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Genetics Largely Underlies Intelligence to School Acheivement Link

Posted: January 31st, 2013 by David Rettew

While the genetic influence on intelligence has been well studied, less is known about school achievement and the genetic/environmental links between intelligence and school achievement. Previous work has also struggled with potential measurement and sampling bias. This study used national data from large Dutch and English samples to address some of these concerns.

The total sample included nearly 174,000 11 year old children in England and 166,000 children in the Netherlands. Intelligence was measured using the Cognitive Ability Test for the English sample while achievement was assessed through schools’ standard school performance tests. Intelligence assessment for the Dutch sample of children ages 8, 10, and 12 came from two tests of nonverbal intelligence while school achievement was measured using scores on arithmetic and language. A “twin extraction” method was used to find twins from the national datasets based on their name and date of birth. Since monozygotic versus dizygotic twins could not be determined through these ratings, the authors used same and opposite sex twin status for their statistical models.

In the English dataset, the heritability of intelligence was found to be high at 70%. The heritability of overall achievement was also found to be high at 75% and ranged from a high of 81% for English to a low of 51% for science. The Dutch dataset found increasing heritability of intelligence between age 8 (43%) and 12 (67%), although at age 10 there was a low heritability of 24% with a shared environmental influence of 29%. This result is generally consistent with other studies that show that the genetic influence on intelligence tends to increase with age. The heritability of school achievement in the Dutch sample ranged from 36% to 74% depending on the age and subject.

As expected, intelligence and achievement were highly correlated with the association somewhat higher in England. This association was related strongly to genetic factors in the English sample and moderately so with the Dutch data. Shared environmental influences explained much of the remaining variance related to the intelligence/achievement link in both samples.

The authors concluded that the known association between intelligence and school achievement is largely accounted for by common genetic factors, although shared environmental factors (things like parenting influences) also played important roles for many subjects and should not be overlooked.

The heritability estimates for intelligence in this study are somewhat above the approximately 50% found in other papers. Some of the differences found between the English and Dutch samples were hypothesized to be related to the different instruments that were used and the Dutch sample having used a greater percentage of children from lower socioeconomic backgrounds.

Finally, it is important to point out that this study was done in two developed countries. As such, the magnitude of the genetic effects could be higher than in developing countries where there are huge discrepancies in opportunity and where sadly many bright children have little chance to show their potential in educational settings.

Reference

Calvin CM, et al. Multivariate genetic analyses of cognition and academic achievement from two population samples of 174,000 and 166,00 school children. Behav Genetics 2012; 42:699-710.

Tags: intelligence, iq, school achievement
Neuroscience, School | No Comments »

Autism Assessment Clinic Has Openings for Vermont Medicaid Families

Posted: January 28th, 2013 by David Rettew

by Jeremiah Dickerson, MD

Director, VCCYF Autism Assessment Clinic

As you may know, the Vermont Center for Children, Youth, & Families, in partnership with the State of Vermont, has established an Autism Assessment Clinic to serve the needs of Medicaid supported children and families throughout Vermont. Over the past two years, we have worked hard to solidify our assessment protocols and are eager to continue to provide comprehensive autism spectrum evaluations to those children suspected of having an autism spectrum disorder.

We hope to continue this work and remain dedicated to offering multidisciplinary evaluations using a collection of standardized, norm-referenced assessment tools that aim to capture each child’s unique array of strengths and struggles for which we can suggest tailored family-based recommendations for prevention, health-promotion, and intervention. Recently, autism spectrum disorders have become a relatively hot topic in both the popular and scientific press. Per the Centers for Disease Control and Prevention, the incidence of children with autistic disorders is rising, and it is becoming increasingly crucial that primary care providers are diligent in their screening for such youngsters so that these children can obtain appropriate services that aim to ensure their developmental, social, behavioral, and academic success.

It is our hope that once children are screened (between the ages of 16-30 months of age) using ASD specific screening tools (e.g. M-CHAT*) that a referral for comprehensive evaluation would immediately follow for those who present with concerns that suggest an autistic disorder. A major objective for our clinic is to assess children age four and under. For these young children, the evaluation can take place over the course of one morning and may include developmental testing, autism-specific testing (using the Autism Diagnostic Interview and the Autism Diagnostic Observation Schedule), a psychiatric assessment, and speech-language testing (if indicated).

