Helen L. Egger

Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches.

OBJECTIVE To examine the associations of somatic complaints with DSM-III-R-defined depression, anxiety disorders, conduct disorder, oppositional defiant disorder, and attention-deficit hyperactivity disorder in a population-based sample of children and adolescents. METHODS Data from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky Mountains Study were analyzed. RESULTS Overall, somatic complaints were strongly associated with emotional disorders in girls and with disruptive behavior disorders in boys. For girls, stomach aches and headaches together and musculoskeletal pains alone were associated with anxiety disorders. For boys, stomach aches were associated with oppositional defiant disorder and attention-deficit hyperactivity disorder. Musculoskeletal pains were associated with depression in both girls and boys. CONCLUSIONS There were gender-, illness- and complaint-specific associations between somatic complaints and psychopathology. It appears likely that there are differences in the psychobiological processes underlying these associations in boys and girls. Clinical recommendations include screening children and adolescents with persistent complaints of headaches, stomach aches, or musculoskeletal pains for psychiatric disorders with an awareness that gender may affect the type of psychopathology associated with the somatic complaints.

Stimulant Treatment for Children: A Community Perspective

OBJECTIVE To examine the use of prescribed stimulants in relation to research diagnoses of attention-deficit hyperactivity disorder (ADHD) in a community sample of children. METHOD Data from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky Mountains Study were analyzed. RESULTS Over a 4-year period, almost three quarters of children with an unequivocal diagnosis of ADHD received stimulant medications. However, girls and older children with ADHD were less likely to receive such treatment. Most children with impairing ADHD symptoms not meeting full criteria for DSM-III-R ADHD did not receive stimulant treatment. Stimulant treatment in this group was significantly related to the level of symptoms reported by parents and teachers and was much more common in individuals who met criteria for oppositional defiant disorder. The majority of individuals who received stimulants were never reported by their parents to have any impairing ADHD symptoms. They did have higher levels of nonimpairing parent-reported ADHD symptoms, higher levels of teacher-reported ADHD symptoms, and interviewer-observed ADHD behaviors, but these typically fell far below the threshold for a DSM-III-R diagnosis of ADHD. CONCLUSIONS In this area of the Great Smoky Mountains, stimulant treatment was being used in ways substantially inconsistent with current diagnostic guidelines.

School Refusal and Psychiatric Disorders: A Community Study

OBJECTIVE To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal. METHOD Data from eight annual waves of structured psychiatric interviews with 9- to 16-year-olds and their parents from the Great Smoky Mountains Study were analyzed. RESULTS Pure anxious school refusal was associated with depression (odds ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95% CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial variables had different associations with the three types of school refusal. CONCLUSIONS Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse experiences at home and school. Implications of these findings for assessment, identification, and intervention for school refusal are discussed.

Prevalence of psychiatric disorders in preschoolers

BACKGROUND   Many disorders in childhood and adolescence were already present in the preschool years. However, there is little empirical research on the prevalence of psychiatric disorders in young children. A true community study using structured diagnostic tools has yet to be published. METHODS   All children born in 2003 or 2004 in the city of Trondheim, Norway, who attended the regular community health check-up for 4-year-olds (97.2% of eligible children) whose parents consented to take part in the study (N = 2,475, 82.0%) were screened for behavioral and emotional problems with the Strengths and Difficulties Questionnaire (SDQ). A screen-stratified subsample of 1,250 children took part in a furthermore comprehensive study including a structured diagnostic interview (the Preschool Age Psychiatric Assessment, PAPA), which 995 parents (79.6%) completed. RESULTS   The estimated population rate for any psychiatric disorder (excluding encopresis - 6.4%) was 7.1%. The most common disorders were attention deficit hyperactivity disorder (1.9%), oppositional defiant disorder (1.8%), conduct disorder (0.7%), anxiety disorders (1.5%), and depressive disorders (2.0%). Comorbidity among disorders was common. More emotional and behavioral disorders were seen in children whose parents did not live together and in those of low socioeconomic status. Boys more often had attention-deficit/hyperactivity disorder (ADHD) and depressive disorders than girls. CONCLUSIONS   The prevalence of disorders among preschoolers was lower than in previous studies from the USA. Comorbidity was frequent and there was a male preponderance in ADHD and depression at this early age. These results underscore the fact that the most common disorders of childhood can already be diagnosed in preschoolers. However, rates of disorder in Norway may be lower than in the USA.

Institutional Rearing and Psychiatric Disorders in Romanian Preschool Children

OBJECTIVE There is increasing interest in the relations between adverse early experiences and subsequent psychiatric disorders. Institutional rearing is considered an adverse caregiving environment, but few studies have systematically examined its effects. This study aimed to determine whether removing young children from institutional care and placing them with foster families would reduce psychiatric morbidity at 54 months of age. METHOD Young children living in institutions in Bucharest were enrolled when they were between 6 and 30 months of age. Following baseline assessment, 136 children were randomly assigned to care as usual (continued institutional care) or to removal and placement in foster care that was created as part of the study. Psychiatric disorders, symptoms, and comorbidity were examined by structured psychiatric interviews of caregivers of 52 children receiving care as usual and 59 children in foster care when the children were 54 months of age. Both groups were compared to 59 typically developing, never-institutionalized Romanian children recruited from pediatric clinics in Bucharest. Foster care was created and supported by social workers in Bucharest who received regular consultation from U.S. clinicians. RESULTS Children with any history of institutional rearing had more psychiatric disorders than children without such a history (53.2% versus 22.0%). Children removed from institutions and placed in foster families were less likely to have internalizing disorders than children who continued with care as usual (22.0% versus 44.2%). Boys were more symptomatic than girls regardless of their caregiving environment and, unlike girls, had no reduction in total psychiatric symptoms following foster placement. CONCLUSIONS Institutional rearing was associated with substantial psychiatric morbidity. Removing young children from institutions and placing them in families significantly reduced internalizing disorders, although girls were significantly more responsive to this intervention than boys.

