- Email: [email protected]
2: Peer victimization and multiple mental and school health indicators among elementary school-aged youth
Abstracts / 40 (2007) S1–S18
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adolescents’ perspective given their more serious immediate and long-term health consequences when engaging in sexual relationships. Results: The female cohort included 206 female respondents who had ever had sex. The prevalence of STIs (Chlamydia or Gonorrhea) was 13.8 % among the female cohort. Sixty seven % (n ⫽ 332) of dyads were non-reciprocal, and 33% were reciprocal dyads. Among the dyads in which a female identified her sexual partner as her main partner, most (89%) of the males identified the female as a casual partner. Among the dyads in which a female identified her sexual partner as her casual partner, about half (51%) of the males also reported the female as a casual partner, but the other half (49%) reported the female as a main partner. Conclusions: The relationships reported by female adolescents were often not reciprocal. Female adolescents’ perceptions of whether their sexual relationships are primary relationships or casual are often discordant with their male partners’. This study challenges fundamental assumptions of couple interventions for STI treatment. STI interventions must acknowledge that female and male adolescents in a relationship may not be in agreement about whom their primary partners are and this has important implications for counseling, testing, and treatment among adolescent couples. Source of Support: National Institutes of Health grants 5 UO1 AI47639.
Results: Four cognitive markers and six brain function markers were identified and entered into a discriminant function analysis (DFA). The DFA revealed that the following cognitive markers: sustained attention, response variability, impulsivity and intrusions together with the brain arousal EEG marker best differentiated ADHD from controls. The classification of this DFA showed a sensitivity of 77% and a specificity of 76%. An overall ‘severity index’ was calculated as a global score of the ten markers, which provides a ‘sliding scale’ of predictive power. The optimal cut-off point of this index showed a positive predictive power of 88% and a negative predictive power of 73%. Conclusions: These ‘ADHD markers’ provide an objective frame of reference to support clinical evaluation and predict diagnosis. By adopting an objective neurocognitive ADHD profile, as revealed here, clinicians may also observe changes within each of the markers in response to any treatment intervention. The cognitive markers alone provide a great deal of converging evidence of sensitivity and is easy to administer. Additional brain function markers could be used to examine more fine-grained mechanisms, providing levels of detail in relation to underlying neurobiology of ADHD individuals. These markers could be employed as an evidence-based approach to diagnostic decision support and treatment evaluation, which would be helpful in any clinical evaluation of a patient with ADHD.
SESSION V: COGNITIVE FUNCTIONING AND ADOLESCENT HEALTH OUTCOMES
2.
1. A PROFILE OF COGNITIVE AND BRAIN FUNCTION MARKERS FOR DIAGNOSTIC USE IN ADHD Daniel F. Hermens, PhD1,3, Simon D. Clarke, MD1,2, Michael R. Kohn, MD1,2, C. Richard Clark, PhD3,4, Nick J. Cooper, BA3, Hannah A.D. Keage, BA4, Evian Gordon, MD PhD1,4, Leanne M. Williams, PhD1,4. 1The Brain Dynamics Centre, Westmead Millennium Institute, Westmead Hospital and Western Clinical School, University of Sydney, Australia; 2Centre for Research into Adolescents’ Health (CRASH), Westmead Hospital, Australia; 3Brain Resource International Database, Australia; 4Cognitive Neuroscience Unit, Flinders University, Adelaide, Australia Objective: Attention Deficit Hyperactivity Disorder (ADHD) is a common, neurodevelopmental disorder, often comorbid with learning, internalizing and externalizing features. Both diagnosis and treatment of ADHD remain controversial and there is a need for new objective assessment tools, complementing clinical information for making diagnostic and treatment decisions. We used a standardized approach to identify cognitive and brain function markers that define an objective ADHD profile to be used diagnostically. Patients and Methods: One-hundred-seventy-five (175) ADHD children/adolescents and 175 matched healthy controls were tested on a comprehensive battery of cognitive (both general and social) tests. They were also tested on electroencephalogram (EEG) measures of brain arousal and cognitive task-related brain activity. A new method for standardizing scores across age and sex was employed. We identified the measures that differentiated ADHD at the highest confidence levels. The combination of these measures, which classified ADHD with the greatest sensitivity, was then determined.
