Psychiatric Symptomology Research Articles

Prevalence and comorbidity of psychiatric symptomology in Pakistani female adolescents

Abstract Background Previous researchers have demonstrated the co-existence of psychiatric conditions across clinical as well as non-clinical samples in diverse situations. The present study examined the prevalence and co-morbidity of various psychiatric symptoms (e.g. learning disabilities, depression and anxiety) in school-age female adolescents. Methods In a cross-sectional random sampling method, 252 girls from two government schools in Lahore were assessed by Learning Disabilities Checklist, Children Depression Inventory and the Spence Anxiety Scale. Results The results demonstrate significant prevalence and co-morbidity of psychiatric symptoms. Of the 252 participants, 34%, 21% and 68% had significant learning disabilities, depression and anxiety symptoms respectively. In addition, 27% of them presented symptoms of three studied psychiatric conditions. A highly significant positive correlation was found between learning disabilities, depression and anxiety symptoms. Methods There is a dire need for preventative intervention programs to promote mental health at school level. Further, assessment plans for the screening of psychiatric symptoms in normative samples also need to be put in place.

Enhancing empathy and positive attitude among nursing undergraduates via an in-class virtual reality-based simulation relating to mental illness

Objective: The study aims to examine the impact of virtual reality simulation that simulates the experience of psychiatric symptomology associated with mental illness in mental health nursing education.Methods: A total of 159 nursing students being exposed to an in-class VR simulation completed pre-test measures about empathy and positive attitudes towards mental illness. Narrative feedback was collected to explore the students' perceptions of the VR simulation. Results: The results indicated a significant increase in the overall empathy and positive attitudes towards mental illness after participating in the in-class VR simulation related to mental illness. Students had a clearer understanding of the patient's experience and difficulties from VR simulation.Conclusions: In-class VR simulation may play a significant role in enhancing empathetic understanding and positive attitudes towards individuals diagnosed with mental illness.

Interpersonal vs. Non-Interpersonal Cumulative Traumas and Psychiatric Symptoms in Treatment-Seeking Incarcerated Women

ABSTRACT Incarcerated women are at elevated risk of lifetime trauma exposure. Prevalence rates of trauma exposure and how these events relate to specific domains of psychiatric symptomology among this group are lacking. This study hypothesized a greater range of diverse cumulative trauma experiences (CTEs) would be positively associated with psychiatric symptoms in general (depression, PTSD, distress tolerance), but that interpersonal CTEs in particular would be uniquely associated with greater symptoms of guilt and shame. A total of 112 women (87% White, Mage = 34 years) seeking treatment for a history of sexual violence victimization participated in the study. Women incarcerated for nonviolent offenses at two minimum-security prisons completed self-report measures of exposure to diverse traumatic events and internalizing symptoms. On average, participants reported a history of experiencing 5.46 traumatic event types. Total CTEs was significantly associated with all psychiatric variables in the expected direction. While both interpersonal and non-interpersonal CTEs were positively associated with levels of PTSD, depression, and distress intolerance, only interpersonal CTEs were significantly associated with guilt and shame. Traumatic experiences that are interpersonal in nature may confer specific risk for psychiatric symptoms in victims.

Prevalence and comorbidity of psychiatric symptomology in Pakistani female adolescents

Prevalence and comorbidity of psychiatric symptomology in Pakistani female adolescents

The Child Outcome Rating Scale: validating a four-item measure of psychosocial functioning in community and clinic samples of children aged 10-15.

Psychosocial functioning is considered an important and valued outcome in relation to young people's mental health as a construct distinct from psychiatric symptomology, especially in the light of an increasing focus on transdiagnostic approaches. Yet, the level of psychosocial functioning is rarely directly asked of young people themselves, despite the widespread recognition that the young person's perspective is valuable andis often at odds with those of other reporters, such as parents or professionals. One possible reason for this is that the field lacks a clear agreed tool to capture this information in a non-burdensome way. To begin to address this gap, this paper describes psychometric analysis of the Child Outcome Rating Scale (CORS), a brief and highly accessible self-report measure of young people's psychosocial functioning already used extensively by mental health professionals around the world but with only limited data on psychometric robustness. Using large community (n = 7822) and clinic (n = 2604) samples, we explore the factor structure, construct validity, internal consistency, differential item functioning, and sensitivity of the CORS. We found that the CORS stands up to psychometric scrutiny, having found satisfactory levels of reliability, validity, and sensitivity in this sample. We also found that the CORS is suitable for use with young people as old as 15years old. That the CORS has been found to be psychometrically robust while being highly feasible (brief, simple, easy to administer) for use in busy clinical settings, combined with the fact that the CORS has already been widely adopted by clinicians and young people, suggests CORS may be an important tool for international use.