Although we are accepting referrals for children of any age, if you have a child patient four years and younger that is supported by Medicaid and that you suspect to be affected by an autism spectrum disorder please consider a referral to our clinic, which is housed in the UHC campus at Fletcher Allen Health Care.

To initiate the referral process, or if you have any questions, please contact us at 802-847-4563 or visit http://blog.uvm.edu/jdickers. We appreciate your time and look forward to working collaboratively for Vermont families.

Autism, Uncategorized | No Comments »

Study Documents Previously Autistic Individuals Who No Longer Show Impairment

Posted: January 23rd, 2013 by David Rettew

Autism is generally considered to be a lifelong condition. While treatment can certainly be effective, the goal is often described more in terms of symptom reduction rather than a true recovery (in which no criteria of the disorder are met). A small but intriguing study by Fein and colleagues, however attempts to document a group of previously autistic children who no longer manifest any significant effects of the condition.

This study examined 34 youth between 8 and 21 years of age who previously met full criteria for rigorously diagnosed autism but presently had no signs of an autistic spectrum disorder. This group was designated the “Optimal Outcome” group and they were compared on a number of measures to an age, sex, and nonverbal IQ group of individuals with high functioning autism and a group with typical development. All subjects has full scale IQs above 77.

With some small exceptions on certain subscales, the Optimal Outcome individuals looked indistinguishable from the control group and performed better than the high functioning autism group on measures of language and communication, social ability, and facial recognition. Compared to the other autistic group, the Optimal Outcome group appeared to have somewhat milder autistic symptoms earlier in childhood, particularly with regard to social behaviors. The Optimal Outcome group also had a mean IQ in the high average range.

The authors concluded they were able to demonstrate the presence of a minority subgroup of autistic individuals who later in life had no significant autistic impairments and cognitive ability within the normal range. The authors qualified that there data were not equipped to answer the question of how many children diagnosed with autism will no longer meet criteria prospectively or what factors might predict this optimal outcome. Additional neuroimaging and intervention data are currently being analyzed by this group.

With evidence that autism truly is a spectrum condition with the continuum existing not only throughout the diagnosis but into the “normal” range as well, it remains to be seen the degree to which these youth no longer “have” autism versus them dropping below diagnostic cutoffs through compensatory strategies. While the authors were careful not to use words such as “cure” or “outgrow,” the same unfortunately cannot be said about some media reports since the study’s publication.

Reference

Fein D, Optimal outcome in individuals with a history of autism. J Child Psychol Psychiatry 2013;54:195-205

Tags: autism recovery, autistic spectrum disorder
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Stimulants for Cognitive Enhancement – Social Justice or Cosmetic Psychopharmacology?

Posted: January 17th, 2013 by David Rettew

A thought provoking article in the NY times raises questions about the practice of giving stimulant medications to children who don’t meet criteria for ADHD but who nonetheless might benefit from their effects. While the issue of stimulants being taken by competitive students trying to gain an edge in college has been well documented, this article describes the activities of at least one physician who takes a different (I might call it a “Robin Hood”) approach of prescribing these medications to younger children from lower socioeconomic groups in order to help level the playing field.

The article raises some important questions and dilemmas that may be looming on the horizon for many physicians. The notion of “cosmetic psychopharmacology” gained popularity following Peter Kramer’s well known book Listening to Prozac in which he described cases of individuals who took SSRIs in the absence of major mental illness in order to “transform” their personality. Some expected a flood of referrals for personality alteration to arrive as a result. For the most part, they never came, perhaps due to the fact that such transformations were not as common as the book suggested. Now, however, the idea may be returning not with antidepressants but with stimulants which are known to enhance some cognitive functions even in the absence of full ADHD. For those interested in reading more, an entire chapter in my upcoming book, linked on this blog, is devoted to the topic of medications and temperament/personality change.

