Association of Reactive–Proactive Aggression and Anxiety Sensitivity with Internalizing and Externalizing Symptoms in Children with Attention-Deficit/Hyperactivity Disorder

This study evaluates the associations among the symptoms of anxiety, depression, and disruptive behavioral disorders (DBD) in the context of their relationships with reactive–proactive aggression and anxiety sensitivity in children with attention-deficit/hyperactivity disorder (ADHD). The sample consisted of 342 treatment-naive children with ADHD. The severity of ADHD and DBD symptoms were assessed via parent- and teacher-rated inventories. Anxiety sensitivity, reactive–proactive aggression and severity of anxiety and depression symptoms of children were evaluated by self-report inventories. According to structural equation modeling, depression and anxiety scores had a relation with the DBD scores through reactive–proactive aggression. Results also showed a negative relation of the total scores of anxiety sensitivity on DBD scores, while conduct disorder scores had a positive relation with anxiety scores. This study suggests that examining the relations of reactive–proactive aggression and anxiety sensitivity with internalizing and externalizing disorders could be useful for understanding the link among these disorders in ADHD.     

Relations of Personality to Substance Use Problems and Mental Health Disorder Symptoms in Two Clinical Samples of Adolescents

There is a high overlap between substance misuse and mental health disorders in adolescents. Certain personality traits (i.e., sensation seeking, impulsivity, hopelessness, and anxiety sensitivity) may be related to increased risk for mental health symptoms and/or substance misuse. The current study examined the relationships between personality and both substance use problems and externalizing and internalizing mental health symptoms in two clinical samples of adolescents. One sample consisted of adolescents receiving treatment for a primary mental health disorder, while the other sample included adolescents receiving treatment for a primary substance use disorder. A total of 116 participants (58 for each sample) completed the Substance Use Risk Profile Scale (SURPS), to examine personality factors, the Brief Child and Family Phone Interview- Self-Report, to examine mental health disorder symptoms, and the Personal Experience Screening Questionnaire, to examine substance use problems. After controlling for age, gender, and sample, sensation seeking and impulsivity were positively related to substance use problems, impulsivity was positively related to symptoms of externalizing disorders, and anxiety sensitivity and hopelessness were positively related to symptoms of internalizing disorders. These findings support the utility of the SURPS in predicting theoretically relevant symptoms in clinical samples of adolescents. Moreover, they extend previous research that has focused on using the SURPS as a predictor of substance misuse to its utility in also predicting mental health disorder symptoms. These findings have implications for improving mental health and addictions treatment services for adolescents.     

Treating comorbid anxiety and aggression in children

OBJECTIVE: The aim of the study was to evaluate the effectiveness of an intervention that targeted both anxious and aggressive behaviors in children with anxiety disorders and comorbid aggression by parent report. METHOD: The effects of a cognitive-behavioral therapy intervention targeting comorbid anxiety and aggression problems were compared with a standard cognitive-behavioral therapy intervention targeting anxiety only. The study was conducted over a period of 2 years, and 69 families were included, with participating children ranging in age from 8 to 14 years. Intervention effects were evaluated at posttreatment and 3 months following treatment. RESULTS: An intent-to-treat analysis identified few significant differences between conditions in level of improvement following treatment and at follow-up, with the exception of parent-reported stress, anxiety, and depression, which improved in the anxiety treatment condition. Both treatment programs led to significant reductions in parent-reported child externalizing and internalizing problems and child-reported internalizing problems and to improved parenting practices. CONCLUSIONS: Comorbidity did not appear to significantly affect treatment outcome for anxiety disorders, and combining existing treatments to address comorbid problems did not enhance treatment effectiveness. Further trials are required to assess the effectiveness of an expanded combined treatment program that allows adequate time to address both internalizing and externalizing problems.     

