHOD Two thousand and twenty-nine (2029) children from a nationally representative sample (1073 boys, 956 girls; mean age = 11.98; age range = 6-18) were rated on emotional and behavior problems by their parents using the CBCL. Comparative model testing via structural equation modeling was conducted to determine whether the CBCL-JBD profile and CBCL-PTSP scale are best described as measuring separate versus unitary constructs. Associations with suicidality and competency scores were also examined. RESULTS The CBCL-JBD and CBCL-PTSP demonstrated a high degree of overlap (r = .89) at the latent variable level. The best fitting, most parsimonious model was one in which the CBCL-JBD and CBCL-PTSP items identified a single latent construct, which was associated with higher parental endorsement of child suicidal behavior, and lower functioning. CONCLUSIONS The CBCL-JBD profile and CBCL-PTSP scale overlap to a remarkable degree, and may be best described as measures of a single syndrome. This syndrome appears to be related to severe psychopathology, but may not conform to traditional DSM-IV classification. These results contribute to the ongoing debate about the utility of the CBCL-JBD and CBCL-PTSP profiles, and offer promising methods of empirically based measurement of disordered self-regulation in youth.

Temperament and Its Role in Developmental Psychopathology

Temperament refers to early-appearing variation in emotional reactivity. The core dimensions of temperament and optimal method for assessment continue to be sources of considerable discussion. Nevertheless, the moderate stability of most temperamental traits and the strong influence of genetic and unique environmental factors have been well established, along with temperaments association with childhood psychiatric disorders. Both temperamental predisposition toward experiencing negative emotions and low inhibitory control are linked to many psychiatric conditions, while other dimensions, such as levels of extraversion, vary by, and likely even within, disorders. Accumulating research directed at understanding the mechanism of these links between temperament and psychopathology indicate that, at least for most disorders, the two constructs cannot be viewed as simply different points along a shared continuum. The effect of temperament upon psychopathology has been found to be mediated and moderated by a number of both internal and external factors. Additional research is needed to help further define the core dimensions of temperament and the complex mechanisms through which temperamental traits interact with other influences in affecting developmental trajectories.

Avoidant Personality Disorder, Generalized Social Phobia, and Shyness: Putting the Personality Back into Personality Disorders

&NA; With increasing recognition of social phobia as a common and often debilitating disorder, interest is developing in its boundaries with other disorders such as avoidant personality disorder and temperamental constructs such as shyness. Such interest reflects the more general debate concerning Axis I disorders, personality disorders, and what is considered normal personality variance. This review summarizes the available literature comparing avoidant personality disorder (APD), generalized social phobia (GSP), and shyness. In studies comparing APD and GSP, comorbidity rates have varied from approximately 25% to numbers high enough that the ability to diagnose one disorder without the other was questioned. Comparisons of the characteristics of APD and GSP have yielded few qualitative differences, although some studies have shown evidence that APD may represent a more severe form of GSP with respect to levels of symptoms, fear of negative evaluation, anxiety, avoidance, and depression. Personality dimensions including, but not limited to, shyness have been found to be strongly associated with GSP and APD, and there is some evidence that persons who suffer from social anxiety also suffer from fears and avoidance across nonsocial domains. In conclusion, although there is evidence that shyness, GSP, and APD exist along a continuum, the factors that constitute this continuum may need to be revised.

Neuropsychological test performance in trichotillomania : a further link with obsessive-compulsive disorder

Abstract Two neuropsychological tests, the Money Road Map test and the Stylus Maze, which had previously distinguished obsessive-compulsive patients from normal controls, were administered to 21 female patients with severe trichotillomania (an irresistible compulsion to pull out ones hair), and the results were compared with those of age- and sex-matched groups with obsessive-compulsive disorder (OCD) (n =12), other anxiety disorders (n=17), and normal controls (n=16). The trichotillo-mania group had significantly more errors than normal controls on the Stylus Maze, but not on the Road Map test. The OCD group differed significantly from normal controls in the number of rule breaks on the Stylus Maze. Within the trichotillomania group, errors on the two tasks correlated with symptom severity and predicted clinical response to clomipramine. Results are examined in terms of possible links between trichotillomania and OCD, and a neurobiological perspective of trichotillomania is discussed.