Diane Chen

Predictive validity of DSM-IV oppositional defiant and conduct disorders in clinically referred preschoolers

BACKGROUND Diagnostic validity of oppositional defiant and conduct disorders (ODD and CD) for preschoolers has been questioned based on concerns regarding the ability to differentiate normative, transient disruptive behavior from clinical symptoms. Data on concurrent validity have accumulated, but predictive validity is limited. Predictive validity is critical to refuting the hypothesis that diagnosing ODD and CD in young children leads to pathologizing normal behavior. ODD and CD have emerged as gateway disorders to many forms of adult psychopathology. Establishing how early we can identify symptoms and disorders that herald poor prognosis is one of the most important goals for research on etiology and prevention. METHODS Subjects were 3-5-year-old consecutive referrals to a child psychiatry clinic (n=123) and demographically matched children from a pediatric clinic (n=100). A diagnostic interview was used to assess DSM-IV ODD and CD in a prospective follow-up design from preschool to school age. Stability of ODD and CD diagnoses and level of impairment were tested as a function of preschool diagnosis. RESULTS Over 80% of preschoolers diagnosed with ODD and approximately 60% of preschoolers diagnosed with CD met criteria for the same disorder during follow-up. Impairment over time varied significantly as a function of stability of diagnosis across three years. CONCLUSIONS These results provide the first evidence of the predictive validity of DSM-IV ODD and CD in clinically referred preschool children. The findings challenge the assumption that symptoms of disruptive behavior disorders that occur during the preschool period tend to be transient.

Source-Specific Oppositional Defiant Disorder Among Inner-City Children: Prospective Prediction and Moderation

We examined prospective prediction from parent- and teacher-reported oppositional defiant disorder (ODD) symptoms to parent-reported ODD, conduct disorder (CD), major depressive disorder (MDD), and generalized anxiety disorder symptoms and whether child executive functioning abilities moderated these relations among an urban, low-income sample of first- to third-grade children (N = 87). Time 1 parent-reported ODD predicted each Time 2 outcome. Time 1 teacher-reported ODD predicted Time 2 CD and MDD symptoms. After controlling for Time 1 co-occurring symptoms, only prediction from Time 1 teacher-reported ODD to CD and MDD symptoms remained significant. Child executive functioning abilities moderated relations between Time 1 parent-reported ODD and Time 2 ODD, and Time 1 teacher-reported ODD and Time 2 CD and MDD. Among children with better executive functioning abilities, higher Time 1 ODD was associated with higher Time 2 symptoms.

Developmental trajectories of aggression from late childhood through adolescence: Similarities and differences across gender

Although numerous investigations of overt aggressive and antisocial trajectories have been undertaken, there is a dearth of literature examining gender differences and similarities in trajectory patterns and their correlates. To address these gaps, we investigated gender differences in the prevalence rates, predictive validity during transition to adulthood, childhood risk factors, and adolescent correlates of different trajectories of teacher-reported overt aggression (i.e., fights, argues, gets in trouble) among 220 participants (116 girls and 104 boys) evaluated annually from grade 4 to grade 12. Four patterns of trajectories were identified: low, increasing (i.e., adolescent-onset), decreasing (i.e., childhood-limited), and high (i.e., childhood-onset). A large proportion of youth, particularly girls, displayed low levels of aggression over time. A small proportion followed the childhood-onset trajectory. Across gender, the childhood-onset trajectory was associated with the highest rates of maladjustment during the transition to adulthood, the highest number of childhood risk factors, and multiple problems during adolescence. The adolescent-onset trajectory was associated with few childhood risk factors, but with high levels of independent status during adolescence. In contrast, the childhood-limited trajectory was associated with several childhood risk factors, but high levels of parental monitoring and school engagement during adolescence. Romantic involvement differentiated the adolescent-onset and childhood-limited trajectories among girls.