Suicide attempts associated with externalizing psychopathology in an epidemiological sample

OBJECTIVE: Borrowing from recent dimensional models of psychopathology, the authors conducted analyses that optimized the common variance shared by internalizing (depression, anxiety) and externalizing (antisocial personality, substance dependence) disorders in statistically predicting suicidal behaviors. These relationships were analyzed in a large epidemiological sample, thus allowing for the examination of gender differences in risk for suicide attempts associated with psychopathology. METHOD: The data were obtained from the Colorado Social Health Survey. Participants (N=4,745) were a community sample recruited by household address. Structured clinical interviews were used to obtain lifetime diagnostic and symptom count information. Symptom counts were included in a factor analysis that yielded two main dimensions of psychopathology: internalizing and externalizing. These factors were used in hierarchical logistic regression analyses to predict history of suicide attempts associated with the presence of internalizing symptoms, externalizing symptoms, and comorbid internalizing and externalizing symptoms. RESULTS: After the investigators controlled for the presence of internalizing symptoms and the comorbidity of internalizing and externalizing symptoms, externalizing symptoms were related to suicidal behavior in both men and women, although comorbidity was most predictive of suicide attempts among women, compared to men. CONCLUSIONS: Suicidal behavior among individuals with externalizing symptoms is not necessarily a result of comorbid depressive or other internalizing disorder. Thus, persons exhibiting antisocial behaviors should receive rigorous assessment for suicidal ideation and behavior.     

Manic symptoms and impulsivity during bipolar depressive episodes

OBJECTIVES: In contrast to the extensive literature on the frequent occurrence of depressive symptoms in manic patients, there is little information about manic symptoms in bipolar depressions. Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior. Therefore, we investigated the prevalence of manic symptoms and their relationships to impulsivity and clinical characteristics in patients with bipolar depressive episodes. METHODS: In 56 bipolar I or II depressed subjects, we investigated the presence of manic symptoms, using Mania Rating Scale (MRS) scores from the Schedule for Affective Disorders and Schizophrenia (SADS), and examined its association with other psychiatric symptoms (depression, anxiety, and psychosis), age of onset, history of alcohol and/or other substance abuse and of suicidal behavior, and measures of impulsivity. RESULTS: MRS ranged from 0 to 29 (25th-75th percentile, range 4-13), and correlated significantly with anxiety and psychosis, but not with depression, suggesting the superimposition of a separate psychopathological mechanism. Impulsivity and history of substance abuse, head trauma, or suicide attempt increased with increasing MRS. Receiver-operating curve analysis showed that MRS could divide patients into two groups based on history of alcohol abuse and suicide attempt, with an inflection point corresponding to an MRS score of 6. DISCUSSION: Even modest manic symptoms during bipolar depressive episodes were associated with greater impulsivity, and with histories of alcohol abuse and suicide attempts. Manic symptoms during depressive episodes suggest the presence of a potentially dangerous combination of depression and impulsivity.     

"Outer-directed irritability": a distinct mood syndrome in explosive youth with a disruptive behavior disorder?

OBJECTIVE: To examine whether "outer-directed irritability," a mood construct from the adult literature, characterizes a subgroup of disruptive behavior disordered children and adolescents previously shown to improve on divalproex, a mood stabilizer. METHOD: A sample (N = 20) of disruptive youth (aged 10-18 years) entering a divalproex treatment study of temper and irritable mood swings was compared to normal controls (N = 18) on measures of aggression/irritability directed against others (externalizing symptoms) and on aggression/ irritability against self, anxiety, and depression (internalizing symptoms). All patients met DSM-IV criteria for a disruptive behavior disorder (oppositional defiant disorder of conduct disorder) in addition to research criteria. RESULTS: "Outer-directed irritability" most clearly distinguished patients from controls (effect size 4.1) and did not correlate with other mood measures. Patients and controls showed no to minimal differences on internalizing symptoms. CONCLUSION: Disruptive behavior disordered children and adolescents characterized by outer-directed irritability exist, can be identified, and should be further investigated, especially since they are potentially treatable.     

Disruptive behavior in young children: what does it mean?