Unfortunately, however, the article also illustrates a number of lingering myths that continue to exist within the public and even in the medical community. One of the physicians interviewed for the article claims that ADHD is not real because it is not binary (that is, existing in an all or none form). While it is quite true that ADHD symptoms exist quantitatively, that doesn’t mean it isn’t real. Hypertension, obesity, and high cholesterol also exist quantitatively with somewhat arbitrary cut-off points for “disease,” but that doesn’t mean those diagnoses are made up. There is overwhelming evidence from genetic, neuroimaging, and other biological studies that ADHD has real manifestations in the brain (how could it be otherwise?). I would also strongly disagree with the characterization of ADHD as “completely subjective,” although there is certainly some judgment that comes in when making the diagnosis. It is similarly faulty logic to think that because there is an association between ADHD and low socioeconomic status (SES), that changing the SES would necessarily improve symptoms on its own. It may help somewhat, but there is also evidence that even very robust nonpharmacological interventions result in only marginal improvement. We need to be mindful of the possibility that some of the less enriched and more chaotic environments these children endure might partially represent a result of ADHD in the family, rather than a cause.

In addition, I don’t see the reason to be so hopeless about these families and these schools with regard to nonpharmacological interventions. In the article, Dr. Anderson seems to be saying that he uses medications because he has given up on changing anything else. I have found that many families and schools, even those with little resources, can take effective measures to improve their environment. Indeed, it ironically seems a bit elitist to me to conclude that only higher SES families and schools are capable of behavioral change without medications.

The other question is what to do with using medication to treat mild or subthreshold cases. If a child meets criteria for ADHD, even if it is “mild,” then I try to treat it not just with medications but with nonpharmacological interventions (school changes, exercise, good sleep practices, reading, limiting TV and video games, treating parents). I have found this practice to be quite effective.

Currently, if a child or young adult does NOT meet ADHD criteria then I do not prescribe them medications. To me, this is cosmetic psychopharmacology. This article did get me to think again about this position for the future due to the inequalities of opportunities that are present and the idea that individuals should have the autonomy to make some of these decisions themselves, but presently I won’t do this because 1) not everyone has equal access to these medications, 2) it lowers the incentive to do other things to improve attention that would be more authentic and long lasting (what Dr. Graf in the article calls “authenticity of development” and 3) the potential long term risks are not well understood.

Putting aside the lingering misconceptions about ADHD and other emotional-behavioral problems, the article does sound the alarm bell that we as prescribing professionals and our organizations may need to think through these issues that may be arriving at our doorstep soon…and science, unfortunately, is probably going to make this issue more complicated, not less.

ADHD, Medications, Public Policy | No Comments »

ADHD Treatment Linked to Reduced Criminal Acts

Posted: January 8th, 2013 by David Rettew

by John Koutas, MD

The beneficial short-term effects of ADHD medication on symptoms of ADHD and associated problems have been demonstrated in numerous studies. Although ADHD symptoms often persist from childhood into adulthood, discontinuation of ADHD medication is common, especially in adolescence and early adulthood. In the present study, the authors used Swedish population-based data to investigate the association between the use of ADHD medication and criminality.

John Koutras, MD

A total of 25, 656 patients were identified with a diagnosis of ADHD. Using the Prescribed Drug Register, data was collected to establish treatment periods of ADHD medications, both stimulants and atomoxetine, with no more than 6 months between two consecutive prescriptions. The main outcome was any conviction for a crime comparing times the same individual was and was not taking medications.

The results showed that, among men, the crime rate was reduced by 32% during treatment periods. A similar association was observed among women, with a reduction in the crime rate of 41%. The authors concluded that there appears to be an inverse association between pharmacological treatment for ADHD and the risk of criminality.

In contrast to randomized, controlled trials, pharmacoepidemiologic studies such as the present study face the potential confound between the effect of a medication and the indications for the drug. In other words, patients who are receiving treatment are different from those who are not receiving treatment, usually because they are more symptomatic and have coexisting disorders. Poorer outcomes among individuals not currently using pharmacotherapy could be related to factors that can accompany indivuals who are currently “out of treatment” such as lack of contact with mental health professionals or supportive parents or partners. The authors creatively addressed these potential issues by analyzing criminality rates among patients who had discontinued SSRIs instead of ADHD medications. The authors found no association between criminality rates and SSRIs discontinuation. The authors only briefly mention the possible effect of comorbid substance abuse on the findings. Effective ADHD pharmacologic treatment has been associated with decreased substance abuse, and, of course, substance abuse is associated with criminality (including, even possession), so substance abuse may be an unaccounted for moderator in these results as well. The impact of stimulants in decreasing criminality in patients with ADHD may be due to their effect in decreasing impulsivity. If stimulants do, in fact, decrease criminality in patients with ADHD, then stimulants are a relatively low financial cost to society compared with the consequences of increased criminal behavior.