PEER VICTIMIZATION AND MULTIPLE MENTAL AND SCHOOL HEALTH INDICATORS AMONG ELEMENTARY SCHOOL-AGED YOUTH Melissa F. Peskin, PhD, Jaana Juvonen, PhD, Ryan Whitworth, MPH, Michael Windle, PhD, Patricia Dittus, PhD, Diana Paulk, PhD, Mark A. Schuster, MD, PhD, & Susan R. Tortolero, PhD. University of Texas at Houston; University of California at Los Angeles–RAND; University of Alabama-Birmingham; CDC Purpose: Studies of middle and high school youth reveal peer victimization to be associated with several mental and school health outcomes. Such studies among younger children, however, are limited. Peer victimization is prevalent among young adolescents; thus, mental and school health related consequences should be examined. Additionally, few studies have examined race/ ethnicity and perpetration (bullying) as moderators of the relationship between peer victimization and these outcomes. The purpose of this study is: 1) to examine the association between peer victimization and mental and school health indicators among early adolescents, adjusted for demographic covariates and perpetration and 2) to examine race/ethnicity and perpetration as moderators of these associations. Study Design: Cross-sectional. Setting: Data were collected at 3 geographic sites in the US for Phase I of the Healthy Passages study. Participants: A 2-stage probability sampling procedure was used to sample 650 5th-grade students and their primary caregivers. The African-American, Hispanic, and White participants were 10-14 years old, with a weighted mean age of 11.31 (SD ⫽ 0.51). Primary Outcome Measures: Negative affect (PANAS Negative Affect scale), Emotional symptoms (Strengths and Difficulties Emotional Symptoms scale), Hyperactivity (Strengths and Difficulties Hyperactivity scale), Global self-worth (Harter’s Global Self-Worth Scale), School functioning (PEDS QL School Functioning scale);
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Abstracts / 40 (2007) S1–S18
Multiple linear regression models were run to describe the association between peer victimization and each outcome. Results: Peer victimization was associated with greater negative affect, increased emotional symptoms, increased hyperactivity, lower global self-worth, and decreased school functioning (p ⬍ 0.05 for each). R2 values ranged from 0.10 to 0.27. Race/ethnicity and perpetration did not act as moderators of peer victimization for emotional symptoms, hyperactivity, or school functioning. However, perpetration was a moderator of peer victimization for negative affect (Adj Wald F ⫽ 8.97, p ⬍ 0.05). In addition, both race/ethnicity (Adj Wald F ⫽ 6.24, p ⬍ 0.05) and perpetration (Adj Wald F ⫽ 13.7, p ⬍ 0.05) were moderators of peer victimization when global self-worth was the primary outcome. Conclusions: Peer victimization is associated with mental and school health problems among early adolescents, even after adjusting for covariates including actual perpetration of bullying. Early intervention may reduce peer victimization among young people. Source of Support: Centers for Disease Control and Prevention.
