Kathleen Pajer

Adrenal androgen and gonadal hormone levels in adolescent girls with conduct disorder

There are few data on the biological correlates of female antisocial behavior. This study compared adrenal androgen and gonadal hormone levels in adolescent girls with conduct disorder (CD) to girls without any psychiatric disorder (NC). We studied 87 girls, (47 CD; 36 NC), ages 15-17 years, obtaining three blood samples, drawn 20 min apart between 8 and 9 AM in the first 72 h of the onset of menstrual flow. Plasma was assayed for testosterone, estradiol, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEA-S), sex hormone binding globulin (SHBG), and cortisol; area under the curve (AUC) for each of the three samples was used in the data analysis. We also calculated the Free Testosterone Index, Free Estrogen Index, Index of Hyperandrogenism and cortisol to DHEA ratio. In addition to receiving a full psychiatric interview, each girl completed a self-report questionnaire on general aggression. Main hormone analyses controlled for potentially confounding variables such as psychiatric comorbidity and race. Girls with CD had significantly lower cortisol to DHEA ratios, but did not differ from NC girls on any other hormone variable. Girls with symptoms of aggressive CD had significantly higher mean free testosterone indexes, lower SHBG levels, and lower cortisol to DHEA ratios than girls with non-aggressive CD. Girls with CD scored higher on the aggression questionnaire, but there was no association between general aggression and any hormone variable for the sample. Our data suggest that girls with CD, particularly aggressive CD, have lower cortisol to DHEA ratios, higher levels of free testosterone, and lower levels of SHBG. Clinical and research implications of these findings are discussed.

Computerized adaptive measurement of depression: A simulation study

BackgroundEfficient, accurate instruments for measuring depression are increasingly important in clinical practice. We developed a computerized adaptive version of the Beck Depression Inventory (BDI). We examined its efficiency and its usefulness in identifying Major Depressive Episodes (MDE) and in measuring depression severity.MethodsSubjects were 744 participants in research studies in which each subject completed both the BDI and the SCID. In addition, 285 patients completed the Hamilton Depression Rating Scale.ResultsThe adaptive BDI had an AUC as an indicator of a SCID diagnosis of MDE of 88%, equivalent to the full BDI. The adaptive BDI asked fewer questions than the full BDI (5.6 versus 21 items). The adaptive latent depression score correlated r = .92 with the BDI total score and the latent depression score correlated more highly with the Hamilton (r = .74) than the BDI total score did (r = .70).ConclusionsAdaptive testing for depression may provide greatly increased efficiency without loss of accuracy in identifying MDE or in measuring depression severity.

Delinquent youth in corrections: Medicaid and reentry into the community.

In general, states and public agencies acting as custodians for youth in the corrections branch of the juvenile justice system are responsible for ensuring that such youth receive access to timely and appropriate physical and mental health care. However, to date, health care for youth in the juvenile justice system has generally been considered inadequate. Note that in this article “health care” refers to the treatment of both physical and mental health problems. The American Academy of Pediatrics and others have issued policy statements in the past 2 decades that stress the need for better health care for juvenile offenders in correctional facilities.1–4 In response, correctional facilities have put in place enhanced acute care services for children and adolescents in juvenile justice.nnAlthough such services are almost certainly needed, these efforts are likely to be deficient on at least 2 counts. First, many of these youth suffer not only from acute medical and psychiatric problems but also chronic ones including substance abuse and other psychiatric disorders. Second, with an estimated 88000 youth being released from juvenile commitment facilities each year,5 the need for ongoing medical treatment after parole and reentry into the community is high. However, care often stops when the juveniles leave the system, with little or no reintroduction to community services.6 Pediatricians and other primary care clinicians have a central role to play in establishing a medical home for these youth and expediting access to critical medical and behavioral services.nnThis review will provide an overview of the juvenile justice system, present the extant literature on the chronic health problems found in incarcerated youth, and discuss how the absence of care after release from the juvenile justice system impacts public health and society. We argue that Medicaid financing could be used as an … nnReprint requests to (K.K.) Office of Clinical Sciences, Columbus Children’s Research Institute, 700 Children’s Dr, Suite J1401, Columbus, OH 43205. E-mail: kellehek{at}pediatrics.ohio-state.edu

