Mina K. Dulcan

The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, Acceptability, Prevalence Rates, and Performance in the MECA Study

OBJECTIVE To describe the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 and to provide data on its performance characteristics in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. METHOD Data were collected on the DISC-2.3 at four sites on 1,285 randomly selected children, aged 9 through 17 years, and their parents. Two hundred forty-seven of these child-parent pairs were reassessed on the DISC-2.3 by a clinician interviewer, 1 to 3 weeks later. RESULTS Administration time was approximately 1 hour and the interview was acceptable to more than 90% of subjects. The reliability of questions to parents assessing impairment and age of onset was generally good to acceptable for most diagnoses but was less satisfactory for the child interview. Using information from parent and child, the prevalence for any diagnosis ranged from 50.6 if no impairment criteria were required to 5.4 if a Global Assessment Scale score of 50 or less was necessary. The prevalence of anxiety disorders and enuresis was markedly reduced by requiring attributable impairment. CONCLUSIONS The DISC-2 is a reliable and economical tool for assessing child psychopathology. Reliability of the DISC-P-2.3 is superior to that of the child DISC for most diagnoses but is least good for anxiety disorders. The 2.3 version of the instrument provides a significant improvement over earlier versions.

Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents, and Adults

ABSTRACT This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.

Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Attention-Deficit/Hyperactivity Disorder

These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

Criterion Validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3)

OBJECTIVE To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings. METHOD Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses. RESULTS In general, the DISC showed moderate to good validity across a number of diagnoses. CONCLUSIONS Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.

The DISC Predictive Scales (DPS): Efficiently Screening for Diagnoses

OBJECTIVE To derive and test a series of brief diagnosis-specific scales to identify subjects who are at high probability of meeting diagnostic criteria and those who may safely be spared more extensive diagnostic inquiry. METHOD Secondary data analysis of a large epidemiological data set (n = 1,286) produced a series of gate and contingent items for each diagnosis. Findings were replicated in a second retrospective analysis from a residential care sample (n = 884). The DISC Predictive Scales (DPS) were then used prospectively as a self-report questionnaire in two studies, in which parents (n = 128) and/or adolescents (n = 208) had subsequent diagnostic interviewing with the Diagnostic Interview Schedule for Children or the Schedule for Affective Disorders and Schizophrenia for School-Age Children. RESULTS All analyses showed that gate item selection was valid and that any missed cases were due solely to inconsistent reports on the same questions. Screening performance of the full scales was shown to be good, and substantial reductions in scale length were not associated with significant changes in discriminatory power. CONCLUSIONS The DPS can accurately determine subjects who can safely be spared further diagnostic inquiry in any diagnostic area. This has the potential to speed up structured diagnostic interviewing considerably. The full DPS can be used to screen accurately for cases of specific DSM-III-R disorders.

Depressive and Disruptive Disorders and Mental Health Service Utilization in Children and Adolescents

OBJECTIVE To examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents. METHOD Data were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9-17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), impairment, child need and use of mental health services, and family socioeconomic status. RESULTS After adjusting for potential confounding factors, disruptive disorder was significantly associated with childrens use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to childrens perception of mental health service need than was disruptive disorder. CONCLUSIONS The findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet childrens needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology.

OBJECTIVE A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents. METHOD Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization. RESULTS More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend. CONCLUSIONS These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Validity of DSM-IV subtypes of conduct disorder based on age of onset

OBJECTIVE To present data from the DSM-IV field trials that led to the distinction between subtypes of conduct disorder (CD) that emerge in childhood or adolescence. In addition, data from a household sample were used to attempt to cross-validate these findings. METHOD Differences between youths who met criteria for the two subtypes of CD were examined in the field trials sample of 440 youths aged 4 through 17 years and in a household sample of 1,285 youths aged 9 through 17 years. RESULTS In both samples, there was a steep decline in aggression occurring around an age of onset of 10 years, but the number of nonaggressive behaviors was unrelated to the age of onset of CD. In the field trials sample, youths who met criteria for the adolescent-onset type were more likely to be girls, less likely to meet criteria for oppositional defiant disorder, and less likely to have a family history of antisocial behavior than the childhood-onset type, but these latter findings were not confirmed in the household sample. CONCLUSIONS The DSM-IV approach to subtyping CD distinguishes subgroups that differ markedly in level of physical aggression. The advantages of a developmental approach to subtyping are discussed.

Representativeness of clinical samples of youths with mental disorders: a preliminary population-based study.

In a household community sample of 1,285, 9-17 years-olds with mental disorders who had received outpatient specialty mental health services in the past year were compared with youths with mental disorders who had not received those services to determine if samples drawn from clinical settings are representative of youths with mental disorders in the general population. Those who had used services were more impaired, less competent, more likely to have comorbid disorders, more likely to belong to non-Hispanic White relative to other ethnic groups, and less likely to be prepubertal girls. Their parents were more educated, but less satisfied with family life, engaged in less monitoring of their children, and more likely to have used mental health services themselves. These findings suggest the hypothesis that samples of youths with mental disorders drawn from outpatient clinical settings are not representative of all youths with mental disorders. If confirmed, this would indicate the importance of population-based samples for the study of psychopathology in youths.

Measurement of risk for mental disorders and competence in a psychiatric epidemiologic community survey: the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

Abstract This paper describes the implementation of the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) studys goals of measuring risk factors and competence. The emphasis is on the development and testing of the measures. Relevant constructs for measurement of risk and competence in relation to psychopathology were selected and pilot tested prior to the field trials. A structured interview was developed and field tested using lay interviewers. Using the full sample from the field trials (n = 1285 caretaker-youth pairs), sample means, standard deviations, internal consistencies, parent-youth agreement, and associations with childhood disorder were computed. Descriptive statistics reveal a range of scores and means consistent with norming samples, when available. Internal consistencies were moderate to high. Parent-youth agreement on factual items was excellent and on scales was consistent with the literature. Several strong associations were found between risk factors and disorder, although most were related to disorder in general and not specific to a diagnostic category. This instrument provides a means of obtaining data that will be useful to researchers conducting epidemiologic and clinical studies designed to contribute to the understanding of mental disorders in children and adolescents, including nosology, risk factors, context, adaptive functioning, and treatment.