OBJECTIVE: To examine how the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) primary diagnoses, Parent-Infant Relationship Global Assessment Scale, and Child Behavior Checklist/2-3 (CBCL/2-3) externalizing and internalizing symptoms augment the DSM-III-R/IV and guide treatment. METHOD: 82 children aged 18 to 47 months, who presented with disruptive behavior to an early childhood psychiatry clinic, were diagnosed using DSM-III-R/IV, DC 0-3, and the CBCL/2-3. RESULTS: Children with DSM-III-R/IV disruptive disorders or attention-deficit/hyperactivity disorder were diagnosed with DC 0-3 regulatory disorders, disorders of affect, and traumatic stress disorder. Clinically significant externalizing and internalizing symptoms co-presented in 45.1% of the children. Of children with disorders of affect, 41.2% had relationships categorized as disordered, contrasting with 21.1% of those with traumatic stress disorder and 10.3% of those with regulatory disorders. Increasingly disordered relationships were significantly correlated with externalizing and internalizing symptoms, and children with disordered relationships were 3.6 times more likely to have clinically significant levels of internalizing symptoms. CONCLUSION: In these children with disruptive behaviors, co-presentation of externalizing and internalizing symptoms is most common. Those with increased relational risk had more externalizing and internalizing symptoms and more disorders of affect.     

Compulsive phenomena in children with tic disorder and attention deficit-hyperactive disorder

Tic disorders (TD), obsessive-compulsive disorders (OCD) and attention-deficit/hyperactivity disorder (ADHD) are often associated with deficits of impulse control and aggressive behavior. Tic disorders and OCD are closely related on epidemiological, psychopathological and neurobiological levels, whereas ADHD and OCD phenomena seem to be at opposite poles. Research evidence on the clinical significance of associated obsessive-compulsive behavior is reviewed and linked to our own new data. Thus the analyses of a worldwide database on Tourette's Syndrome (TS) (N = 4,833) showed that that the associated symptomatology of the OCD spectrum has to emphasized. In further investigations, premonitory sensorimotor phenomena reminiscent of OCD were more frequent in children with tic disorders as they grew older. Obsessive-compulsive behavior concomitant with TS was particularly associated with impulsive and aggressive behavior, as well as with depression and anxiety. The data suggest a reduced serotonergic transmission. Self-reports by children with ADHD, as opposed to those by their parents, mentioned a significantly higher quantitative degree of OC phenomena than those by children with TS. These findings suggest that OC symptoms in children with ADHD have so far been neglected in assessments by others. In summary, a complex psychopathological pattern of tic, OC behavior, impulsivity and internalizing symptomatology emerges that requires discriminating assessment and treatment.     

Self-report measures in the study of comorbidity in children and adolescents with social phobia: research and clinical utility

We examined differences in self-reported anxiety and depression according to the number and pattern of DSM-IV comorbid diagnoses in 172 children and adolescents (mean age=11.87, S.D.=2.67; range=7-17) with a primary diagnosis of social phobia. Three hypotheses were tested: (1) children with comorbid anxiety disorders would show significantly higher scores than children with social phobia-only on self-report measures, (2) self-report measures would significantly differentiate between children with social phobia and comorbid internalizing versus externalizing disorders, and (3) self-report measures would significantly differentiate children according to the type of anxiety comorbidities present. Multinomial logistic regressions showed that children with three anxiety disorders scored significantly higher than children with one and two diagnoses on two of three self-report measures used. Logistic regressions revealed that children's scores on measures did not differ according to the nature of the comorbid diagnoses (internalizing vs. externalizing). Finally, ROC curves showed that the MASC and the SPAI-C accurately classified children with additional diagnoses of SAD and GAD, respectively. The potential of self-report measures to further our understanding of childhood anxiety comorbidity and the clinical implications of their use to screen for comorbidity are discussed along with suggestions for further study.     