Reference

Lichtenstein P, Halldner L, et al. Medication for Attention-Deficit Hyperactivity Disorder and Criminality. NEJM 2012: 367 Nov 22: 2006-2014.

Tags: adhd, criminal acts, criminality
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Living in a World of Cyber-Everything

Posted: January 3rd, 2013 by David Rettew

(Editor note: I am pleased to post a new entry by one of our first year child psychiatry fellows – Feyza Basoglu, MD. After all the new electronics many families received for the holidays, it gives us something to ponder – DR).

“Addiction” has long been used as a term for only chemical dependence but is gaining popular use for behaviors such as gambling, shopping, food, work, and sex. Steadily increasing numbers of studies are being conducted on “internet addiction” that captures a wide variety of behaviors like browsing, social networking, playing video games etc. There is no universally accepted definition or an assessment tool for internet addiction and this may be why the prevalence has a very wide range

Feyza Basoglu, MD

of 0.3-10%. One widely accepted definition is “a psychological dependence on the Internet, regardless of the type of activity once logged on”. On the other hand, some argue that if a person logs on for a particular use each time, for example, playing video games, this makes him/her addicted to video games, not the internet. Studies suggest that the internet itself is not addictive, but that some specific applications, especially those with interactive functions, appear to contribute to the development of pathological use.

Internet infidelity and serious relationship problems are the most common “consequences” in the US. On the other hand, loss of productivity has been more of an issue in Asian and some developing countries. The Chinese Government instituted laws to limit the number of hours adolescents can play online games and in 2005 and opened the first treatment center for internet addiction in Beijing. Predominantly they treat addicted online gamers. Online gaming addiction continues to raise such serious concerns that detox centers for video game addiction have opened and the American Medical Association considered video game overuse an addiction at their annual policy meeting.

Although there is not a standardized terminology, internet addiction is conceptualized as an impulse control disorder. It will not be specifically included in DSM V but has been considered to be mentioned in the appendix. The most valid and reliable way to assess internet addiction is to use the adapted DSM IV criteria for pathological gambling by changing the word “gambling” to “internet use”. There are also tools like the Internet Addiction Diagnostic Questionnaire (IADQ) developed as an initial screening instrument utilized for diagnosis in academic, research and clinical treatment settings.

Depression, dysthymia, anxiety, hostility and interpersonal sensitivity are the most frequent co-occurrences in internet addiction. Data suggest that internet addiction is a relevant factor among minors in psychiatric institutions. Those with comorbid internet addiction show distinct patterns of psychopathology and may require disorder-specific treatment. Adolescents with substance abuse issues have been proven to be highly likely to have internet addiction. Especially young, male patients in treatment for cannabis dependence or pathological gambling are at risk for co-morbid internet addiction. This is not surprising given the fact that internet use, for whatever application it is tempting to that adolescent, has been shown to increase dopamine activity in nucleus accumbens, the pleasure center of our brains. For depressed adolescents, however, it has been a dilemma whether internet use helps to cope with or amplify depressive symptoms. Adolescents see the internet as a safe place to absorb themselves mentally to reduce their tension, sadness, or stress. Individuals may feel overwhelmed and can lose themselves in anything from online pornography, internet gambling, or online gaming and once online, the difficulties of their lives fade into the background as their attention becomes completely focused on the computer. The Internet becomes a new way of escaping without really dealing with it.

