Or Oppositional Defiant Disorder Research Articles

Neuropsychological mechanisms of social difficulties in disruptive mood dysregulation disorder versus oppositional defiant disorder

ABSTRACT Children with Disruptive Mood Dysregulation Disorder (DMDD) or Oppositional Defiant Disorder (ODD) are characterized by irritability and social difficulties. However, the mechanisms underlying these disorders could be different. This study explores differences in social cognition and executive function (EF) across DMDD and ODD and the influence of these factors and their interaction on social problems in both groups. Children with DMDD (n = 53, Mage = 9.3) or ODD (n = 39, Mage = 9.6) completed neuropsychological tasks measuring social cognition (Theory of Mind and Face-Emotion Recognition) and EF (cognitive flexibility, inhibition, and working memory). Parents reported social problems. More than one-third of the children with DMDD and almost two-thirds of those with ODD showed clear difficulties with Theory of Mind. Most children with DMDD (51–64%) or ODD (67–83%) showed difficulties with EF. In children with DMDD, worse EF (β = –.36) was associated with more social problems, whereas in children with ODD, better EF (β = .44) was associated with more social problems. In those with ODD, but not in those with DMDD, the interaction between social cognition and EF contributed to the explained variance of social problems (β = –1.97). Based on the observed interaction pattern, enhanced EF may lead to increased social problems among children with ODD who also exhibit social cognition difficulties. This study suggests the existence of distinct neuropsychological mechanisms underlying the social issues observed in children with DMDD versus those with ODD.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4–11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [–0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. Trial registrationThe study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

Parenting Behaviors as Mediators of the Association Between Parental Internalizing Symptoms and Child Externalizing Symptoms.

This study analyzes whether the association between parental internalizing symptoms (depression, anxiety, stress) and child symptoms of attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) is mediated by positive and negative parenting behaviors. Cross-sectional data of 420 parents of children (age 6-12years) with elevated levels of externalizing symptoms were collected in a randomized controlled trial. Measures included parent ratings of their internalizing symptoms and parenting behaviors and of their child's externalizing symptoms. Two mediation models were examined, one including ADHD symptoms and one including ODD symptoms as the dependent variable. Parental internalizing symptoms were modeled as the independent variable and positive and negative parenting behaviors were modeled as parallel mediators. Regression analyses support negative parenting behavior as a mediator of the association between parental internalizing symptoms and child ODD symptoms. For the ADHD model, no significant mediator could be found. Future studies should use prospective designs and consider reciprocal associations.

Sluggish Cognitive Tempo among Iranian Children and Adolescents: A Validation Study of the Farsi Child and Adolescent Behavior Inventory (CABI)-Parent Version.

Sluggish cognitive tempo (SCT), recently renamed cognitive disengagement syndrome (CDS), is a set of behavioral symptoms that includes excessive daydreaming, mental confusion and fogginess, being lost in one's thoughts, and slowed behavior and thinking. Symptoms of SCT show overlap with a broad range of other symptoms such as attention-deficit/hyperactivity disorder inattention, anxiety, and depression, or oppositional defiant disorder (ODD). To measure SCT, one of the optimal measures is the Child and Adolescent Behavior Inventory (CABI). Here, we report the psychometric properties of the Farsi version of the CABI Parent Version, including the CABI SCT scale and its subscales. The participants were the parents of 209 children and adolescents (53.9% girls; ages 8-19 years; Mage = 14.23, SDage = 2.72). Parents completed the SCT, ADHD inattention (ADHD-IN), ADHD-hyperactivity/impulsivity (ADHD-HI), oppositional defiant disorder (ODD), limited prosocial emotions (callous-unemotional (CU) traits), anxiety, depression, social impairment, and academic impairment scales of the Child and Adolescent Behavior Inventory (CABI). Parents also completed four dimensions of the Strengths and Difficulties Questionnaire (SDQ: emotional problems; conduct problems; peer problems; prosocial behavior), and five dimensions of the Kidscreen questionnaire (physical health; psychological well-being; autonomy and parental well-being; peers and social support; school environment). SCT symptoms demonstrated strong discriminant validity from the ADHD-IN symptoms. SCT showed stronger first-order and unique associations than ADHD-IN with anxiety, depression, and ODD, whereas ADHD-IN showed stronger first-order and unique associations than SCT with ADHD-HI, CU, and social and academic impairment. Further, SCT showed stronger first-order and unique associations than ADHD-IN with more emotional problems, peer problems, and with lower prosocial behavior, as assessed with the SDQ. Higher scores for SCT were associated with lower psychological well-being, autonomy and parental relations, and lower peer and social support, as assessed with the Kidscreen. Higher ADHD-IN scores were associated with lower peer and social support, and a lower school environment. The Farsi version of the CABI-Parent Version has very good psychometric properties for assessing SCT and other dimensions of psychopathology/impairment and replicates the findings from similar studies with children and adolescents from South Korea, Spain, Turkey, and the United States. Accordingly, the present study provides further support of the transcultural validity of the sluggish cognitive tempo construct.

