Susan Shur-Fen Gau

Association between morningness-eveningness and behavioral/emotional problems among adolescents.

Adolescent eveningness is associated with age, parental monitoring, daytime sleepiness, sleep problems, moodiness, and the use of coffee. This study investigated the association between adolescent morningness-eveningness and psychopathology, substance use, and suicidality in 1332 students ages 12 to 13. Each student-participant completed the Chinese version of the Child Morningness/Eveningness Scale (CMES), the Pubertal Development Scale, and a questionnaire about their sleep schedule, trouble sleeping, habitual substance use, and suicidality. Their mothers completed the Child Behavioral Checklist and Chinese Health Questionnaire. The morning (n = 412), intermediate (n = 740), and evening (n = 180) groups were operationally defined by the CMES t scores. The mixed model was used for data analysis. The evening group had shorter weekday sleep time, longer weekend sleep time, more daytime napping, and greater sleep compensation on weekends and was more likely than the other 2 groups to have behavioral/emotional problems, suicidality, and habitual substance use. Internalizing and externalizing problems partially explained the association between eveningness, substance use, and suicidality. The findings suggest that eveningness may be an indicator for adolescents with behavioral/emotional problems and risky behaviors and suggest an investigation for possible intervention.

Executive functions as endophenotypes in ADHD: evidence from the Cambridge Neuropsychological Test Battery (CANTAB).

BACKGROUND Little is known about executive functions among unaffected siblings of children with attention deficit/hyperactivity disorder (ADHD), and there is lack of such information from non-Western countries. We examined verbal and nonverbal executive functions in adolescents with ADHD, unaffected siblings and controls to test whether executive functions could be potential endophenotypes for ADHD. METHODS We assessed 279 adolescents (age range: 11-17 years) with a childhood diagnosis of DSM-IV ADHD, 136 biological siblings (108 unaffected, 79.4%), and 173 unaffected controls by using psychiatric interviews, the Wechsler Intelligence Scale for Children - 3rd edition (WISC-III), including digit spans, and the tasks involving executive functions of the Cambridge Neuropsychological Test Automated Battery (CANTAB): Intra-dimensional/Extra-dimensional Shifts (IED), Spatial Span (SSP), Spatial Working Memory (SWM), and Stockings of Cambridge (SOC). RESULTS Compared with the controls, adolescents with ADHD and unaffected siblings had a significantly shorter backward digit span, more extra-dimensional shift errors in the IED, shorter spatial span length in the SSP, more total errors and poorer strategy use in the SWM, and fewer problems solved in the minimum number of moves and shorter initial thinking time in the SOC. The magnitudes of the differences in the SWM and SOC increased with increased task difficulties. In general, neither persistent ADHD nor comorbidity was associated with increased deficits in executive functions among adolescents with ADHD. CONCLUSIONS The lack of much difference in executive dysfunctions between unaffected siblings and ADHD adolescents suggests that executive dysfunctions may be useful cognitive endophenotypes for ADHD genetic studies.

Psychometric properties of the Chinese version of the Swanson, Nolan, and Pelham, version IV scale - parent form.

This study aimed to establish the psychometric properties of parent ratings on the Chinese version of the Swanson, Nolan, and Pelham IV scale (SNAP‐IV) in a school‐based sample of 3534 students in grades 1 to 8 from two cities and two suburbs in Taiwan and 189 children diagnosed with attention deficit/hyperactivity disorder (ADHD) (aged 6 to 15) consecutively recruited from a medical center in Taipei. Parents completed the Chinese versions of the SNAP‐IV, Strengths and Difficulties Questionnaire, and Child Behavior Checklist. The Chinese SNAP‐IV demonstrated similar three factor structure (Inattention, Hyperactivity/Impulsivity, and Oppositional) as its English version, and satisfactory test–retest reliability (intraclass correlation = 0.59∼0.72), internal consistency (alpha = 0.88∼0.90), concurrent validity (Pearson correlations = 0.56∼0.72), and discriminant validity. Boys scored higher than girls across the eight school grade levels. The SNAP‐IV clearly distinguished children with ADHD from school‐based participants. Comorbidity with oppositional defiant disorder/conduct disorder predicted higher SNAP‐IV scores among children with ADHD. Our findings suggest that the Chinese SNAP‐IV is a reliable and valid instrument for rating ADHD‐related symptoms in both clinical and community settings in Taiwan. Copyright

The initial field trials of DSM-5: New blooms and old thorns

Three articles in this issue detail the process and results of reliability tests for proposed DSM-5 diagnoses and cross-diagnosis symptom domains. The editorial highlights the good reliability of borderline personality disorder and relates the questionable reliability of major depressive disorder to its heterogeneity. The editorial is also available in Spanish, Traditional Chinese, and Simplified Chinese.