To many parents’ confusion and frustration, youth with ADHD can stay still and attend to their video games. Core symptoms reported in ADHD are ‘‘being easily bored’’ and ‘‘having an aversion for delayed reward’’. Internet behavior is characterized by rapid response, immediate reward, and multiple windows with different activities, which may reduce the feeling of boredom or provide immediate stimulation and reward. Striatal dopamine is released during video gaming, which helps the game players keep focused on gaming. Also lack of self-control may cause individuals with ADHD to have difficulty in controlling internet use and hence become vulnerable to addiction. Motivation deficit, an anomalous reaction to reward and punishment, has been reported to be an endophenotype of ADHD. Internet activities, especially for online gaming, usually provide immediate response and reward. Finally impulsivity, hyperactivity, and inattention usually negatively influence individuals’ interpersonal relationships. However, these deficits could be masked well online.

Cognitive-Behavioral Therapy (CBT) has been found to be the most effective approach with Internet-addicted clients. Underlying psychosocial issues that often coexist with this addiction (e.g., social phobia, mood disorders, sleep disorders) need to be diligently addressed. Establishing a sleep cycle has been shown to be essential.

Activity monitoring schedules, working towards controlled use rather than complete abstinence, refraining from problem applications, education to increase parent-child communication and family time, identifying core beliefs (I am worthless but important online), addressing rationalization (a few more minutes won’t hurt) are all potentially useful interventions. Identifying responsible and effective ways to satisfy needs through other activities beyond the computer and cultivating a ‘success identity’ by joining a gym, take up yoga, or join a book club, anything that empowers them motivate to stay away from the computer can also be helpful. Motivational therapy has not been proven successful. Ironically, for a subgroup who otherwise would not present in treatment, online courses have been created. Pharmacological approaches are limited; two studies showed significant decrease in hours and decreased cravings with use of escitalopram and bupropion SR.

This is an era of shifting traditions. It is a curious question whether Generation Z and Alpha will benefit or suffer from this shift in their future. Realistically, how many of us needed to apply rules in our houses to limit our kids’ internet times? Let alone our kids, how many of us ourselves have checked our e-mails or Facebook accounts first thing in the morning? Is the world addicted all at some level or this is part of normality as long as it stays within reasonable limits? All yet to be answered.

References:

1-Cash et.al. Internet addiction: A Brief Summary of Research and Practice. Current Psychiatry Reviews,2012,8,292-298.

2-Chou et.al. A Review of the Research on Internet Addiction. Educational Psychology Review, Vol. 17, No. 4, December 2005

3-Internet addiction: hours spent online, behaviors and psychological symptoms. General Hospital Psychiatry 34 (2012) 80–87.

4-The association between Internet addiction and psychiatric disorder:A review of the literature. European Psychiatry 27 (2012) 1–8

5-Problematic Internet Use Among US Youth: A Systematic Review. Arch Pediatr Adolesc Med. 2011 September; 165(9): 797–805.

6-Shapiro et.al (2000). Psychiatric evaluation of individuals with problematic Internet use. Journal of Affect Disorders, 57:267-272.

7-Sang-Min et.al (2003) Internet Over-Users’ Psychological Profiles: A Behavior Sampling Analysis on Internet Addiction, CyberPsychology & Behavior.

8-King et.al. Cognitive-Behavioral Approaches to Outpatient Treatment of Internet, Addiction in Children and Adolescents. JOURNAL OF CLINICAL PSYCHOLOGY: 68(11), 1185–1195 (2012)

9- www.netaddiction.com The Center for Internet Addiction Recovery

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Talking with Children About the Connecticut School Shootings

Posted: December 14th, 2012 by David Rettew

All over the country people are horrified at the shootings that happened at Sandy Hook Elementary School. Our hearts go out to all the families affected by this tragedy. While many facts of the shooting remain to be learned, tonight millions of parents will do their best to try and talk to their children about what happened. While there is no right answer for every child, a few principles might be useful to keep in mind during this process. Local Fox44 News aired an interivew that we did today on the topic. The overall goal of these conversations should be to help children feel safe about going to school. Among the things that were discussed but didn’t make the final broadcast include the following.

Younger children may not need to know much about this event, if anything. For toddlers and preschool children, it is quite likely that they will not know about what happened, and it is fine to keep it that way. If they do know, they also will be quite likely to ask.

Older children, however, will probably have heard the news and it is good for parents to have a conversation with them so that they can hear things from a parent’s perspective. Many of these kids may not spontaneously bring up the topic on their own. For these children, a few principles may be good to consider.