Recognition of facial affect in girls with conduct disorder

Impaired recognition of facial affect has been reported in youths and adults with antisocial behavior. However, few of these studies have examined subjects with the psychiatric disorders associated with antisocial behavior, and there are virtually no data on females. Our goal was to determine if facial affect recognition was impaired in adolescent girls with conduct disorder (CD). Performance on the Ekman Pictures of Facial Affect (POFA) task was compared in 35 girls with CD (mean age of 17.9 years+/-0.95; 38.9% African-American) and 30 girls who had no lifetime history of psychiatric disorder (mean age of 17.6 years+/-0.77; 30% African-American). Forty-five slides representing the six emotions in the POFA were presented one at a time; stimulus duration was 5s. Multivariate analyses indicated that CD vs. control status was not significantly associated with the total number of correct answers nor the number of correct answers for any specific emotion. Effect sizes were all considered small. Within-CD analyses did not demonstrate a significant effect for aggressive antisocial behavior on facial affect recognition. Our findings suggest that girls with CD are not impaired in facial affect recognition. However, we did find that girls with a history of trauma/neglect made a greater number of errors in recognizing fearful faces. Explanations for these findings are discussed and implications for future research presented.

Medicaid Insurance Policy for Youths Involved in the Criminal Justice System

Juvenile justice and Medicaid agencies share an interest in serving delinquent youths, many of whom have a relatively poor health status. However, many state and local Medicaid policies result in these youths having no insurance coverage, making access to needed services difficult. A nationally representative survey of state and community juvenile justice and Medicaid agencies was conducted to assess Medicaid policies. Evidence from the survey suggests that in some areas delinquent youths are actively disenrolled from Medicaid benefits, and in others little effort is made to connect them to Medicaid coverage. Discrepancies between justice agency and Medicaid agency responses point to poor communication and coordination. Overall, the survey identified several opportunities for policy intervention to enhance access to services for justice-involved youths.

Commentary: Cortisol Levels and Conduct Disorder in Adolescent Mothers

The study by Azar et al. (2004) in this issue investigates the function of the hypothalamic-pituitary-adrenal (HPA) axis in adolescent antisocial girls. This question is important because disturbance of HPA functioning has been found in populations of violent adult males and antisocial adolescent males, suggesting that it may be a marker of a physiological disorder associated with antisocial behavior. The investigators examined 228 pregnant or postpartum teenage girls, categorizing them as having conduct disorder (CD) or not having conduct disorder (NCD). HPA axis function was assessed with saliva cortisol samples obtained in the midmorning when the girls were 4 and 9 months postpartum. The hypothesis was that girls with CD would have lower cortisol levels than girls without CD. The investigators did not find any significant difference in cortisol levels between the two groups, an important but puzzling finding. Azar et al. suggested that this result may demonstrate a lack of clear HPA axis involvement in antisocial mothers.

Erratum to “Recognition of facial affect in girls with conduct disorder” [Psychiatry Research 175(3) (2010) 246–251]

Children/adolescents 1. Walker (1981) 60 patients; 15 CD 12± 2 years ? 6 Clinical diagnosis Single photos; forced choice: 4 min CD=controls No covariates tested; no data on girls 2. Cadesky et al. (2000) 200; 87 CD or CD+ ADHD 9± 1 year ? 13 Research diagnosis; parent/teacher DANVA forced choice: 2 s CD<ADHD+CD< ADHD<controls in total score ADHD+CD more accurate sad faces; no data on girls 3. Guyer et al. (2007) 250; 6 diagnostic categories; 7 CD; 10 ADHD+CD 15± 1 year 40% black 10 girls Research diagnosis; parent/youth DANVA forced choice: 2 s ADHD+CD=controls IQ, race, age= covariates; no data on girls 4. McCown et al. (1986) 80; 40 DEL; 40 controls 15± 1 year 50% black 0 Incarceration Ekman POFA: 5 s DEL<controls total score; DEL<controls sadness, surprise, disgust No covariates tested; no girls in sample