Correlates of comorbid psychopathology in children with ADHD

OBJECTIVE: To investigate correlates of internalizing and externalizing psychopathology in a clinical sample of children with attention-deficit/hyperactivity disorder (ADHD). METHOD: Parent and teacher Child Behavior Checklists were administered to 300 children with ADHD to ascertain comorbid symptoms. Based on previous research, a seven-step hierarchical regression analysis was developed. Six hierarchical regression analyses were conducted with either parent or teacher Child Behavior Checklist aggression, delinquency, or anxious/depressive comorbid symptoms as dependent measures. RESULTS: Controlling for (1) variables known to increase risk for ADHD child psychopathology and (2) estimated duration of ADHD, our results suggest that the presence of comorbid symptoms is influenced by age of onset. An early age of onset of ADHD was correlated with a greater rate of parent-reported child aggressive symptoms, and a later age of onset was correlated with a greater rate of parent-reported child anxious/depressive symptoms. Elevated levels of comorbid externalizing and internalizing symptoms are associated with greater ADHD symptom severity. CONCLUSIONS: Comorbid externalizing and internalizing symptoms are correlated with age of ADHD onset and are related to the severity of clinical presentation in a referred sample of children with ADHD.     

Temperament Moderators of Prospective Associations Between Community Violence Exposure and Urban African American Adolescents’ Aggressive Behavior

Research suggests that neighborhood risks are associated with internalizing symptoms for adolescents high on temperament characteristics related to the behavioral inhibition system (BIS). However, it is unclear whether newer conceptualizations of the BIS distinguishing fear from anxiety operate similarly. Furthermore, it is unclear whether the BIS attenuates community violence exposure effects on externalizing problems. The current study examined whether the BIS or the fight-flight-freeze system (FFFS) moderated associations between community violence exposure and internalizing and externalizing problems. Participants were 367 urban African American adolescents who reported on temperament characteristics in grade 9, and community violence exposure and adjustment problems in grades 9 and 10. Hierarchical linear regression analyses indicated that the FFFS, but not the BIS, moderated the association between community violence exposure and aggressive behavior. Grade 9 community violence exposure was positively associated with grade 10 aggression for adolescents low on FFFS, suggesting that the FFFS may partly differentiate community violence-exposed adolescents’ aggressive behavior.     

A closer look at co-rumination: gender, coping, peer functioning and internalizing/externalizing problems

Co-rumination, defined as repetitive, problem-focused talk explains higher levels of friendship quality in youth (Rose, 2002) and increased levels of anxiety/depression in females. Middle adolescents (N = 146) participated in a study of co-rumination, individual coping, externalizing/internalizing problems, and peer functioning. Consistent with past research, girls reported higher levels of co-rumination and internalizing symptoms. Co-rumination was also positively correlated with self-reports, but not teacher reports, of anxiety/depression and aggressive behavior. Both self-reported number of friends and teacher-rated social acceptance were negatively associated with co-rumination. Co-rumination partially accounted for the significant indirect effect of gender on internalizing symptoms. Additionally, co-rumination was associated with internalizing and externalizing symptoms but not individual coping efforts. Finally, co-rumination accounted for a unique amount of variance in internalizing symptoms, controlling for externalizing problems and secondary control coping. Theoretical implications and the importance of including broad domains of adjustment and peer functioning in future investigations of co-rumination are discussed.     

Clinical Characteristics of Pediatric Trichotillomania: Comparisons with Obsessive–Compulsive and Tic Disorders

This study compared youth ages 5–17 years with a primary diagnosis of trichotillomania (TTM, n = 30) to those with primary OCD (n = 30) and tic disorder (n = 29) on demographic characteristics, internalizing, and externalizing symptoms. Findings suggest that youth with primary TTM score more comparably to youth with tics than those with OCD on internalizing and externalizing symptom measures. Compared to the OCD group, youth in the TTM group reported lower levels of anxiety and depression. Parents of youth in the TTM group also reported fewer internalizing, externalizing, attention, and thought problems than those in the OCD group. Youth with TTM did not significantly differ from those with primary Tic disorders on any measure. Findings suggest that pediatric TTM may be more similar to pediatric tic disorders than pediatric OCD on anxiety, depression, and global internalizing and externalizing problems.     