Psychiatric comorbidity among children and adolescents with and without persistent attention-deficit hyperactivity disorder

Objectives: The aims of the present study were to examine the current psychiatric comorbidity among children and adolescents with and without persistent attention-deficit hyperactivity disorder (ADHD) as compared to school controls, and to determine the factors predicting psychiatric comorbidity. Method: The sample included 296 patients (male, 85.5%), aged 11–17, who were diagnosed with DSM-IV ADHD at the mean age of 6.7 ± 2.7 years and 185 school controls. The ADHD and other psychiatric diagnoses were made based on clinical assessments and confirmed by psychiatric interviews. The ADHD group was categorized into 186 patients (62.8%) with persistent ADHD and 110 (37.2%) without persistent ADHD. Results: Compared to the controls, the two ADHD groups were more likely to have oppositional defiant disorder (ODD), conduct disorder (CD), tics, mood disorders, past and regular use of substances, substance use disorders and sleep disorders (odds ratios (ORs) = 1.8–25.3). Patients with persistent ADHD had higher risks for anxiety disorders, particularly specific phobia than the controls. Moreover, patients with persistent ADHD were more likely to have ODD than their partially remitted counterparts. Advanced analyses indicated that more severe baseline ADHD symptoms predicted ODD/CD at adolescence; longer methylphenidate treatment duration was associated with an increased risk for tics and ODD/CD at adolescence; and older age predicted higher risks for mood disorders and substance use disorders. Conclusion: Reduced ADHD symptoms at adolescence may not lead to decreased risks for psychiatric comorbidity, and identification of severe ADHD symptoms at childhood and age-specific comorbid patterns throughout the developmental stage is important to offset the long-term adverse psychiatric outcomes of ADHD.

Association of Cerebrovascular Events With Antidepressant Use: A Case-Crossover Study

OBJECTIVE The authors sought to assess the risk of cerebrovascular events associated with use of antidepressant medications. METHOD The authors conducted a case-crossover study of 24,214 patients with stroke enrolled in the National Health Insurance Research Database in Taiwan from 1998 to 2007. The authors compared the rates of antidepressant use during case and control time windows of 7, 14, and 28 days. Adjustments were made for time-dependent variables, such as health system utilization and proposed confounding medications. Stratified analyses were performed for valuing the interaction between the stroke risk of antidepressant use and age, sex, presence of mood disorder, stroke type, severity of chronic illness, and duration of antidepressant treatment. A conditional logistic regression model was used to determine the odds of antidepressant use during case time windows. RESULTS The adjusted odds ratio of stroke risk with antidepressant exposure was 1.48 (95% confidence interval=1.37-1.59) using 14-day time windows. Stroke risk was negatively associated with the number of antidepressant prescriptions reported. Use of antidepressants with high inhibition of the serotonin transporter was associated with a greater risk of stroke than use of other types of antidepressants. CONCLUSIONS These findings suggest that antidepressant use may be associated with an increased risk of stroke. However, the underlying mechanisms remain unclear.

The loss of asymmetry and reduced interhemispheric connectivity in adolescents with autism: A study using diffusion spectrum imaging tractography

Evidence from neuroimaging and neurobiological studies suggests that abnormalities in cortical-cortical connectivity involving both local and long-distance scales may be related to autism. The present study analyzed the microstructural integrity of the long-range connectivity related to social cognition and language processing with diffusion tractography among adolescents with autism compared with neurotypical adolescents. Tract-specific analyses were used to study the long-range connectivity responsible for integrating social cognition and language processing. Specifically, three pairs of association fibers and three portions of callosal fiber tracts were analyzed. Generalized fractional anisotropy (GFA) values were measured along individual targeted fiber tracts to investigate alterations in microstructure integrity. The asymmetry patterns were also assessed in three pairs of association fibers. In neurotypical participants, we found a consistent leftward asymmetry in three pairs of association fibers. However, adolescents with autism did not demonstrate such asymmetry. Moreover, adolescents with autism had significantly lower mean GFA in three callosal fiber tracts than neurotypical participants. The loss of leftward asymmetry and reduction of interhemispheric connection in adolescents with autism suggest alterations of the long-range connectivity involved in social cognition and language processing. Our results warrant further investigation by combining developmental and neurocognitive data.