A Developmental Perspective on Peer Rejection, Deviant Peer Affiliation, and Conduct Problems Among Youth

Peer rejection and deviant peer affiliation are linked consistently to the development and maintenance of conduct problems. Two proposed models may account for longitudinal relations among these peer processes and conduct problems: the (a) sequential mediation model, in which peer rejection in childhood and deviant peer affiliation in adolescence mediate the link between early externalizing behaviors and more serious adolescent conduct problems; and (b) parallel process model, in which peer rejection and deviant peer affiliation are considered independent processes that operate simultaneously to increment risk for conduct problems. In this review, we evaluate theoretical models and evidence for associations among conduct problems and (a) peer rejection and (b) deviant peer affiliation. We then consider support for the sequential mediation and parallel process models. Next, we propose an integrated model incorporating both the sequential mediation and parallel process models. Future research directions and implications for prevention and intervention efforts are discussed.

The Ethics of Fertility Preservation for Pediatric Patients With Differences (Disorders) of Sex Development

Differences (disorders) of sex development are diverse conditions with variations in chromosomal, gonadal, and/or genital development. Fertility potential in this population is variable. Recent investigations into fertility potential in those previously thought to be infertile suggest that the majority may have fertility potential through experimental protocols. Fertility preservation may be more successful if pursued in childhood. As fertility research and techniques advance, it is important to carefully consider pediatric ethical issues specific to this population, including gonadectomy, consent/assent, experimental treatment and false hope, cost and insurance coverage, genetic transmission to offspring, and gender dysphoria.

Attitudes Toward Fertility and Reproductive Health Among Transgender and Gender-Nonconforming Adolescents

PURPOSE Little is known about the reproductive desires of transgender and gender-nonconforming (TGNC) adolescents who may seek gender-affirming medical care that leads to infertility. The current study addressed this gap by examining attitudes toward fertility and family formation in a diverse sample of TGNC youth. METHOD An online survey about sexual/reproductive health in sexual and gender minority (SGM) adolescents ages 14-17 years was conducted from September to October 2016. RESULTS A total of 156 TGNC adolescents (Mage = 16.1 years; 83.3% assigned female at birth; 58.3% youth of color) responded. Overall, 70.5% of TGNC adolescents were interested in adoption and 35.9% in biological parenthood; more gender-nonconforming youth (43.8%) than transgender youth (25.8%) expressed interest in biological fertility. Discussions with health-care providers about fertility and reproductive health were uncommon-only 20.5% of youth had discussed fertility in general and only 13.5% had discussed effects of hormones on fertility. However, 60.9% of respondents were interested in learning more about their fertility and family building options. Key themes emerging from qualitative comments included concerns related to fertility/reproductive health (e.g., stigma of SGM parenthood, effect of gender-affirming treatments on fertility), and the need for additional reproductive health information both tailored to their individual experience and for SGM individuals more generally. DISCUSSION TGNC adolescents expressed interest in multiple family building options, including adoption and biological parenthood, and identified a need for more information about these options. Thus, clinicians working with adolescents should be aware of the unique fertility and reproductive health needs of TGNC youth.

Future fertility for individuals with differences of sex development: Parent attitudes and perspectives about decision-making