Neuropsychological Characterization of Aggressive Behavior in Children and Adolescents with CD/ODD and Effects of Single Doses of Medications: The Protocol of the Matrics_WP6-1 Study.

Aggressive behaviors and disruptive/conduct disorders are some of the commonest reasons for referral to youth mental health services; nevertheless, the efficacy of therapeutic interventions in real-world clinical practice remains unclear. In order to define more appropriate targets for innovative pharmacological therapies for disruptive/conduct disorders, the European Commission within the Seventh Framework Programme (FP7) funded the MATRICS project (Multidisciplinary Approaches to Translational Research in Conduct Syndromes) to identify neural, genetic, and molecular factors underpinning the pathogenesis of aggression/antisocial behavior in preclinical models and clinical samples. Within the program, a multicentre case-control study, followed by a single-blind, placebo-controlled, cross-over, randomized acute single-dose medication challenge, was conducted at two Italian sites. Aggressive children and adolescents with conduct disorder (CD) or oppositional defiant disorder (ODD) were compared to the same age (10–17 y) typically developing controls (TDC) on a neuropsychological tasks battery that included both “cold” (e.g., inhibitory control, decision making) and “hot” executive functions (e.g., moral judgment, emotion processing, risk assessment). Selected autonomic measures (heart rate variability, skin conductance, salivary cortisol) were recorded before/during/after neuropsychological testing sessions. The acute response to different drugs (methylphenidate/atomoxetine, risperidone/aripiprazole, or placebo) was also examined in the ODD/CD cohort in order to identify potential neuropsychological/physiological mechanisms underlying aggression. The paper describes the protocol of the clinical MATRICS WP6-1 study, its rationale, the specific outcome measures, and their implications for a precision medicine approach.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): protocol of a feasibility and pilot study