The Correlates of Sleep Disturbance in Symptomatic Youth

Background: Sleep disturbances are common across many mental health disorders, with evidence suggesting a bidirectional relationship. Furthermore, there is evidence of a significant association between sleep disruption and worse symptomology in disorders such as anxiety, depression, and psychosis. Additionally, research has demonstrated the negative impact of stress and stressful life events on psychiatric illness progression. However, little is known about possible links between sleep disturbance and these psychiatric symptoms, ongoing stress, stressful life events and functioning, especially in adolescence and early adulthood, a time when many mental illnesses first begin. Exploring these relationships may allow for a better understanding of the role sleep disruption plays in the early stages of illness. Objective: The objective of this study is to investigate potential correlates of sleep disturbance in youth experiencing subthreshold psychiatric symptoms. Methods: This study included 160 youth, ages 12 to 25 who were help seeking due to experiencing distress, mild symptoms of anxiety or depression, and/or attenuated syndromes such as clinical high risk for psychosis. Youth meeting criteria for full psychiatric diagnoses were excluded. The Pittsburgh Sleep Quality Index was used to assess sleep disruption. A range of clinical symptoms were assessed using the Scale for Assessment of Psychosis-Risk Symptoms, The Calgary Depression Scale for Schizophrenia and the Generalized Anxiety Disorder 7-Item Scale. Current stress was assessed with the Daily Stress Inventory, and the K10 Distress Scale. Past history of major stress was measured with a Childhood Trauma and Abuse Scale, and the Life Events scale. Fourthly, functioning was assessed with the Global Functioning Scale: Social and Role. Results: Global sleep quality was most highly realted to subthreshold symptoms of anxiety (r=0.425, p<0.01), depression (r=0.420, p<0.01), and disorganized symptoms of psychosis (r=0.232, p<0.05). Additionally, global sleep was related to total distress (r=0.356, p<0.01), daily stress (r=0.268, p<0.01), and stressful life events (r=0.291, p<0.01). Social functioning did not reveal any significant correlations with sleep, however, role functioning (r=0.170, p<0.05) did exhibit a relationship with global sleep quality. Finally, bullying (r=0.196, p<0.05) and trauma (r=0.266, p<0.01) were significantly correlated with global sleep quality scores. Conclusion: This study provides early evidence for the interaction that sleep disruption may have with stress, trauma, bullying, and subthreshold psychiatric symptomology in youth. Further research is required to increase the understanding of these relationships early on in youth psychiatric illness progression.

Therapeutic Outcomes of Changing Lives and Changing Outcomes for Male and Female Justice Involved Persons with Mental Illness

Changing Lives and Changing Outcomes (CLCO) was developed to address the unique treatment needs of individuals with co-occurring mental illness and criminogenic risk. Previous evaluations of CLCO demonstrated effectiveness for male participants, but did not examine treatment effectiveness across participant sex. Therefore, the aim of this study was to examine differences in treatment outcomes among male and female probationers receiving CLCO. Participants were assessed pre- and posttreatment. Results indicated positive treatment effects across both psychiatric and criminogenic domains, including psychiatric symptomology and global mental health functioning, medication adherence, attitudes toward mental illness recovery, and antisocial cognitions. Female participants demonstrated enhanced treatment responsiveness relative to males across several domains. This study underscores the effectiveness of the program in addressing both mental health and criminogenic needs in correctional populations, while highlighting the differential impact of the program across participant sex. Implications, future directions, and limitations of the present study are discussed.

