John S. Werry

Attention Deficit, Conduct, Oppositional, and Anxiety Disorders in Children: I. A Review of Research on Differentiating Characteristics

Abstract Studies comparing Attention Deficit. Anxiety, and Conduct Disorders are reviewed. Most studies only compare one diagnostic group with normal subjects, and there are remarkable similarities to observed abnormalities across diagnostic groups. The few studies that have compared Attention Deficit with Hyperactivity (ADDH) with Conduct Disorder with or without Anxiety Disorder suggest that ADDH may be a cognitive disorder, possibly of neurodevelopmental origin; Conduct Disorder one of social relationships of psychosocial origin; and Anxiety Disorder less predominantly male, associated with parental anxiety, and less severe in every way than the other two. Coexistence of Attention Deficit and Conduct Disorders is probably common and increases the degree of disability.

Attention deficit, conduct, oppositional, and anxiety disorders in children: II. Clinical characteristics.

Abstract One hundred and five children aged 5-12 with diagnoses of Anxiety, Attention Deficit (ADDH), Conduct, or Oppositional Disorders were compared with each other and with normal subjects. Conduct and Oppositional Disorders resembled each other and seldom occurred in the absence of ADDH so were combined into an ADDH plus Conduct group. Anxiety Disorder children were less predominantly male, less socially or academically disabled, but had more anxious parents. The two ADDH groups resembled each other but the addition of Conduct Disorder brought greater social disability and more adverse family environments.

Practice Parameters for the Assessment and Treatment of Children and Adolescents With Schizophrenia

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs.

Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996, and were previously published in J. Am. Acad. Chil Adolesc. Psychiatry, 1997, 36:138-157.

Attention Deficit, Conduct, Oppositional, and Anxiety Disorders in Children: III. Laboratory Differences.

Children aged 5–13 years with DSM-III diagnoses of Attention Deficit (ADDH), Anxiety, (ANX), or Conduct plus ADDH (HC) Disorder and matched normal controls were compared on a set of laboratory measures of impulsivity, arousal, motor performance, activity level, and cognition, and on behavior ratings during testing. While ANX patients did not differ from their controls, ADDH and HC patients did on Verbal IQ, most of the behavior ratings, and on about one-third of the test variables. ANX patients were about 1 year older, and more likely to be female, than ADDH and HC patients. When age, sex, and verbal IQ effects were partialed out, very few differences among the three diagnostic groups remained. The importance of precise control of such variables is emphasized and the impact of the failure to do so in past studies is discussed. The question is raised whether the deficit in verbal IQ is not so much a defect of matching as the essential feature of ADDH from which most of the other commonly reported cognitive symptoms stem.

Evidence-Based Treatments in Child and Adolescent Psychiatry: An Inventory

OBJECTIVE To provide a list of evidence-based psychopharmacology and psychotherapy treatments for child psychiatry. METHOD Published reviews and Medline searches were examined to generate a list of treatments supported by randomized controlled trials. RESULTS For psychopharmacology, the best evidence to date supports the use of stimulant medications for attention-deficit/hyperactivity disorder and selective serotonin reuptake inhibitors (SSRIs) for obsessive-compulsive disorder. There is also reasonable evidence addressing SSRIs for anxiety disorders and moderate to severe major depressive disorder, and risperidone for autism. The psychosocial interventions best supported by well-designed studies are cognitive-behavioral and behavioral interventions, especially for mood, anxiety, and behavioral disorders. Family-based and systems of care interventions also have been found effective. CONCLUSIONS Although the number of evidence-based treatments for child psychiatry is growing, much of clinical practice remains based on the adult literature and traditional models of care. Challenges toward adopting evidence-based practices are discussed.

Child and Adolescent (Early Onset) Schizophrenia: A Review in Light of DSM-III-R.

Early onset schizophrenia (EOS) is defined as that beginning in childhood or adolescence (under 16 or 17). Studies of EOS are infrequent, and comparative adult figures not always available, but tentative conclusions may be drawn. EOS is more common in males; symptomatology is often undifferentiated; frequencies of homotypic family disorder, premorbid schizotypal personality, and neurodevelopmental abnormalities high; outcome poor but only slightly worse than in adults; response to psychotropic drug treatment probably similar though not properly tested; and confusion with psychotic bipolar disorder particularly common. Onset before language is developed presents special diagnostic difficulties. There are a few reports of autistic children developing schizophrenia but this requires replication. Differences from adult schizophrenia are more marked when onset is in childhood than in adolescence but all are quantitative rather than qualitative suggesting that the disorders are the same and that there should be no separate category for children or adolescents.

A follow-up study of early onset psychosis : Comparison between outcome diagnoses of schizophrenia, mood disorders and personality disorders

This study examined the outcome of youth previously diagnosed with psychotic disorders at a public-sector tertiary care hospital. Of 95 children and adolescents retrospectively identified, follow-up information (mean interval 3.9 years) was obtained on 24 subjects with an outcome diagnosis of schizophrenia, 9 with psychotic mood disorders, 5 with personality disorders (antisocial or borderline), and 1 with schizo-affective disorder. The schizophrenic group was more often odd premorbidly and functioned worse at outcome, while the mood-disordered group had a shorter follow-up period and was more often anxious or dysthymic premorbidly. The personality-disordered group resembled the schizophrenics in their degree of impairment and chronicity. All three groups had high rates of family disruption, low SES, substance abuse, and chronicity, and were similar in their degree of premorbid impairment, length of prodrome, age of onset, initial diagnosis, and family psychiatric history. Misdiagnosis at onset was quite common and highlights the need for systematic longitudinal assessment of early onset psychotic disorders.

Methylphenidate in Children—Effect of Dosage*

A clinical trial in two groups of hyperactive/ aggressive children showed that methylphenidate was superior to placebo for about 2/3 of the children, but that there was little difference in effectiveness between different dosage levels, especially once 0.3 mg/kg is attained. Mild side effects were common at higher dosages. Of a variety of physician, parent, teacher and psychological test and behavioral measures, teacher and physician ratings were the most sensitive to drug effects. No measures including neurological ones discriminated between responders and non-responders. It is concluded that methylphenidate is a useful treatment for hyperactive/aggressive children but that current doses may be too high and side effects more common than stated.

The interrater reliability of DSM III in children.

A total of 195 admissions to a child psychiatric inpatient unit were diagosed independently by two to four clinicians on the basis of case presentations at the first wardround after admission. The DSM HI as a whole and the major categories were of high or acceptable reliability, though a few were clearly unreliable. The results are generally consistent with other studies. Unlike other studies, the subcategories were examined and found to vary widely in reliability both as a whole across the system and within parent major categories, throwing considerable doubt upon their utility. The results indicate the need both for improved diagnostic datagathering techniques in child psychiatry and for more betterdesigned studies of reliability and, most necessarily, of validity.