BackgroundConduct disorder (CD) is a complex mental disorder characterized by severe rule-breaking and aggressive behavior. While studies have shown that several therapeutic interventions are effective in treating CD symptoms, researchers call for treatments based on etiological knowledge and potential patho-mechanisms. Mentalization-based treatment (MBT) may represent such a treatment approach: Studies have shown that individuals with CD show mentalizing deficits and that mentalizing might represent a protective factor against the development of the disorder. As MBT focuses on the understanding of social behavior in terms of mental states, fostering mentalizing might help CD individuals to (re)gain an adaptive way of coping with negative emotions especially in social interactions and thus reduce aggressive behavior. For this purpose, MBT was adapted for adolescents with CD (MBT-CD). This is a protocol of a feasibility and pilot study to inform the planning of a prospective RCT. The primary aim is to estimate the feasibility of an RCT based on the acceptability of the intervention and the scientific assessments by CD individuals and their families indicated by quantitative and qualitative data, as well as based on necessary organizational resources to conduct an RCT. The secondary aim is to investigate the course of symptom severity and mentalizing skills.MethodsThe bi-center study is carried out in two outpatient settings associated with university hospitals (Heidelberg and Mainz) in Germany. Adolescents aged between 11 and 18 years with a CD or oppositional defiant disorder (ODD) diagnosis are included. Participants receive MBT-CD for 6 to 12 months. The primary outcome of the feasibility study (e.g., recruitment and adherence rates) will be descriptively analyzed. Multilevel modeling will be used to investigate secondary outcome data.DiscussionFostering the capacity to mentalize social interactions triggering non-mentalized, aggressive behavior might help CD individuals to behave more adaptively. The feasibility trial is essential for gathering information on how to properly conduct MBT-CD including appropriate scientific assessments in this patient group, in order to subsequently investigate the effectiveness of MBT-CD in an RCT.Trial registrationClinicalTrials.gov, NCT02988453. November 30, 2016Sources of monetary supportDietmar Hopp Stiftung, Heidehof StiftungRecruitment statusRecruitment complete and intervention complete, follow-up assessments ongoing (Heidelberg). Recruitment and assessments ongoing (Mainz).Primary sponsor, principal investigator, and lead investigator in HeidelbergSvenja Taubner is responsible for the design and conduct of MBT-CD intervention and feasibility and pilot study, preparation of protocol and revisions, and publication of study results.Secondary sponsor and lead investigator in MainzEsther Sobanski is responsible for the recruitment and data collection in the collaborating center MainzRecruitment countryGermanyHealth condition studiedConduct disorder, oppositional defiant disorderInterventionMentalization-based treatment for conduct disorder (MBT-CD): MBT-CD is an adaptation of MBT for Borderline Personality Disorder. This manualized psychodynamic psychotherapy focuses on increasing mentalizing, i.e., the ability to understand behavior in terms of mental states, in patients. MBT-CD includes weekly individual sessions with the patient and monthly family sessions.Key inclusion and exclusion criteriaIncluded are adolescent individuals with a diagnosis of conduct disorder or oppositional defiant disorder aged between 11 and 18 years.Study typeFeasibility and pilot study (single-group)Date of first enrollment19.01.2017Study statusThe trial is currently in the follow-up assessment phase in Heidelberg and in the recruitment and treatment phase in Mainz.Primary outcomesAcceptability of MBT-CD intervention (as indicated by recruitment rates, completion rates, drop-out rates, treatment duration, oral evaluation), acceptability of scientific assessments (as indicated by adherence, missing data, oral evaluation), and necessary organizational resources (scientific personnel, recruitment networks, MBT-CD training and supervision) to estimate feasibility of an RCTSecondary outcomesAdolescents’ symptom severity and mentalizing abilityProtocol version20.08.2020, version 1.0

Cross-Cultural Validity of the Child and Adolescent Dispositions Model in a Clinical Sample of Children With Externalizing Behavior Problems.

Background: The Child and Adolescent Dispositions Scale—parent rating (CADS-P) explores three emotional dispositions that may enlarge the probability of future externalizing problem behavior. The English version has proven its psychometric quality within a population-based sample of children and adolescents. The presents study investigates the German version of the CADS-P by examining a clinically referred sample of children with externalizing behavior problems.Methods:The sample included 132 children aged 4–11 years with a diagnosis of attention- deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD). The factor structure of the CADS-P was evaluated using exploratory (EFA) and confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha). Validity was assessed through linear regression analyses, with symptoms of externalizing [conduct disorder (CD), ODD, ADHD] and internalizing behavior problems (anxiety, depression) as criterion variables and the three CADS-P factor scores as predictors.Results:After eliminating eight items due to insufficient psychometric properties, EFA and CFA supported a three-factor solution for the German CADS-P. Cronbach's alpha coefficient exceeded α = 0.70 for all subscales. Mostly, as predicted, the CADS-P dimensions were associated with symptoms of ODD/CD and ADHD and symptoms of anxiety and depression.Conclusions:The present study provides evidence for the cross-cultural validity of the CADS- P in a non-English-Speaking country. Results show that the German version of the CADS-P is a reliable and valid parent questionnaire for assessing prosociality, negative emotionality and daring as emotional dispositions that may enlarge the probability to develop externalizing problem behavior.Trial Registration: The study was approved by the review board of the Medical Faculty of the University of Cologne (ID 09-123) and was pre-registered at ClinicalTrials.gov (ID: NCT01350986).

Parental Stress of Preschool Children With Generalized Anxiety or Oppositional Defiant Disorder.

Background: Generalized anxiety and oppositional defiant disorders are among the most common psychopathological disorders in pre-school children. We investigated the symptom rate and perception of the child's disorders in parents of preschool children with generalized anxiety disorder (GAD) or oppositional defiant disorder (ODD).Methods: The parents of preschool children (mean age 54.35 months, SD ± 11.60) with ODD, GAD, or typical development (TD) filled the Symptom Check List-90-Revised (SCL-90-R) and the Child Behavior Checklist- 1½−5 (CBCL 1½ 5). Parents and children's diagnoses were determined by clinical assessment.Results: The parents of children with ODD reported a symptoms rate higher than parents of children with GAD or TD on most of the SCL-90-R (Global Severity Index of mental distress, p = 0.010; Somatization, p = 0.002; Paranoid Ideation, p < 0.000; and Phobic Anxiety scales, p = 0.030).Conclusions: On the CBCL scales, the parents of the ODD group overestimated the children's problems, while parents of children with GAD reported mainly children's emotional difficulties. Parents of children with ODD seem to be psychologically more vulnerable than parents of children with GAD. Parenting programs might be tailored considering the child's diagnosis and family functioning.