A Pilot Study Evaluating a School-Based, Trauma-Focused Intervention for Immigrant and Refugee Youth

Immigrant and refugee children often experience stressful or traumatic events that greatly impact their ability to function in school. The dysregulatory and somatic symptoms of trauma such as hyper-arousal and dissociation as well as co-morbid anxiety and depression can have a profound impact on academic and social functioning. Addressing these symptoms requires approaches that help children develop the ability to calm their bodies and achieve a state of emotional regulation and brain-body integration. This pilot study examined the effectiveness of a school-based somatic soothing intervention designed to help children manage dissociative and dysregulatory symptoms. A convenience sample of 34 mostly refugee and immigrant youth who struggled with these symptoms were recruited for this study. The children were between the ages of 6 and 11 and reported experiencing war, interpersonal violence and neglect as well as stressors associated with migration, displacement, and resettlement. Participants in this study scored highly on baseline measures for post-traumatic stress disorder, depression, and anxiety indicating a high amount of comorbid psychiatric symptomology. Participants reported statistically significant improvement in anxiety, depression, psychological functioning, and trauma symptomology post-intervention with medium to large effect sizes ranging from .46 to 1.08. Qualitative results from teacher reports indicated strides in confidence, communication, academic functioning and social interaction for most participants. The positive associational findings suggest that this intervention may hold promise and warrants further investigation using more rigorous designs.

Gambling-Related Cognitive Distortions in Residential Treatment for Gambling Disorder.

Gambling-related cognitive distortions are associated with gambling disorder severity, but few studies have provided an in-depth examination of the interrelationship between cognitive distortions, gambling severity, psychiatric comorbidity and treatment outcomes. The present study sought to identify factors associated with elevated cognitive distortions among problem gamblers entering residential treatment, examine changes in cognitive distortions through treatment, and explore the association between cognitive distortions and treatment outcomes. Pre- and post-treatment data were extracted from the charts of 125 individuals who participated in a 21-day residential treatment program for gambling disorder. Assessments included measures of demographics, gambling disorder severity, psychiatric symptoms and gambling-related cognitive distortions. Several significant associations were found between baseline cognitive distortions and psychiatric symptoms. Cognitive distortions decreased significantly from pre- to post-treatment. Pre- to post-treatment changes on several cognitive distortion scales were positively associated with greater baseline psychiatric symptomology. Treatment drop-out was associated with higher scores on measures reflecting greater impulsivity/addiction and greater perceived predictive control. Gambling-related cognitive distortions represent an important mechanism of gambling disorder and its treatment and provide a target for the development and refinement of treatment for gambling disorder.

Racial/Ethnic Discrimination and Suicidal Ideation in Emerging Adults: The Role of Traumatic Stress and Depressive Symptoms Varies by Gender not Race/Ethnicity

Drawing from Race-Based Traumatic Stress theory, the present study examined whether traumatic stress and depressive symptoms differentially help explain the relation between racial/ethnic discrimination and suicidal ideation across gender and racial/ethnic groups. A racially/ethnically diverse group of emerging adults (N = 1344; Mage = 19.88, SD = 2.25; 72% female; 46% Hispanic) completed a battery of self-report measures. A cross-sectional design was employed with a series of hierarchical linear regression models and bootstrapping procedures to examine the direct and indirect relation between racial/ethnic discrimination and suicidal ideation through traumatic stress and depressive symptoms across gender and race/ethnicity. The findings suggest an indirect relation through depressive symptoms, but not traumatic stress, and a serial indirect relation through traumatic stress to depressive symptoms in young women and young men, the latter of which was stronger in young women. The indirect relations did not vary by racial/ethnic group. Cumulative experiences of racial/ethnic discrimination may impact suicide-related risk via increases in psychiatric symptomology (i.e., traumatic stress and depressive symptoms), particularly in young women. Racial/ethnic discrimination experiences should be accounted for as a potential source of psychological distress in the assessment, diagnosis, and treatment of suicidal thoughts and behavior, especially among young women endorsing traumatic stress and depressive symptoms. Further research is warranted to better understand the gender difference in the relation between racial/ethnic discrimination and suicide-related risk.

Mental health and imprisonment: Measuring cross-cutting symptoms among convicts in Punjab, Pakistan.