Association between childhood sleep problems and perinatal factors, parental mental distress and behavioral problems

The aim of this study was to examine the effect of age, gender and perinatal risk factors on the risks for sleep problems, and investigate the relation between childhood sleep problems and childrens behavioral syndromes and parental mental distress in early and middle childhood. We recruited a representative sample of 1391 children, ages 4–9, from nine kindergartens and three elementary schools by using a multistage sampling method. Parents of child participants completed a questionnaire including perinatal risk factors, sleep habits and problems, the Child Behavior Checklist (CBCL) and the Chinese Health Questionnaire (CHQ). A mixed model was used for data analysis to address cluster effect from the same classes and schools. Results showed that boys suffered from more sleep problems than girls. Early insomnia, sleep terrors and enuresis decreased with ages, but sleepwalking increased with ages. Perinatal exposure to alcohol, coffee and non‐prescribed medication, vaginal bleeding, artificial delivery, first‐born order and higher parental CHQ score (≥4) were significantly associated with several childhood sleep problems. In addition, children with sleep problems had higher T‐scores of the eight behavioral syndromes derived from the CBCL. Our findings indicated that the childhood sleep problems were associated with perinatal risk factors, parental psychopathology and childrens behavioral problems.

Associations Between Chronotypes, Psychopathology, and Personality Among Incoming College Students

Chronotye is associated with age, sex, personality, and parental monitoring during childhood. The evening type is associated with poor school performance, sleep problems, anxious/depressive symptoms, tobacco smoking, caffeine consumption, alcohol drinking, and suicidality in adolescents. The present study tested the relationships between chronotype and a wide range of psychopathology and personality traits among 2919 incoming undergraduate students. Each participant completed a self-administered questionnaire that included demographics, plus the Morningness-Eveningness (M-E) scale, Brief Symptom Rating Scale (BSRS), Tridimensional Personality Questionnaire, and Maudesley Personality Inventory. The t-score distribution of the M-E scale was used to form the morning (t-score >60, n = 419), evening (t-score <40, n = 371), and intermediate (40 ≤ t-score ≤ 60, n = 2129) groups. Multivariable regression was employed for data analysis. For males, the evening type scored higher on all subscales of the BSRS than the morning type, except phobic anxiety. For females, the evening type had higher scores than the other two types on all subscales, except in obsession/compulsion and phobic anxiety, where the evening type only scored higher than the intermediate type. The evening type of both sexes also scored higher than the morning type in novelty seeking, harm avoidance, and neurotic personality characteristics, but lower than the morning type in extraversion and social desirability. In reward dependence, the evening type scored lowest for males, but there was no difference for females. The findings of the evening type being associated with possible psychopathology and certain types of personality have public health implications, that is, chronotype needs to be taken into account in the development of mental health prevention programs and assessment of and intervention for mental problems in young adults. (Author correspondence: gaushufe@ntu.edu.tw)

Improvement of executive functions in boys with attention deficit hyperactivity disorder: an open-label follow-up study with once-daily atomoxetine

Atomoxetine is efficacious in reducing symptoms of attention deficit hyperactivity disorder (ADHD) but its effect on executive functions needs more investigation. We examined the effect of atomoxetine on a wide range of non-verbal executive functions among 30 drug-naive male patients with DSM-IV ADHD, aged 8-16 yr, in an open-label 12-wk atomoxetine treatment trial. Before administration of atomoxetine, the participants were assessed by psychiatric interviews, the WISC-III, and the tasks involving executive functions of the Cambridge Neuropsychological Test Automated Battery (CANTAB): Intra-dimensional/Extra-dimensional Shifts (IED), Rapid Visual Information Processing (RVIP), Spatial Span (SSP), Spatial Working Memory (SWM), and Stockings of Cambridge (SOC); and reassessed at weeks 4 and 12. All the raw scores of the CANTAB were transformed to z scores based on a normative sample of 180 children aged 8-16 yr. Results showed significant improvement in executive functions after treatment with atomoxetine for 4 wk or 12 wk including improved shifting and flexibility of attention in the IED; improved spatial short-term memory in the SSP; improved sustained attention and increased response inhibition in the RVIP; improved spatial working memory in the SWM; and improved spatial planning and problem solving in the SOC. Our findings suggested that atomoxetine was associated with significant improvement in various non-verbal executive functions among boys with ADHD, in addition to its well-known efficacy in ADHD-related symptom reductions. However, owing to lack of a placebo-controlled trial design, the findings should be interpreted with caution that changes in performance may be due to practice effects.