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Clinical characteristics of psychiatrically referred adolescent outpatients with substance use disorder.

OBJECTIVE: There is increasing interest in the developmental relationship of psychopathology and substance use disorders (SUD) in youths. Because the bulk of literature is focused in inpatient or incarcerated youths, inferences and generalizations are limited in outpatient settings. The clinical characteristics of psychiatrically referred outpatients were studied to determine whether differences existed in the nature and severity of comorbid psychiatric disorders when substance abuse was involved. METHOD: All diagnoses were derived from structured psychiatric interviews completed on all youths on intake assessment. Adolescents with an identified SUD (n = 38) were compared with those without SUD (n = 321) on a number of variables including past and current psychopathology, cognitive and school functioning, and overall impairment. RESULTS: Eleven percent of referred outpatients (mean age = 15.9 +/- 1.3 years) met full criteria for a SUD by parental report. Controlling for age, adolescents with SUD had higher risk for mood and disruptive behavioral disorders compared with psychiatric controls. In the majority of cases, the onset of psychopathology preceded the onset of SUD by at least 1 year. The group with SUD also had lower overall functioning and more school dysfunction and psychiatric hospitalizations than their non-SUD peers. CONCLUSIONS: Despite the small number of adolescents with SUD in this sample, these data indicate that SUD is common in outpatient psychiatry referrals. Youths with SUD appear to be at increased risk for more psychopathology and dysfunction in a number of domains.

Adolescent

Social competence in the school setting: prospective cross-domain associations among inner-city teens.

In this 6-month prospective study of 138 ninth-grade inner-city students, associations among different aspects of school-based social competence were examined. In addition, links between initial emotional adjustment and subsequent social competence at school were explored. Aspects of social competence examined included academic achievement, peer reputation, and teacher-related classroom behaviors. Emotional adjustment was measured based on self-reported internalizing and externalizing symptoms. Consonant with views positing continuity and coherence of development, high temporal consistency was found within each social competence domain. In addition, superior adjustment in one domain was sometimes associated with subsequent improvements in other spheres as well. Exceptions found to this pattern were that (a) both as an antecedent and as a consequent variable, peer-rated sociability was negatively linked with other indices of school-based functioning, and (b) among girls, high anxiety was related to improved performance at school over the year. Ecological influences in adolescent adjustment are discussed, and implications of the findings for future research are explored.

Adolescent

Social and psychological adjustment of Soviet-born and Israeli-born adolescents: the effect of the family.

This study examined the impact of family functioning on the educational, social and emotional behavior of Soviet-born and Israeli-born adolescents in Israel. The parents of the Israeli-born adolescents were born in Russia; thus, this study controlled for their national background. The results showed that the two groups were similar in their perception about the way their families function. Both groups perceived that social and psychological well-being among adolescents were significantly related to family functioning. Multivariate analysis revealed that family functioning was the major factor predicting the level of self-esteem and peer relationships among adolescents, as well as a myriad of psychological symptoms. Directions for future research are discussed.

Adaptation, Psychological

Treatment results in dental school orthodontic patients in 1983 and 1993.

The effect of incremental changes in materials and techniques on orthodontic treatment outcomes is difficult to evaluate objectively. Treatment results for two groups of patients whose treatments were completed approximately 10 years apart were evaluated using the peer assessment rating (PAR) index and the index of orthodontic treatment need (IOTN) using the Wilcoxon matched-pairs signed-rank test. Patients in the later group who had been treated by postgraduate students primarily (using fixed appliances) had significantly lower IOTN and PAR scores at the end of treatment and showed a significantly greater reduction in the PAR score than a similar group of patients in the earlier group. There were no significant differences in treatment results between patients in the early and late groups who were treated with removable appliances. Differences in treatment results were most likely the result of changes in materials and techniques that had occurred in the 10 intervening years.

Adolescent

The sexual and reproductive consequences of congenital genitourinary anomalies.