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult (APA, 2013) is a self-reported instrument to measure comorbidity of psychiatric symptomology. Translation and validation of this instrument contribute to the literature, both in terms of its availability in native language Urdu and its usefulness in the prison settings of Pakistan. The purpose of the present study is to translate DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult (APA, 2013) and to measure comorbid psychiatric symptomology among convicted criminals of Central Jail Bahawalpur (CJB) and Central Jail Sahiwal (CJS). Cross-sectional design was used and guideline proposed by Mapi Institute (Acquadro et al., 2012) was used for the translation and adaptation process. Data were collected from 362 imprisoned convicts. For construct validity, Confirmatory Factor Analysis (CFA) was done by taking domains as continuous variables. The analysis was conducted using AMOS. Cross-tabulation analysis was conducted to see the association of comorbid psychiatric symptomology with respect to crime-related variables by using SPSS. Goodness of fit showed that the translated version of the instrument has a satisfactory to good construct validity. For domains with more than one items, Guttmann and Alpha reliability analysis showed satisfactory reliability of domains (.52-.71) and Alpha reliability of .89 for the overall instrument. Sleep disturbance and anger related symptoms showed a high prevalence in the current sample. Current and previous crime-related variables do associate significantly with comorbid psychiatric symptomology.

Decreased functional brain response to emotional arousal and increased psychiatric symptomology in FMR1 premutation carriers

The FMR1 premutation is an expansion of the CGG repeat island in the FMR1 gene to between 55 and 200 repeats. Evidence suggests that as well as conferring risk for neurodegeneration, the premutation is also associated with increased risk for autistic traits and psychiatric symptoms. An emotional processing fMRI task was used to examine the response to a change in emotional arousal in 17 male carriers and 17 matched controls. A psychiatric symptom checklist (SCL-90-R), autism spectrum and empathy quotients (AQ and EQ), and the Ekman Faces Test were used to investigate clinical symptoms and emotional processing. Carriers exhibited significantly lower activation compared to controls at the bilateral superior parietal lobe, bilateral Brodmann Area (BA) 17 (V1), right intraparietal area and right BA18 (V2) when comparing high and low arousal conditions. Group by age analyses were not significant. Assessments revealed that carriers displayed significantly worse symptoms of psychiatric symptoms and higher levels of autistic traits, as well as impaired facial emotion recognition. No measurements revealed an association with age. Here, we show significantly altered emotional processing in carriers which display stability over age, suggesting that, unlike degenerative aspects, emotional symptoms may be consistent over the lifespan in carriers.

Problematic Pornography Use and Physical and Sexual Intimate Partner Violence Perpetration Among Men in Batterer Intervention Programs.

Recent decades witnessed a surge in pornography use, contributing to what some researchers referred to as problematic pornography use (PPU; excessive, compulsive, and uncontrollable pornography use). Informed by cognitive scripts theory, cross-sectional, longitudinal, and experimental research spanning several decades documented a positive association between men's pornography use and physical and sexual violence perpetration. However, there is a paucity of research investigating pornography use broadly, and PPU specifically, among men who perpetrate intimate partner violence (IPV). The present cross-sectional study investigated the association between self-reported PPU and physical and sexual IPV perpetration among 273 men in batterer intervention programs. After accounting for psychiatric symptomology and substance use and problems, results revealed a positive association between PPU and both physical and sexual IPV perpetration. Findings highlighted the need for continued investigation of the function of pornography use for violent men, particularly as it relates to physical and sexual IPV perpetration.

Linking the Medical and Educational Home to Support Children With Autism Spectrum Disorder: Practice Recommendations.

Children with autism spectrum disorder (ASD) present with complex medical problems that are often exacerbated by a range of other intellectual and psychiatric comorbidities. These children receive care for their physical and mental health from a range of providers within numerous child-serving systems, including their primary care clinic, school, and the home and community. Given the longitudinal nature in which care is provided for this chronic disorder, it is particularly necessary for services and providers to coordinate their care to ensure optimal efficiency and effectiveness. There are 2 primary venues that serve as a "home" for coordination of service provision for children with ASD and their families-the "medical home" and the "educational home." Unfortunately, these venues often function independently from the other. Furthermore, there are limited guidelines demonstrating methods through which pediatricians and other primary care providers (PCPs) can coordinate care with schools and school-based providers. The purpose of this article is 2-fold: (1) we highlight the provision of evidence-based care within the medical home and educational home and (2) we offer practice recommendations for PCPs in integrating these systems to optimally address the complex medical, intellectual, and psychiatric symptomology affected by autism.

T47. IS THERE A DIURNAL VARIATION IN PSYCHIATRIC SYMPTOMS IN SCHIZOPHRENIA?