1) Start the conversation with questions rather than statements. This tip can also help you know how much they know about the shooting. Have you heard about what happnened in Connecticut? How did you hear? What are your friends saying about it? All of these starter questions can help open the dialogue and show your child that you want to listen as much as talk. It also can help you find potential myths or misconceptions about the events that need correction.

2) Remind kids that schools are safe. It may not seem like it at times, but these kinds of horrible events remain very rare and schools continue to be very safe places for kid to be. It can be useful to remind children of this fact clearly.

3) Refocus on the heros. Many of us are naturally drawn to questions about the shooter, but it can be good to remember that in many tragedies there are heros such as teachers or first responders who put their lives on the line for others. If older children want to talk more about the shooting, help them think about the helpers so that their attention isn’t drawn exclusively to the perpetrators.

4) Keep yourself in check. This tip doesn’t mean parents should be emotionally flat (even our president couldn’t do that), but it is important to stay in control so that you can say and do what is going to be most helpful for your child.

5) Limit media expsoure to the shooting. While it can be hard to resist, kids do not need to be watching 24 hour coverage of the shooting. In fact, it can make things worse and cause higher levels of anxiety. Waiting until after the kids go to sleep to get an update on the news is not going change what happened.

In many ways, today’s shooting is likely to be harder on parents than for children. Nevertheless, some kids, especially those who already struggle with anxiety, may need extra support and guidance. For parents looking for additional tips and information, a good source is the American Academy of Child and Adolescent Psychiatry. Tonight, as our president says, many of us will be hugging our kids a little tighter. Tomorrow, we need to think about how we as a community can keep something like this from ever happening again.

Tags: connecticut school shooting, school violence, talking to children
Anxiety, Disaster, Parenting, Uncategorized | No Comments »

Genes for Responsiveness to Parenting Practices?

Posted: December 12th, 2012 by David Rettew

In classic models of psychiatric risk, particular child characteristics are seen as generally negative things that under the wrong conditions can get amplified into full-fledged psychiatric disorders. A newer model, however, holds that some of these characteristics are better understood as related to environmental sensitivity, which means that in positive environments these same traits may convey an actual developmental advantage. A new study published in the November 2012 edition of the Journal of Child Psychiatry and Psychology tests the hypothesis that children with emotional dysregulation would show a greater improvement to a parental guidance intervention than those without such behaviors.

The data come from 112 children who participated in the SPOKES project in London, England. The children were between 5 and 6 years old and possessed elevated levels of oppositional and conduct behavior as assessed through questionnaires and the DSM ODD criteria. Subjects were further sorted into an Irritable, Hurtful and Headstrong group based on previous research by Stringaryis with the Hurtful and Irritable group designated as Emotionally Dysregulated. Families were then randomized with half of the parents participating in a parenting intervention based on the Incredible Years program.

The results revealed that while the treatment improved parenting behaviors similarly in both child groups, only the Emotionally Dysregulated group and not the Headstrong Group had a significant improvement in child conduct problems.

The authors concluded that emotional dysregulation in children may reflect a genetically influenced trait that reflects a heightened sensitivity to the environment which under positive conditions could result in more robust improvement.

However, from my reading it does seem to be a bit of a stretch to conclude that emotional dysregulation should be viewed purely as environmental sensitivity based on improved treatment response. More convincing would be data that show that children with this disposition, under positive rearing conditions, are actually more well than their less sensitive peers rather than doing less poorly as these data suggest. Nevertheless, this study offers hope that many children who are prone to emotional dysregulation can be significantly helped though improving the quality of their home environment.

Reference,

Scott S, O’Connor TG. An experimental test of differential susceptibility to parenting among emotionally dysregulated children in a randomized controlled trial of oppositional behavior. J Child Psychiat Psychology 2012; 53:1184-1193.

Tags: conduct disorder, ODD, parenting
ODD, Parenting | No Comments »

New DSM5 Diagnosis of Disruptive Mood Dysregulation Disorder Under Scrutiny

Posted: December 6th, 2012 by David Rettew

Disruptive Mood Dysregulation Disorder (DMDD) is a new entity coming to DSM5 in May 2013 that describes children with noncyclic but frequent and severe outbursts along with a chronically irritable mood. The diagnosis was built to capture many children who have previously been diagnosed with entities such as Bipolar Disorder. The disorder remains controversial and this new study sought to examine some of the characteristics of this new diagnosis.