Saliva oxytocin, cortisol, and testosterone levels in adolescent boys with autism spectrum disorder, oppositional defiant disorder/conduct disorder and typically developing individuals

The aim of the current study was to compare levels of oxytocin, cortisol, and testosterone in adolescents with either autism spectrum disorder (ASD), or oppositional defiant disorder (ODD)/conduct disorder (CD), and in typically developing individuals (TDI), and relate hormone levels to severity and subtype of aggression and callous-unemotional (CU) traits. Saliva concentrations of oxytocin, cortisol, and testosterone were assessed in 114 male participants (N = 49 ASD, N = 37 ODD/CD, N = 28 TDI,) aged 12–19 years (M = 15.4 years, SD = 1.9). The ASD and the ODD/CD groups had significantly lower levels of oxytocin than the TDI group, and the ODD/CD group had significantly higher levels of testosterone than the ASD group. There were no group effects on cortisol levels. Group differences remained for oxytocin after correcting for the influence of CU traits, but were not significant after controlling for aggression. Results for testosterone became non-significant after correction for either CU traits or aggression. Across groups, higher levels of CU traits were related to higher levels of cortisol and testosterone, however, proactive and reactive aggression were unrelated to all three hormonal levels. The current findings show that, regardless of cognitive ability or comorbid disorders, the diagnostic groups (ASD, ODD/CD) differ from each other by their hormonal levels, with the ASD group characterized by relative low level of oxytocin, and the ODD/CD group by a relative low level of oxytocin and high level of testosterone. These group effects were partly driven by differences in CU traits between the groups.

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4–11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post-assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination.

The Association Between Bullying and the Psychological Functioning of Children with Autism Spectrum Disorders

Bullying has become a major national concern, particularly as it affects children with disabilities. The current study aimed to determine the association between psychiatric comorbid conditions, involvement in bullying (victim, bully, or bully-victim), and the immediate psychological correlates of bullying among children with autism spectrum disorders (ASDs). A national sample of 1221 parents completed a survey dedicated to the bullying and school experiences of their child with ASD, reporting on the immediate consequences of bullying involvement, including their child's psychological well-being and any psychiatric comorbidity. Multivariate logistic regressions were performed to determine whether specific psychiatric comorbidities were associated with an increased risk of involvement as victim, bully, or bully-victim. Analyses of variance determined the relationship between bullying frequency and psychological functioning. All models adjusted for child and school covariates. Children who were frequently victimized were more likely to present with internalizing symptoms, whereas children who frequently bullied others were more likely to exhibit emotion regulation problems. Children who were identified as frequent bully-victims presented with both internalizing symptoms and emotion regulation problems. Children with attention-deficit hyperactivity disorder (ADHD) and depression were more likely to have been victimized, whereas children with conduct disorder (CD) or oppositional defiant disorder (ODD) were more likely to have bullied other children. Children identified as bully-victims were more likely to have ADHD, CD, or ODD. Children with ASDs who had displayed bullying behaviors in the past month exhibited psychological impairments, including psychiatric comorbidity. The frequency of bullying behaviors was significantly associated with the level of impairment.

Evidence for a Multi-Dimensional Latent Structural Model of Externalizing Disorders

Strong associations between conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (SUD) seem to reflect a general vulnerability to externalizing behaviors. Recent studies have characterized this vulnerability on a continuous scale, rather than as distinct categories, suggesting that the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) take into account the underlying continuum of externalizing behaviors. However, most of this research has not included measures of disorders that appear in childhood [e.g., attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD)], nor has it considered the full range of possibilities for the latent structure of externalizing behaviors, particularly factor mixture models, which allow for a latent factor to have both continuous and categorical dimensions. Finally, the majority of prior studies have not tested multidimensional models. Using lifetime diagnoses of externalizing disorders from participants in the Fast Track Project (n = 715), we analyzed a series of latent variable models ranging from fully continuous factor models to fully categorical mixture models. Continuous models provided the best fit to the observed data and also suggested that a two-factor model of externalizing behavior, defined as (1) ODD+ADHD+CD and (2) SUD with adult antisocial behavior sharing common variance with both factors, was necessary to explain the covariation in externalizing disorders. The two-factor model of externalizing behavior was then replicated using a nationally representative sample drawn from the National Comorbidity Survey-Replication data (n = 5,692). These results have important implications for the conceptualization of externalizing disorders in DSM-5.