BackgroundAnecdotally we have observed subgroups of schizophrenic patients who experienced a diurnal variation in a wide range of psychiatric symptomology. Such a pattern could have substantial ramifications in both clinical care and clinical trials. For example, two commonly used measures of symptom severity in clinical trials, the Positive and Negative Symptom Scale (PANSS) and the Negative Symptom Assessment Scale (NSA-16) contain numerous items that are rated based entirely or in part on observations of the subject during the interview. We hypothesized that inconsistency in the time of day of assessment in subjects whose symptoms were influenced by circadian rhythms could introduce an erratic “noise” element in the longitudinal measure of their symptoms.To investigate this hypothesis we compared the change in PANSS total score and individual PANSS items across consecutive visits by whether the assessments had been conducted at consistent vs. inconsistent times of day.Methods2109 individual subject visits from multiple schizophrenia clinical trials for which PANSS interview start time was available were included in the analysis. 1,764 pairs of consecutive PANSS interviews within individual subjects were identified and the time difference between the start times of the interviews were calculated. The absolute time difference was divided into quartiles and the first quartile (assessments least disparate in time) and the fourth quartile (assessments most disparate in time) were compared in the analyses. The mean absolute change in PANSS total and PANSS individual items between the consecutive visits was compared between the 2 groups using a t-test. Given the exploratory and hypothesis driven nature of the analysis we did not correct for multiple comparisons.ResultsThe average absolute difference in interview start times was 79.5 minutes. The group with assessments closest in time (N = 446) had their interviews start no later than 30 minutes apart while the group with assessments most disparate in time (N = 445) had their interview start with at least 170 minutes difference. Of the 30 PANSS items, items P4 (Excitement 0.33 vs. 0.44, p =0.0077), P7 (Hostility 0.31 vs. 0.47, p < 0.001), N5 (Difficulty in abstract thinking 0.28 vs. 0.35, p = 0.043), N7 (Stereotyped thinking0.26 vs. 0.35, p = 0.021) G1 (Somatic concern 0.34. vs. 0.43, p = 0.041), G2 (Anxiety 0.42 vs. 0.53, p = 0.019), G6 (Depression 0.38 vs.0.52, p = 0.0044), G7 (Motor retardation 0.28 vs. 0.37, p = 0.025), and G8 (Uncooperativeness 0.29 vs. 0.39, p = 0.02) had an absolute difference significantly higher in the disparate group than in the close group. The mean absolute difference in the PANSS total was 5.1(+/-5.8) in the close group and 5.9(+/-5.4) in the disparate group, (p = 0.08).DiscussionThe results demonstrate a statistically significant effect of variation in time of day on symptom severity. These findings underscore the risk of potential noise (erratic changes) in longitudinal assessment of symptom severity when ratings are done at different times of day. Moreover, it suggests that symptom severity assessed in a standard PANSS interview may not generalize over the entire day, much less over the standard one week rating period. This is important because many PANSS items are rated partially or entirely on the interview which may not be a representative “biopsy” of the subject’s mental state or behavior during the one week rating period. This highlights the potential remedies of more frequent or ecological measurements.Hufford et al (2014) demonstrated a statistically significant effect of variation in the time of day on signal from the MCCB cognitive battery. Our results confirm our anecdotal observations that severity of non-cognitive schizophrenic symptoms are impacted by circadian rhythms as well.

Factors Associated With Staff Engagement in Patients’ Tobacco Treatment in a State Psychiatric Facility

Persons with mental illnesses (MI) who use tobacco are likely to experience poorer physical health and worsened psychiatric symptomology as compared to their non-tobacco-using counterparts. Therefore, engaging them in treatment is an important aspect of evidence-based care. To use the theory of planned behavior to examine factors associated with intentions to provide and the provision of evidence-based tobacco treatment. This study is based on a cross-sectional analysis of survey data from 195 staff at a state psychiatric hospital. When controlling for demographic variables, attitudes, subjective norms, and perceived behavioral control toward providing tobacco treatment were associated with intentions to provide tobacco treatment, but only subjective norms and perceived behavioral control were associated with reported provision of evidence-based tobacco treatment. Understanding factors that influence provider delivery of tobacco treatment can better determine strategies to reduce the disproportionate tobacco use and related illnesses in behavioral health settings.