The major congenital anomalies of the genitourinary tract may result in disturbances of sexual and reproductive function. In general the children grow up with the same aspirations as their more normal peers, which are to marry, have intercourse and produce children. Some achieve this despite the deformities and in others specific reconstructive surgery may be needed. In exstrophy the vagina lies parallel to the floor when the girl is standing and the introitus is seen on the lower abdominal wall rather than in the perineum. Episiotomy is required in 34% and formal vaginoplasty in 23% of the cases. The exstrophy penis has a tight dorsal chordee that must be corrected to allow intercourse. The neurological and social consequences of myelomeningocele do not prevent patients from having an interest in sex. Those who are able to walk are likely to have normal sexual function compared to about 50% of those who are wheelchair bound. The recurrence risk for neural tube defects in their offspring is 1:50 for sons and 1:13 for daughters regardless of the sex of the affected parent. The physiological consequences of posterior urethral valves result in weak ejaculation in 50% and highly viscous and alkaline semen in 50% of the cases. Of male patients with ambiguous genitalia or micropenis 75% have normal intercourse.

Epispadias

Psychosocial functioning in prepubertal major depressive disorders. I. Interpersonal relationships during the depressive episode.

Psychosocial environment and relationships with parents, peers, and siblings of 115 prepubertal children were measured by interview with their parent(s) for the three-month period preceding the assessment. The children had a current diagnosis of major depression (52 children) or nondepressed neurotic disorder (23) or were assessed to be normal (40). Most aspects of psychosocial relationships were found to be significantly impaired in the psychiatric groups. This impairment was generally worse in the depressives and significantly worse for aspects of verbal and affective communication with parents and siblings. Prepubertal children with major depressive disorder regularly present social relation deficits in which two components can be distinguished: one general to childhood psychiatric disorder and another specific to major depression.

Age Factors

The incidence of chronic headache in children with shunted hydrocephalus.

Report of chronic headache amongst children with shunted hydrocephalus is frequent, and often leads to investigation for raised intra-cranial pressure and shunt malfunction, and much debate has appeared in the literature concerning possible cause. However headache is a common neurological symptom amongst children, and studies of prevalence indicate incidence of frequent non-migrainous headache to be 6.8%, and migrainous headache 4% in the general child population. A relationship between stress and anxiety and headache is recognised, and the hydrocephalic child has many reasons above those of his/her peers to be subject to stress. It is also hypothesised that this group may be more vulnerable than peers to developing a migraine-like condition in the face of adequate shunt function. The clinician dealing with complaint of chronic headache in a hydrocephalic child must therefore be wary of over-investigation in a child with a working shunt, or missing possible shunt malfunction when the only symptom is chronic headache. It was speculated therefore that incidence of non-shunt related chronic headache in this group would be high, and an attempt was made to document incidence of migrainous and non-migrainous headache in the medical notes, and in replies to postal questionnaire sent to a sample of 130 children with shunted hydrocephalus of varying aetiology. Incidence of migrainous headache was documented in the medical notes in 8.5% of cases, with incidence rising to 21.5% using self-report. Incidence of non-migrainous headache was also very high (15.4%) and the overlap between migraine and tension headache, combined with difficulty of diagnosis in children may indicate migraine to be more frequent still. The concept of "Shunt Migraine" is therefore worthy of consideration. Report of chronic headache led to investigation in a large proportion of cases, but symptomatology often continued. Even when shunt malfunction was indicated, shunt revision did not "cure" complaint of headache. Headache was not found to be related to diagnosis associated with hydrocephalus, to presence of seizure disorder, or to the sex of the child, although in common with other studies, there was a strong trend towards girls being statistically more likely to experience headache than boys. There was a relationship however between report of chronic headache, and the sort of school a child was likely to attend; children who attended mainstream school without the support of a Statement of Special Educational Need were more likely to report headache than their peers, and it is hypothesised that these children may be suffering sufficient stress to contribute to maintenance of headache. The importance of the multi-disciplinary team in assessment of children's physical, intellectual and emotional status is stressed, in order that medical interventions have the greatest chance of success.

Cerebrospinal Fluid Shunts

Rating and recognition of peers' personal odors by 9-year-old children: an exploratory study.