3. THE EFFECT OF SCHOOLS ON TEENAGE DEPRESSION AND PROBLEM BEHAVIOURS Simon Denny, FRACP, MPH, Susan Morton FAPHM, PhD, Peter Watson, FRACP. Department of Paediatrics, University of Auckland, Auckland, New Zealand Purpose: The objectives of this study are to describe the schoollevel variation in student depression scores and conduct problems using data from a nationally-representative youth health survey in New Zealand (Youth 2000). Methods: Data were collected from a random selection of high school students during 2001 using laptop computers with multimedia graphics and audiofiles. The overall response rate was 64.3% (n ⫽ 9570). The main outcome variables were the Reynolds Adolescent Depression Scale (RADS) and a conduct problem scale based on DSM IV criterion. Possible scores for RADS range from 30 to 120 with higher scores indicating higher levels of depressive symptomatology. Possible scores for the conduct scale range from 0 to 11 with higher scores indicating more problem behaviours. Random effects models were used to examine the school-level variance in outcomes and the effect of schools on student level outcomes. Results: Among the 114 high schools the average RADS score was 59 and average conduct score was 1.2. There was a wide range of average scores between schools with a range of 48.9 to 72.6 for the RADS and 0.27 to 2.35 for the conduct problem scale. For the depression score, the between-school variance was 7.474 and the variance between students within schools was 231.45. The intraclass correlation was 0.031 meaning only 3.1% of the total variance in the depression score could be attributable to differences between schools. For conduct problems the between-school variance was 0.077 and the variance between students within schools was 2.33 with 3.2% of the total variance attributable to differences between schools. When age, sex and socio-economic student-level variables were controlled for the intra-class correlation was reduced even further to 1.1% and 1.3% respectively. Conclusion: While the range of average scores between schools in outcomes like depression and conduct problems is high, the actual variance that may be attributable to differences between schools is low. This is even further reduced after controlling for student level demographic variables that may influence school selection. Caution needs to be taken when interpreting individual school averages in student-level outcomes when intra-class correlations are
low as differences between schools may reflect underlying between-student variation. This suggests that interventions in school settings where intra-class correlations are low should target students rather than schools themselves. Sources of Support: This research was supported by grant 00/208 from the Health Research Council of New Zealand. Portables Plus and the Starship Foundation provided support with laptop computers.
4. EFFECTS OF MENSTRUAL FUNCTION AND WEIGHT RESTORATION ON COGNITIVE FUNCTION IN FEMALES WITH ADOLESCENT-ONSET ANOREXIA NERVOSA Harold T. Chui, BSc, Bruce Christensen, PhD, Robert B. Zipursky, MD, and Debra K. Katzman, MD. Institute of Medicine Science, University of Toronto, Toronto, Ontario, Canada Purpose: Cognitive dysfunction is a common feature reported in patients with anorexia nervosa (AN). While current evidence suggests that cognition improves with weight gain, it remains unclear whether cognition recovers fully or equally across all neuropsychological domains. The purpose of this study was to understand whether cognitive functioning was associated with clinical measures of recovery such as the resumption of regular menstrual function. Methods: This cross-sectional study included 67 women (age ⫽ 21.3 ⫾ 2.3 years) with a history of adolescent-onset AN treated in a tertiary care facility 6.5 ⫾ 1.7 years earlier and 42 healthy controls (age ⫽ 20.7 ⫾ 2.5 years). All participants underwent an MRI scan of the brain as well as a clinical and cognitive evaluation. Subjects were grouped by 1) weight recovery (body mass index (BMI) ⱖ 19.5 kg/m2 (n ⫽ 53) and ⬍19.5 kg/m2 (n ⫽ 14) and 2) menstrual status (n ⫽ 20 regular menses, n ⫽ 29 oral contraceptive pill (OCP), n ⫽ 18 irregular or absent menses). Scores from the Woodcock Johnson III - Tests of Cognitive Abilities and Tests of Achievement, Hopkins Verbal Learning Test and Wechsler Memory Scale - Revised were compared among subject and control groups using analysis of variance. Results: Post-hoc analysis (Tukey HSD) revealed that compared to controls, subjects with a history of AN who had irregular or absent menses at the time of study had significant deficits across a range of cognitive domains including oral language (p ⫽ .009), verbal ability (p ⫽ .027), cognitive efficiency (p ⫽ .029) and working memory (p ⫽ .045). Subjects who had return of normal menses or were on OCP did not differ significantly from controls on any cognitive measures. Cognitive functioning was not associated with the degree of weight recovery. Conclusions: This study suggests that failure to resume normal menses may contribute to persistence of cognitive deficits in patients with adolescent-onset AN. Estrogen is known to affect diverse brain functions including learning and memory. Some studies suggest that estrogen may reduce the risk of cognitive decline in postmenopausal women. Like postmenopausal women, women with AN are amenorrheic and have low circulating estrogen levels. It is thus biologically plausible that an amenorrhea-associated decline in estrogen may be associated with cognitive impairment in AN, while the return of menses and therefore normal circulating serum estrogen levels may contribute to the recovery of cognitive function. Our results underscore the importance of weight gain and resumption of menses in patients with AN. Sources of Support: The Ontario Mental Health Foundation, Ontario Graduate Scholarship and RESTRACOMP, Research Institute, Hospital for Sick Children.