Symptom Dimensions of Disruptive Behavior Disorders in Adolescent Drivers

Objective: Adolescents with disruptive behavior disorder, including ADHD, are more likely to engage in risky driving practices and, consequently, are more likely to be involved in a motor vehicle crash (MVC) than their non-ADHD peers. It is unclear whether symptoms of inattention, hyperactivity/impulsivity, or oppositional defiant disorder (ODD) increase risk of poor driving outcomes. Method: A total of 41 participants (16-19 years old) reported their ADHD and ODD symptoms and risky driving practices (errors and violations). History of citations and MVCs were acquired from state records. Relative predictive utility of symptom dimensions was assessed using multiple regressions. Results: Inattention solely predicted driving variables of interest: Greater levels of inattention were predictive of more citations, MVCs, and self-reported errors and violations. Conclusion: Findings suggest that symptoms of inattention play a primary role in driving-related problems among adolescents. Implications for future research and practice are discussed.

The Dopamine Receptor D4 Gene (DRD4) Moderates Family Environmental Effects on ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a prime candidate for exploration of gene-by-environment interaction (i.e., G x E), particularly in relation to dopamine system genes, due to strong evidence that dopamine systems are dysregulated in the disorder. Using a G x E design, we examined whether the DRD4 promoter 120-bp tandem repeat polymorphism, previously associated with ADHD, moderated the effects of inconsistent parenting and marital conflict on ADHD or Oppositional-Defiant Disorder (ODD). Participants were 548 children with ADHD and non-ADHD comparison children and their parents. Homozygosity for the DRD4 promoter 120-bp tandem repeat insertion allele increased vulnerability for ADHD and ODD only in the presence of inconsistent parenting and appeared to increase susceptibility to the influence of increased child self-blame for marital conflict on ADHD inattention. DRD4 genotypes may interact with these proximal family environmental risk factors by increasing the individual's responsivity to environmental contingencies.

The Enrichment Study of the Minnesota Twin Family Study: Increasing the Yield of Twin Families at High Risk for Externalizing Psychopathology

The Enrichment Study (ES) was designed to extend the Minnesota Twin Family Study (MTFS) by oversampling 11-year-old twins at especially high risk for substance use disorders by virtue of having a childhood disruptive disorder. The sample was ascertained from Minnesota birth records. To identify high-risk twins, we conducted telephone screening interviews for parent-reported symptoms of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) as well as indications of academic disengagement. Twins who exceeded a predetermined threshold were invited to participate. To facilitate comparison with the previously ascertained MTFS participants, a random sample of 11-year-old twins was also recruited. As part of the ES study, 499 twin pairs, and their parents, visited the University of Minnesota, where each participant completed a clinical interview, psychophysiological evaluation, and thorough assessment of environmental risk. We were highly successful in recruiting at-risk twins; 52% of the screened male twins and 41% of the screened females met criteria for a diagnosis of ADHD, CD, or oppositional defiant disorder (ODD). At the pair level, 63% of the screened pairs had at least one member with a childhood disruptive disorder. This article provides an overview of the study design and includes a review of recent findings using this sample of twins.