Sleep-related problems in pediatric obsessive-compulsive disorder

Although attention has been given to presence of sleep related problems (SRPs) in children with psychiatric conditions, little has been reported on SRPs in youth with obsessive-compulsive disorder (OCD). Sixty-six children and adolescents with OCD were administered the Children's Yale Brown Obsessive-Compulsive Scale and completed the Children's Depression Inventory and Multidimensional Anxiety Scale. Their parents completed the Child Behavior Checklist and Children's Obsessive-Compulsive Impact Scale. A subset of youth (n=41) completed a trial of cognitive-behavioral therapy. Frequency of eight specific SRPs was examined in relation to age, gender, OCD symptom severity, child-rated symptoms of depression and anxiety, parent-proxy ratings of internalizing and externalizing problems, and functional impairment. Ninety-two percent of youth experienced at least one SRP, with 27.3% reporting five or more SRPs. Total SRPs were positively associated with OCD symptom severity, child-rated anxiety, and parent-proxy ratings of internalizing problems. Total and several specific SRPs were reduced following cognitive-behavioral treatment. These results suggest that SRPs are relatively common in youth with OCD, are associated with symptom severity, and warrant attention during assessment and treatment.     

Dimensions of religiosity and their relationship to lifetime psychiatric and substance use disorders

OBJECTIVE: The role of religion in mental illness remains understudied. Most prior investigations of this relationship have used measures of religiosity that do not reflect its complexity and/or have examined a small number of psychiatric outcomes. This study used data from a general population sample to clarify the dimensions of religiosity and the relationships of these dimensions to risk for lifetime psychiatric and substance use disorders. METHOD: Responses to 78 items assessing various aspects of broadly defined religiosity were obtained from 2,616 male and female twins from a general population registry. The association between the resulting religiosity dimensions and the lifetime risk for nine disorders assessed at personal interview was evaluated by logistic regression. Of these disorders, five were "internalizing" (major depression, phobias, generalized anxiety disorder, panic disorder, and bulimia nervosa), and four were "externalizing" (nicotine dependence, alcohol dependence, drug abuse or dependence, and adult antisocial behavior). RESULTS: Seven factors were identified: general religiosity, social religiosity, involved God, forgiveness, God as judge, unvengefulness, and thankfulness. Two factors were associated with reduced risk for both internalizing and externalizing disorders (social religiosity and thankfulness), four factors with reduced risk for externalizing disorders only (general religiosity, involved God, forgiveness, and God as judge), and one factor with reduced risk for internalizing disorders only (unvengefulness). CONCLUSIONS: Religiosity is a complex, multidimensional construct with substantial associations with lifetime psychopathology. Some dimensions of religiosity are related to reduced risk specifically for internalizing disorders, and others to reduced risk specifically for externalizing disorders, while still others are less specific in their associations. These results do not address the nature of the causal link between religiosity and risk for illness.     

Beyond treatment effects: comorbid psychopathologies and long-term outcomes among substance-abusing delinquents

Secondary analyses of a randomized clinical trial controlled for treatment condition effects and examined the impact of comorbid psychopathologies on the mental health, physical health, and criminal behavior of 80 substance abusing delinquents approximately 5 years later in emerging adulthood. Overall, emerging adults with a comorbid disorder during adolescence scored higher on psychopathology, criminal behavior, and health problems. Participants with both internalizing and externalizing disorders exhibited more negative outcomes than those with a comorbid externalizing disorder. For the entire sample, more internalizing diagnoses forecasted higher internalizing and aggression scores, more criminality, and poorer physical health. More externalizing disorders predicted higher internalizing, delinquency, and criminality scores, but was unrelated to physical health. More internalizing diagnoses for females but not males predicted greater criminality, and especially more aggressive crimes in emerging adulthood.     