Cannabis use in early adolescence: Evidence of amygdala hypersensitivity to signals of threat

Cannabis use in adolescence may be characterized by differences in the neural basis of affective processing. In this study, we used an fMRI affective face processing task to compare a large group (n=70) of 14-year olds with a history of cannabis use to a group (n=70) of never-using controls matched on numerous characteristics including IQ, SES, alcohol and cigarette use. The task contained short movies displaying angry and neutral faces. Results indicated that cannabis users had greater reactivity in the bilateral amygdalae to angry faces than neutral faces, an effect that was not observed in their abstinent peers. In contrast, activity levels in the cannabis users in cortical areas including the right temporal-parietal junction and bilateral dorsolateral prefrontal cortex did not discriminate between the two face conditions, but did differ in controls. Results did not change after excluding subjects with any psychiatric symptomology. Given the high density of cannabinoid receptors in the amygdala, our findings suggest cannabis use in early adolescence is associated with hypersensitivity to signals of threat. Hypersensitivity to negative affect in adolescence may place the subject at-risk for mood disorders in adulthood.

The impact of childhood gender expression on childhood sexual abuse and psychopathology among young men who have sex with men

Young men who have sex with men (MSM) are a risk group highly vulnerable to HIV infection and psychiatric symptoms are direct predictors of sexual risk behavior in MSM. Childhood sexual abuse (CSA) is associated with psychiatric symptomology in adolescence, and MSM are disproportionately impacted by CSA compared to heterosexuals. Some evidence suggests that childhood gender nonconformity, a natural variation of human gender expression, is more common in MSM than heterosexual males and places MSM at greater risk for CSA. This study examined whether or not childhood gender expression moderated the association between incidents of unwanted, early sexual experiences occurring before age 13 (ESE) and current psychiatric symptomology in a community-based sample of 449 young MSM aged 16–20. Analyses revealed significant bivariate associations between ESE and psychological symptoms, and significant multivariable associations between ESE, gender nonconformity and psychiatric outcomes. Young MSM with childhood gender nonconformity may be disproportionately victimized by CSA thereby increasing their likelihood of developing psychiatric symptoms in adolescence. Early intervention addressing these factors may help reduce lifetime negative sequelae.

Variants of cognitive deficiency depending on the clinical characteristics of the disease in patients with paranoid schizophrenia

Pecific aspects of cognitive impairments in patients with paranoid schizophrenia depending on the clinical characteristics of the disease have been studied. One hundred and thirty patients were examined. A clinico-psychological, experimental psychological and statistical methods were used. Three main types of cognitive deficiency with paranoid schizophrenia, associated with the onset, disease duration, and severity of psychiatric symptomology : 1) long-term course of the disease accompanied by the average level of clinical symptomology associated with abnormal attention and visuospatial functions; 2) late onset of the disease and unexpressed clinical symptomology combined with memory impairments; 3) acute onset and early age combined with the absence of cognitive impairments.

Executive function and mental health in adopted children with a history of recreational drug exposures.

Adoptive children are at increased risk for problematic behaviors but the origin of these individual differences in neurobehavioral function is unclear. This investigation examined whether adopted children with prenatal exposure to a wide variety of recreational drugs exhibited higher scores (i.e. more problems) with executive function and psychiatric symptomology. Caregivers of children ages 5 to 18 completed an online survey with items about use of alcohol, nicotine, or methamphetamine during pregnancy followed by the Behavior Rating Inventory of Executive Function (BRIEF, N = 437 including 59 adoptive parents) or the Child Behavior Checklist (CBCL, N = 549 including 54 adoptive parents). Relative to a comparison group of children raised by their biological parents, adoptive children that were polysubstance exposed during prenatal development exhibited higher rates of academic difficulties and were behind their classmates in math and reading. Adoptive children had statistically and clinically significant higher BRIEF ratings and this pattern was similar for boys and girls. CBCL ratings were significantly increased in adoptive children, particularly for Externalizing and Attention problems. Adoptive children with a history of polysubstance exposures including alcohol, nicotine, and methamphetamine are at heightened risk for difficulties with executive function as well as various psychopathologies. These findings suggest that increased monitoring to identify and implement remediation strategies may be warranted for adopted children with a history of in utero drug exposures.