Relationship between atomoxetine plasma concentration, treatment response and tolerability in attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder

The purpose of this study was to examine whether atomoxetine plasma concentration predicts attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) response. This post-hoc analysis assessed the relationship between atomoxetine plasma concentration and ADHD and ODD symptoms in patients (with ADHD and comorbid ODD) aged 6–12 years. Patients were randomly assigned to atomoxetine 1.2 mg/kg/day (n = 156) or placebo (n = 70) for 8 weeks (Study Period II). At the end of 8 weeks, ODD non-remitters (score >9 on the SNAP-IV ODD subscale and CGI-I > 2) with atomoxetine plasma concentration <800 ng/ml at 2 weeks were re-randomized to either atomoxetine 1.2 mg/kg/day or 2.4 mg/kg/day for an additional 4 weeks (Study Period III). ODD remitters and non-remitters with plasma atomoxetine ≥800 ng/ml remained on 1.2 mg/kg/day atomoxetine for 4 weeks. Patients who received atomoxetine, completed Study Period II, and entered Study Period III were included in these analyses. All the groups demonstrated improvement on the SNAP-IV ODD and ADHD-combined subscales (P < .001). At the end of Study Periods II and III, ODD and ADHD improvement was significantly greater in the remitter group compared with the non-remitter groups. Symptom improvement was numerically greater in the non-remitter (2.4 mg/kg/day compared with the non-remitter 1.2 mg/kg/day) group. Atomoxetine plasma concentration was not indicative of ODD and ADHD improvement after 12 weeks of treatment. ADHD and ODD symptoms improved in all the groups with longer duration on atomoxetine. Results suggest atomoxetine plasma concentration does not predict ODD and ADHD symptom improvement. However, a higher atomoxetine dose may benefit some patients.

Behavioral Parent Training as an Adjunct to Routine Care in Children with Attention-Deficit/Hyperactivity Disorder: Moderators of Treatment Response

To investigate predictors and moderators of outcome of behavioral parent training (BPT) as adjunct to ongoing routine clinical care (RCC), versus RCC alone. We randomly assigned 94 referred children (4-12 years) with attention-deficit/hyperactivity disorder (ADHD) to BPT plus RCC or RCC alone. Outcome was based on parent-reported behavioral problems and ADHD symptoms. Predictor/moderator variables included children's IQ, age, and comorbidity profile, and maternal ADHD, depression, and parenting self-efficacy. Superior BPT treatment effects on behavioral problems and ADHD symptoms were present in children with no or single-type comorbidity-anxiety/depression or oppositional defiant disorder (ODD)/conduct disorder (CD)-and when mothers had high parenting self-efficacy, but absent in children with broad comorbidity (anxiety/depression and ODD/CD) and when mothers had low parenting self-efficacy. In older children ADHD symptoms tended to decrease more through BPT than in younger children. Adjunctive BPT is most useful when mothers have high parenting self-efficacy and in children with no or single-type comorbidity.

Preschool parent-pediatrician consultations and predictive referral patterns for problematic behaviors.

The present study examined parents' reports of the frequency, nature, and outcome of pediatrician consultation and interventions about significant preschool behavior problems. Parents were asked whether they consulted with their pediatric providers about disruptive behavioral problems during a longitudinal study of preschool children. Eighty 4-year-old children had parents who had consulted with their pediatricians versus 90 children whose parents did not. Children who eventually met criteria for attention-deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) 2 years later, received different pediatric interventions at age 4 years than children who did not have a diagnosis, chi (2) = 9.28, based on parent report. Eighty-nine percent of children who were referred for evaluation or treatment by pediatricians later met criteria for ADHD or ODD. However, 56% of children who later met criteria for ADHD or ODD were not referred by age 4 years. Pediatricians were able to differentiate between preschool children with transient versus persistent behavioral problems significantly better than chance, though a large number of children with behavioral problems were not provided with early assistance or referrals. Additional research is needed to obtain data directly from pediatricians about their interventions and resources for this vulnerable population.

Parent-child interaction therapy: An examination of cost-effectiveness.