BACKGROUND Children, adolescents, and young adults (children/youth) with differences/disorders of sex development (DSD) face challenges related to future fertility; this may be due to variations in gonadal development, and, for some, gonadectomy performed to reduce the risk of malignancy. Childhood may be the only time for preservation of biological fertility potential for children/youth who undergo gonadectomy or have early gonadal failure. Fertility-related decision-making for these patients is particularly complicated, due to the need for parental proxy decision-making, potential discordance between gender identity and gonadal type, and uncertain future assisted reproductive technologies. OBJECTIVE This study aimed to assess: (1) attitudes regarding future fertility, and (2) healthcare needs for fertility-related decision-making among parents of children/youth with DSD. STUDY DESIGN Semi-structured qualitative interviews about future fertility were conducted with parents of children/youth with DSD. Parents who had never discussed fertility with a healthcare provider were excluded. Grounded theory methodology was used to identify emergent themes and patterns. Demographics and clinical characteristics were assessed via survey and medical chart review. RESULTS Nineteen parents were interviewed (participation rate: 60%, 14 mothers/5 fathers, median patient age at diagnosis 6 months (range 0-192), eight DSD diagnoses). The most common emergent themes are summarized in the Summary Table. Most parents identified fertility as a key concern, both at time of diagnosis and throughout development. Parents expressed difficulty with timing of disclosure about potential infertility to their children. Multiple preferences related to medical decision-making about future fertility and fertility preservation were expressed, including: a desire for step-by-step decision-making, and use of medically vetted information and research to guide decisions. DISCUSSION This qualitative study provided new information about the perspectives of parents of children/youth with DSD regarding future fertility. Previous studies have suggested that the possibility of biological parenthood is important to many individuals with DSD. This study provided an in-depth parental perspective. This is important because many decisions that affect future fertility are made in childhood, and require parents to make decisions on behalf of their children. The study sample was limited in its geographic diversity. Strengths of the study included diversity in age of the child/youth, ethnic backgrounds, and the DSD diagnoses that were represented. CONCLUSIONS Future fertility was a concern for many parents of children/youth with DSD. Parents expressed multiple priorities and preferences related to making difficult fertility-related medical decisions for their children. Many of the study findings could be incorporated into future best practices for discussions about fertility with families of children/youth with DSD.

Ethical considerations in fertility preservation for transgender youth: A case illustration.

Increasing numbers of transgender adolescents are presenting for transition-related medical care, including gender-affirming estrogen and testosterone. The decision to transition with hormones has long-term implications, including possible irreversible impairment of future reproductive functioning. The commentary by Hudson, Nahata, Dietz, and Quinn (2018) outlines the importance of fertility counseling for transgender adolescents and young adults as ethical, interdisciplinary practice. Key considerations raised include implementing shared decision-making strategies that account for youths’ maturity and individual decisional capacity, evaluating co-occurring psychiatric conditions that could interfere with future-oriented decision-making, and considering benefits and harms of fertility preservation (FP) in the context of a youth’s values, identity, and comfort. This report includes two case illustrations of transmasculine youth which highlight how ethical considerations emerge in clinical practice and underscore the nuance and complexity of fertility-related decision-making among transgender adolescents.

Ethical Issues in Pediatric and Adolescent Fertility Preservation

According to recent estimates, there are more than 270,000 survivors of pediatric cancer and long-term survivorship for pediatric cancer is around 80 % [28]. Given the large number of survivors as well as the high survivorship rate, coupled with the fact that pediatric cancer survivors typically have a full lifetime ahead of them, it is increasingly important to examine their quality of life issues. Our goal in this chapter is to highlight some of the ethical issues that arise in the context of fertility preservation for pediatric cancer patients and survivors. Specifically, we explore assent/consent, best interest standard, parental and provider pressure, cost and insurance coverage, and experimental treatment.

Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions

Growing numbers of transgender and gender-nonconforming (TGNC) youth are presenting for medical and mental health care, and increasingly, pediatric psychologists are being called upon to serve as critical members of interdisciplinary care teams. In this commentary, we present information on TGNC youth in three distinct developmental cohorts: prepubescent TGNC children, peripubertal TGNC youth, and pubertal TGNC adolescents. First, we describe the social, medical, and/or surgical treatments available to each cohort of youth. Next, we address the state of the science related to these treatments. Then, we highlight some of the ongoing controversies related to social, medical and/or surgical interventions that are most relevant to pediatric psychologists and the role they play in gender-affirming care. Finally, we conclude with a call for papers for an upcoming special issue of Clinical Practice in Pediatric Psychology focused on advancing the practice of pediatric psychology in transgender health care.