Impulsivity,gender, and response to fenfluramine challenge in borderline personality disorder

Behavioral impulsivity in borderline personality disorder (BPD) is associated with indices of diminished central serotonergic function, independent of suicidal behavior, depression or alcohol use disorder. Many of these studies have been conducted among males in specialized settings. Studies of BPD females, who constitute the majority of BPD patients, are generally conducted in community settings and report inconsistent findings. We studied gender differences in behavioral impulsivity and the prolactin response to D,L-fenfluramine (FEN) in BPD subjects in a community setting. A FEN challenge study was conducted with 64 BPD subjects (20 male, 44 female), and 57 controls (36 male, 21 female). Axis I and II disorders, including BPD, and suicidal histories were assessed by structured interviews. Controls were free of Axis I and II disorders. Impulsivity and aggression were assessed by the Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, Minnesota Multiphasic Personality Inventory-Psychopathic Deviate subscale, and the Brown-Goodwin Lifetime History of Aggression. Male, but not female, BPD subjects had significantly diminished prolactin responses compared to controls. Impulsivity and aggression each predicted prolactin responses. A significant effect of BPD diagnosis on prolactin response was eliminated when impulsivity was co-varied. Impulsivity and aggression were inversely related to delta-prolactin and peak-prolactin responses among male but not female subjects. Gender differences in central serotonergic function may contribute to variations in impulsivity in BPD.     

Effects of the First Step to Success Intervention on Preschoolers with Disruptive Behavior and Comorbid Anxiety Problems

Preschoolers with elevated anxiety symptoms are at high risk not only of developing more severe mental health disorders in later life but are also apt to respond more poorly to intervention if they present with comorbid disruptive behavior. Because early signs of anxiety disorders may not be recognized as such in preschool settings, many children selected for Tier 2 interventions that target externalizing problem behaviors may also have co-occurring anxiety symptoms and disorders. The First Step to Success intervention has recently been adapted for preschoolers with externalizing behaviors and was found to be efficacious in a randomized controlled trial. The current report examines effects of the First Step intervention on a subsample of 38 preschoolers with comorbid anxiety symptoms. Compared to usual-care controls, preschoolers who were assigned to the First Step intervention demonstrated medium-to-large effects in reducing externalizing behavior and improving social functioning outcomes, but had small effects for reductions in internalizing behaviors. Implications for intervening with preschoolers at risk of comorbid disruptive and anxiety behaviors are discussed.     

Agreement between parents and children regarding anxiety and depression diagnoses in children with asthma

This study examined parent-child agreement regarding anxiety and depressive disorders in youth with asthma and evaluated key demographic and health differences associated with parent-child agreement. Of 756 outpatient youth with asthma, 122 (16.0%) were diagnosed with a DSM-IV anxiety or depression disorder using the Diagnostic Interview Schedule for Children (C-DISC). Parents reported on internalizing symptoms using the Child Behavior Checklist (CBCL). Logistic regression analyses were used to examine factors related to parent- and child-reported symptom agreement. Low rates of agreement (48.9%) between youth and parents regarding diagnosis of a DSM-IV anxiety or depressive disorder were found among youth with asthma. Increased agreement was associated with higher externalizing behavior score on the CBCL and more anxiety and depressive symptoms on the C-DISC. Children without behavioral problems and with less severe anxiety and depression were recognized significantly less often by their parents.     

Parents’ State and Trait Anxiety: Relationships with Anxiety Severity and Treatment Response in Adolescents with Autism Spectrum Disorders

Comorbid anxiety is common among children with Autism Spectrum Disorder (ASD), and parents of children with ASD are more likely to have anxiety disorders. This study investigated the relationship between parents’ state and trait anxiety and parent-reported internalizing and externalizing symptoms among adolescents (n = 30) with ASD, as well as the relationship of parents’ anxiety symptoms and adolescent treatment response in the context of a randomized controlled trial. Parental state anxiety correlated with severity of adolescent anxiety, and trait anxiety in parents correlated with parent-reported adolescent internalizing and externalizing symptoms. Also, parents of adolescent treatment responders experienced a decrease in their own trait anxiety. Findings highlight the importance of considering parental anxiety when targeting anxiety among youth with ASD.