Headaches and Psychopathology in Children and Adolescents

OBJECTIVE To examine the association between chronic headaches and DSM-III-R-defined psychiatric disorders, including depression, anxiety disorders, conduct disorder, oppositional defiant disorder and attention-deficit hyperactivity disorder, in a population-based sample of children and adolescents. METHOD 1,013 children aged 9 to 15 years in the Great Smoky Mountains Study were evaluated annually over a 3-year period using the Child and Adolescent Psychiatric Assessment, a child and parent diagnostic psychiatric interview. Headaches that lasted at least 1 hour and occurred at least once a week during the 3 months prior to the interview were studied. RESULTS Girls with depression and anxiety disorders had a significantly greater prevalence of headaches than girls without an internalizing disorder. This association was not found for boys. Conduct disorder was significantly associated with headaches in boys. Each of these associations was constant with age. CONCLUSIONS This study suggests that a distinct gender difference exists between boys and girls in the associations between headaches and psychopathology. Carrolls theory of dysfunction in central pain regulation as an underlying cause of depression is discussed in relation to the proposed serotonergic dysregulation common to headaches, depression, anxiety, aggression, and pain.

Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types.

OBJECTIVE This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD). METHOD As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time. RESULTS As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time. CONCLUSIONS Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.

Observational Assessment of Preschool Disruptive Behavior, Part II: validity of the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS).

OBJECTIVE To examine the reliability of the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS), a new observational method for assessing preschool disruptive behavior. METHOD The DB-DOS is a structured clinic-based assessment designed to elicit clinically salient behaviors relevant to the diagnosis of disruptive behavior in preschoolers. Child behavior is assessed in three interactional contexts that vary by partner (parent versus examiner) and level of support provided. Twenty-one disruptive behaviors are coded within two domains: problems in Behavioral Regulation and problems in Anger Modulation. A total of 364 referred and nonreferred preschoolers participated: interrater reliability and internal consistency were assessed on a primary sample (n = 335) and test-retest reliability was assessed in a separate sample (n = 29). RESULTS The DB-DOS demonstrated good interrater and test-retest reliability. Confirmatory factor analysis demonstrated an excellent fit of the DB-DOS multidomain model of disruptive behavior. CONCLUSIONS The DB-DOS is a reliable observational tool for clinic-based assessment of preschool disruptive behavior. This standardized assessment method holds promise for advancing developmentally sensitive characterization of preschool psychopathology.

Schedule for Affective Disorders and Schizophrenia for School- Age Children (K-SADS-PL) for the Assessment of Preschool Children- A Preliminary Psychometric Study

OBJECTIVE To assess the psychometrics of the schedule for affective disorders and schizophrenia for school-age children present and lifetime version (K-SADS-PL) in diagnosing DSM-IV psychiatric disorders and subsyndromal symptomatology in preschool children. METHOD Parents were interviewed about their children using the K-SADS-PL, and they completed the early childhood inventory-4 (ECI-4) and child behavior checklist for ages 1(1/2)-5 years (CBCL). Discriminant, divergent, and convergent validity of the K-SADS-PL were evaluated in 204 offspring ages 2-5 years old of parents from an ongoing study. Inter-rater reliability as well as predictive validity of intake diagnoses at second assessment approximately two years after intake were evaluated. Fourteen children were also assessed by the preschool age psychiatric assessment (PAPA). RESULTS Children who were diagnosed with oppositional defiant disorder, attention deficit hyperactivity disorder, anxiety, mood, or elimination disorders had significantly higher scores on the ECI-4 than children without these disorders. Significant correlations were found for all convergent CBCL scales. Divergent validity was acceptable for emotional disorders. Inter-rater kappa coefficients for all diagnoses were good. Above noted results were similar for children with at least one positive K-SADS-PL key screen symptom. A significantly higher percentage of children with an intake diagnosis had a diagnosis approximately two years after intake compared to those without an intake disorder. Overall, there was consistency between the PAPA and the K-SADS-PL. CONCLUSIONS Pending further testing, the K-SADS-PL may prove useful for the assessment of psychopathology in preschoolers.

The Epidemiology and Diagnostic Issues in Preschool Attention-Deficit/Hyperactivity Disorder: A Review

This study aims to review the nosology and epidemiology of attention-deficit/hyperactivity disorder (ADHD) in children aged 2 through 5 years. Studies, primarily in community or pediatric clinic settings, were reviewed. In studies using DSM diagnostic criteria, the prevalence of ADHD in preschool children ranges from 2.0% to 7.9%, with hyperactive-impulsive type and combined type significantly more common than pure inattentive type ADHD. Boys and older preschoolers (4- and 5-year-olds vs 2- and 3-year-olds) are more likely to meet criteria for ADHD. Preschoolers with ADHD are significantly impaired in their relationships with adults and other children, in their functioning at home and outside the home, and in cognitive and academic performance. Preschoolers with ADHD are significantly more likely to meet criteria for other psychiatric disorders and those who do meet criteria for other psychiatric disorders are more severely impaired than preschoolers with ADHD alone. Despite the severity of impairment, only about a quarter of preschoolers with ADHD are referred for mental health evaluation or treatment. Preschool ADHD predicts future ADHD and persistent impairment. Preschoolers with ADHD look like older children with ADHD with similar symptom presentations, associated features, and prognosis. These findings suggest that DSM-IV-TR ADHD is a reliable and valid diagnosis for children aged 2 through 5 years.