Eighteen elementary school children assessed the pleasantness and perfumed aspect of familiar peers' odors, sampled through tee shirts worn without modification of hygienic habits. The participants were also requested to categorize the odors by sex and to recognize those of several target classmates varying in sex and socioemotional status (the participant's most preferred classmate vs. a mere acquaintance). The ratings of odors by familiar peers appeared consistent with those obtained from nonfamiliar peers and adults and varied according to the sex of wearer of the tee shirts. For the five categories of peers examined, as well as for the participants themselves, olfactory recognition was better than chance. Moreover, it was higher for the same-sex preferred peers than for the others only for the female perceivers. The results are discussed in terms of their behavioral relevance for peer relationships, focusing especially on (a) the relations between sex differences in odors and gender development and (b) the function of olfactory memory in the emotional regulation of friendships.

Adult

Clinic children with poor peer relations: who refers them and why?

Children who have poor peer relationships are at high risk for developing psychopathology in adulthood. Schools can provide an essential link between these children and mental health services by proper identification and referral. The role of schools in the referral process was evaluated for 298 boys and 98 girls seen at a child guidance clinic. Half of these referrals were made by schools, but referral because of poor peer relationships was unusual. It is suggested that teachers learns to attend more closely to children's social functioning as an important identifier of children at risk.

Adolescent

Interpersonal functioning and depressive symptoms in childhood: addressing the issues of specificity and comorbidity.

Research has supported linkages between depression and social impairment in youngsters, but has often focused on depressive symptoms in isolation. We collected data on depressive, anxiety, and externalizing symptoms in 161 school children. Information about interpersonal competence was gathered from several sources, including children, teachers, and behavioral observations. Depressive symptoms were found to be related to difficulties in multiple areas of competence, including maladaptive social problem-solving styles, conflict-negotiation and affect-regulation deficits, and peer rejection. Comparisons of the relative contributions made by depressive and anxiety symptoms to the prediction of functioning yielded some evidence for a specific relation between depressive symptoms and impairment. Children with cooccurring internalizing and externalizing symptoms generally suffered from the most social dysfunction. If replicated in clinical samples, findings such as these may help to guide intervention efforts with depressed children.

Analysis of Variance

School adjustment, school performance and peer relations among first-graders in a Swedish suburban area.

A study of 95 first-graders in one school management area used teacher ratings of problems and sociometric ratings to assess school adjustment and peer relations; 14% of the children had difficulties in reading/writing, motor skill, concentration and psychosocial function. Behavioural problems did not generally coincide with poor scholastic performance, but a small group (6.3%) exhibited problems in both reading/writing, concentration, gross and fine motor skill and psychosocial functions. Sociometric results showed only moderate agreement with teacher ratings. Extremely popular boys had no teacher-rated problems, but children with teacher-rated problems did not to any high degree tend to be isolated. Poor gross motor skill did distinguish isolated boys from others, a relationship that was not evident among the girls. The need to study the validity of teacher ratings as well as the prognostic value of school adjustment in first grade was stressed.

Achievement

The role of the manuscript reviewer in the peer review process.

Peer review of submitted manuscripts is recognized as a critical component of the publication process in all major medical journals. It lends respectability and scientific credibility to those journals that have adopted the process [1]. This function is delegated to a group of persons who perform the task selflessly and without compensation. Of the many facets of the peer review process, the selection of manuscript reviewers and their subsequent interaction with both editors and authors may be so poorly understood by aspiring authors that certain misconceptions ensue. Authors of rejected manuscripts may fear that reviewers have acted in an arbitrary and possibly censorial fashion [2, 3]. Conversely, authors of accepted manuscripts who face a mountain of revisions may wonder if such an effort is likely to improve their manuscript [4, 5]. The following questions come to mind: Where do the reviewers come from? What do they do, and what constitutes a good reviewer? What power do they have? How is reviewer performance measured? Can the editor recognize publicly the good reviewer? Are reviewers really blinded? How does one become a good reviewer? Who will be the reviewers of the future? While looking at these questions, we should consider objective approaches of assessing reviewer quality and wonder whether they would improve the quality of the published manuscript.

Peer Review, Research

Follow-up of adolescents treated in a psychiatric hospital. Predictors of outcome.

In the context of a long-term follow-up of 60 hospitalized adolescent psychiatric patients (26 months to four years after discharge), we examined correlates of outcome. The variables were as follows: (1) severity of psychopathology; (2) onset of symptomatology (process or reactive); (3) type of hospital treatment termination; (4) continuation of individual psychotherapy following discharge; (5) physically destructive behavior before hospitalization; and (6) energy level. Follow-up was by personal clinical interview exploring the expatient's current living conditions, peer relationships, current psychopathology and drug or alcohol use, legal difficulties, academic and work functioning, subjective contentment, and plans for the future. An evaluation was also obtained from parents and/or spouse. Statistical analyses of the interrelationships among the predictor variables and outcome demonstrated the importance of a multivariate approach.