In regard to mental health impairment, disruptive behavior has been found to be the most frequent cause of child outpatient or inpatient referral (Wells & Forehand, 1985) and is estimated to affect up to 23% of children (O'Brien, 1996). In addition to an especially poor prognosis, the societal cost of children with disruptive behavior disorders (DBD) is great. Estimates indicate that a child with severe behavioral problems is about ten times more expensive than a child without such problems (Scott, Knapp, Henderson, & Maughan, 2001). Given the potential monetary benefits of early among this population, as well as the intangible gains associated with improved behavior and a safer community, it is advantageous to explore DBD treatments that are efficacious and financially prudent. The current paper sets out to evaluate the cost-effectiveness of Parent-Child Interaction Therapy (PCIT; Eyberg, Boggs, & Algina, 1995; Hembree-Kigin & McNeil, 1995), an empirically supported treatment for child DBD, and in doing so, assess the anticipated financial costs and behavior improvements associated with its implementation and practice. First, we will review the extant literature and examine the implications, financial and otherwise, of untreated DBD. Next, we introduce PCIT and demonstrate the empirical support for the use of PCIT for children with DBD. Following such an introduction, we commence with an analysis of the costs and anticipated behavior changes associated with the use of PCIT on a per-child basis. Additionally, we discuss the startup costs necessary for implementing PCIT. Lastly, we conclude with a discussion of the implications of the results and suggest future directions for research in this area. We hope that this paper will encourage the use of PCIT in new settings, including both community and university clinics. Particularly when considering the exuberant costs of DBD, PCIT may be an attractive option to clinicians and policymakers if it is demonstrated to be a cost-effective treatment. The class of externalizing behaviors referred to as DBD is generally typified by aggressive, defiant, and impulsive behaviors which are commonly diagnosed as either Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD). CD is characterized by aggression, theft, destruction of property, and defiance of societal norms. ODD is defined as a persistent pattern of behavior which includes arguing, disobedience of adult requests, and anger. All, by definition, lead to clinically significant impairment in the academic, interpersonal, and/or occupational domains (American Psychiatric Association, 2000). Additionally, these disorders are typically present early in life and can be recognized in children as as two years of age (Muntz, Hutchings, Edwards, Hounsome, & O'Celleachair, 2004). Among the numerous biological and situational correlates for the development of DBD, some of the strongest data indicate that family factors greatly contribute to child behavior. Indeed, among others, parental depression (Querido, Eyberg, & Boggs, 2001), reports of parental stress (Eyberg, Boggs, & Rodriguez, 1992), and parent-child interactions (Olson, Bates, & Bayles, 1990) have all been demonstrated to be associated with the display of child disruptive behavior. Indeed, research on this population indicates that parent-child interactions are one of the strongest determinants of the development of childhood behavior problems (Campbell, 1997; Patterson, 1982). Given the severity of these behaviors, there is a strong need for effective and early interventions. McNeil, Capage, Bahl, and Blanc (1999) reported that young children with severe behavior problems do not immediately 'outgrow' their disruptive behaviors without intervention (p. 451). Such a statement is not hyperbole as early-onset disruptive behavior is indicative of an especially poor prognosis (McMahon & Wells, 1998). …

The Efficacy and Tolerability of Quetiapine versus Divalproex for the Treatment of Impulsivity and Reactive Aggression in Adolescents with Co-Occurring Bipolar Disorder and Disruptive Behavior Disorder(s)

The aim of this study was to compare the efficacy and tolerability of quetiapine and divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorders. Patients were included in this post hoc analysis if they scored > or = 14 on the Positive and Negative Syndrome Scale (PANSS) Excited Component (EC) and > or = 4 on at least one of the PANSS EC items, had a current diagnosis of bipolar I disorder, manic or mixed episode, and had a lifetime and/or current diagnosis of a disruptive behavioral disorder (DBD) [conduct disorder (CD) or oppositional defiant disorder (ODD)]. Thirty-three (92%) of the 36 subjects with bipolar disorder and DBD met the PANSS EC inclusion criteria. These thirty-three adolescents were randomized to quetiapine (400-600 mg/day) or divalproex (serum level 80-120 microg/mL) for 28 days in this double-blinded study. The primary efficacy measure was change in PANSS Excited Component (EC) score over the study period and at each time point. Repeated measures analysis of variance (ANOVA) demonstrated statistically significant within-treatment-group effects for divalproex (baseline = 20.6, end point = 13.3, p < 0.0001) and quetiapine (baseline = 18.8, end point = 10.8, p < 0.0001) for the PANSS EC. There were no statistically significant treatment group differences in PANSS EC changes from baseline to end point scores (p = 0.7, d = 0.14). Mixed regression analyses (comparison of slopes, DAY*TREATMENT) revealed that there was no significant difference in the rate of improvement in the PANSS EC scores between the two treatment groups [F(1,31) = 0.78, p = 0.39, d = 0.28]. Quetiapine and divalproex showed similar efficacy for the treatment of impulsivity and reactive aggression related to co-occurring bipolar and disruptive behavior disorders in adolescents. Quetiapine and divalproex are both useful as monotherapy for the treatment of impulsivity and reactive aggression in adolescents with bipolar and disruptive behavior disorders. Placebo-controlled studies are necessary.