The data come from the multi-centered Longitudinal Assessment of Manic Symptoms Study that examined 706 children between the ages of 6 and 12. The sample was followed at baseline and again 12 and 24 months later using a number of instruments and assessments including the adaptation of items from a semi-structured interview that was used to retrofit the DSM5 criteria items of DMDD since it didn’t exist at the time the study was started.

A total of 26% of their sample at intake met criteria for DMDD. Compared to those without DMDD, these children had higher rates of ADHD, oppositional defiant and conduct disorder and their symptoms of these disorders as well as overall impairment were more severe. The rate of Bipolar Disorder and ratio of males to females among other things, was not statistically different between the two groups. There were also no significant differences with regard to family history. Approximately 53% of the DMDD group at intake also met criteria at 12 month follow up while only 19% of the sample were positive at all three assessments. An intake DMDD diagnosis was not related to the onset at follow-up of Bipolar Disorder.

The authors conclude that DMDD is a common condition but one that is somewhat transient and difficult to distinguish from oppositional and conduct disorder. Overall, they raise some concern about the validity of this new entity.

One irony to this study is that the criticism of this new DMDD diagnosis resembles that leveled against more broadly defined Bipolar Disorder – the condition this new diagnosis was designed to fix and where studies show that nearly all children meet criteria for something else as well. If we are to reject DMDD because subjects meet criteria for something else and many children over time don’t retain their diagnosis (especially as assessed in a naturalistic study) then many other diagnoses are in jeopardy as well. There is also some concern of a selection bias for this study as subjects needed to have elevated scores on a questionnaire designed to assess mania to be included.

Reference

Axelson et al., Examining the proposed diagnosis of disruptive mood dysregulation disorder in children in the longitudinal assessment of manic symptoms in children study. J Clin Psychiatry 2012;73:1342-1350.

Tags: bipolar disorder, disruptive mood dysregulation disorder, dmdd
Bipolar Disorder, Diagnosis | 1 Comment »

Dysregulated Infant – Dysregulated Child?

Posted: November 28th, 2012 by David Rettew

It is well known that babies get upset, but are infants who get REALLY upset and are very difficult to manage more likely to have behavioral problems later in life? The data so far has been somewhat inconclusive and long-term follow-up is lacking.

A new study from the journal Pediatrics may add some insight into the question. This Australian study examined approximately 6000 infants. Dysregulated infants were assessed using a questionnaire that asked about colic, sleeplessness, feeding problems, and overactivity with the top 10% classified as dysregulated. The children were followed-up at age 5, 14, and 21 using our very own Achenbach rating scales such as the Child Behavior Checklist which in the early waves of the study were “modified” and shortened. About half of the original patients were assessed at age 21. DSM Diagnoses were also obtained using a structured interview. Logistic regressions were used for the analysis and to caclulate odds ratios.

The results showed that infant dysregulation assessed at 6 months was indeed associated with parent-reported behavioral problems at age 5 and 14 but not self-reported behavioral problems at 14 or 21. For example, 9.7% of the nondysregulated infants versus 19.4% of the dysregulated infants were classified as having clinical levels of externalizing problems at age 5 (odds ratio 2.23). When maternal levels of anxiety and depression were taken into account, the associations between infant dysregulation and later behavioral problems were diminished but generally still statistically significant. There were no significantly elevated rates of DSM disorders assessed by self-report at age 21.

There were some problems with the paper. The authors reported that maternal anxiety/depression were MEDIATORS of the infant dysregulation-child behavior problems link (meaning that they believe the results worked through this mechanism), but from my reading it looks more like a confound variable (i.e another variable that could account for the association), which in other areas of the paper they acknowledge. For example, increased maternal anxiety and depression could have resulted in the perception of a more difficult to manage infant. It is also worth pointing out, as is easily missed in studies that report odds ratios, that the vast majority of dysregulated infants did not manifest clinical behavior problems even at age 5 let alone later in life.

Reference

Hyde et al., Long-term Outcomes of Infant Behavioral Dysregulation. Pediatrics 2012; 130:5 e1243-e1251

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