Acting Out

Adolescent adjustment to amputation.

We investigated the psychological effects of amputation on adolescent patients by interviewing 27 persons who had a limb amputation because of cancer during their adolescence and compared them to data obtained from eight patients with amputations due to trauma at similar ages. In cancer patients, mobility-related activities and social matters including relations with peers and the opposite sex and self-consciousness were of paramount concern. All cancer patients considered themselves functionally independent and 67% had little or no concern for the future. While malignancy and amputation had a significant impact on the patients' lives, the vast majority had a positive view of life and 85% were found to have what we assessed as adequate overall adjustment. Individual variables examined included marital and child-bearing patterns, educational attainments, vocational attainments, perceived parental and peer support, adaptation to prosthesis, and variables relating to general outlook on life and psychological adjustment. Our results suggest that the patients who have had amputations due to malignancy differ from traumatic amputees in their adjustment to amputation, with cancer patients showing, in many instances, evidence of better adaptation to disability. This may in part be due to different backgrounds and social orientation of traumatic amputees. We found the majority of cancer amputees to adjust well to their circumstances and to report leading full and productive lives.

Adolescent

Aspects of body image perception in obese and normal-weight youngsters.

Perceptual and projective aspects of body image in obese youngsters (not in psychological treatment) and normal-weight youngsters 8-9 years of age and 12-13 years of age were investigated. The results indicate that perceptual distortions in estimating various body dimensions of oneself are primarily a function of age rather than weight status. The accuracy of estimating the weight of peers and an adult showed an association with the sex of the subject. No group differences were found in terms of projective aspects of body image as measured by barrier and penetration responses. This study suggests that obese youngsters in the middle childhood and entering puberty periods in comparison to normal-weight youngsters of the same age do not manifest differences in perceptual factors of body image.

Adolescent

Interviews with children who experienced major life stress: family and child attributes that predict resilient outcomes.

Demographically comparable groups of children exposed to major life-stress, with stress resilient (SR) and stress affected (SA) outcomes at ages 10 to 12, were interviewed to assess perceptions of their caregiving environments, peer relationships, and themselves. SR children compared with SA children reported more: (1) positive relationships with primary caregivers, (2) stable family environments, (3) inductive and consistent family discipline practices, and (4) positive expectations for their futures. SR girls viewed their mothers as more nurturing than did SA girls. Perceptions of fathers, quality of peer relationships, and global self-concept did not differentiate the groups. A discriminant function analysis identified four variables that correctly classified 74% of the subjects as SR or SA. Findings support the view that caregiver-child relationships play a key role in moderating children's developmental outcomes under conditions of high stress.

Adaptation, Psychological

Systematic literature review for clinical practice guideline development.

The purpose of this paper was to evaluate the quality and scope of the published literature on functional impairment due to cataract in adults as reviewed for the Agency for Health Care Policy and Research Clinical Practice Guideline. We examined the method of literature retrieved and analysis performed in the course of development of literature-based recommendations for the guideline panel. To collect data, we reviewed the process of literature acquisition and identification and the quality assessments made by reviewers of 14 individual topics composed of 77 issues related to the guideline. We collated this information to provide an assessment of the quality and scope of the relevant literature. Less than 4% (310) of the approximately 8,000 articles initially identified as potentially relevant to the guideline were ultimately used. The majority covered three topics (surgery and complication, 100; Nd:YAG capsulotomy, 77; and potential vision testing, 40). Three other topics--indications for surgery, preoperative medical evaluation, and rehabilitation--were devoid of articles meeting inclusion criteria. For 43 issues, there was no identifiable relevant literature. With few exceptions, the quality of the literature was rated fair to poor owing to major flaws in experimental design. Case series (256 reports) of one type or another accounted for the majority of the included literature. There were 17 random controlled trials. This review revealed a sparse and generally low-quality literature relevant to the management of functional impairment due to cataract, despite a relatively large data base in reputable peer-reviewed journals.

Adult