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adolescents’ perspective given their more serious immediate and long-term health consequences when engaging in sexual relationships. Results: The female cohort included 206 female respondents who had ever had sex. The prevalence of STIs (Chlamydia or Gonorrhea) was 13.8 % among the female cohort. Sixty seven % (n ⫽ 332) of dyads were non-reciprocal, and 33% were reciprocal dyads. Among the dyads in which a female identified her sexual partner as her main partner, most (89%) of the males identified the female as a casual partner. Among the dyads in which a female identified her sexual partner as her casual partner, about half (51%) of the males also reported the female as a casual partner, but the other half (49%) reported the female as a main partner. Conclusions: The relationships reported by female adolescents were often not reciprocal. Female adolescents’ perceptions of whether their sexual relationships are primary relationships or casual are often discordant with their male partners’. This study challenges fundamental assumptions of couple interventions for STI treatment. STI interventions must acknowledge that female and male adolescents in a relationship may not be in agreement about whom their primary partners are and this has important implications for counseling, testing, and treatment among adolescent couples. Source of Support: National Institutes of Health grants 5 UO1 AI47639.
Results: Four cognitive markers and six brain function markers were identified and entered into a discriminant function analysis (DFA). The DFA revealed that the following cognitive markers: sustained attention, response variability, impulsivity and intrusions together with the brain arousal EEG marker best differentiated ADHD from controls. The classification of this DFA showed a sensitivity of 77% and a specificity of 76%. An overall ‘severity index’ was calculated as a global score of the ten markers, which provides a ‘sliding scale’ of predictive power. The optimal cut-off point of this index showed a positive predictive power of 88% and a negative predictive power of 73%. Conclusions: These ‘ADHD markers’ provide an objective frame of reference to support clinical evaluation and predict diagnosis. By adopting an objective neurocognitive ADHD profile, as revealed here, clinicians may also observe changes within each of the markers in response to any treatment intervention. The cognitive markers alone provide a great deal of converging evidence of sensitivity and is easy to administer. Additional brain function markers could be used to examine more fine-grained mechanisms, providing levels of detail in relation to underlying neurobiology of ADHD individuals. These markers could be employed as an evidence-based approach to diagnostic decision support and treatment evaluation, which would be helpful in any clinical evaluation of a patient with ADHD.
SESSION V: COGNITIVE FUNCTIONING AND ADOLESCENT HEALTH OUTCOMES
2.
1. A PROFILE OF COGNITIVE AND BRAIN FUNCTION MARKERS FOR DIAGNOSTIC USE IN ADHD Daniel F. Hermens, PhD1,3, Simon D. Clarke, MD1,2, Michael R. Kohn, MD1,2, C. Richard Clark, PhD3,4, Nick J. Cooper, BA3, Hannah A.D. Keage, BA4, Evian Gordon, MD PhD1,4, Leanne M. Williams, PhD1,4. 1The Brain Dynamics Centre, Westmead Millennium Institute, Westmead Hospital and Western Clinical School, University of Sydney, Australia; 2Centre for Research into Adolescents’ Health (CRASH), Westmead Hospital, Australia; 3Brain Resource International Database, Australia; 4Cognitive Neuroscience Unit, Flinders University, Adelaide, Australia Objective: Attention Deficit Hyperactivity Disorder (ADHD) is a common, neurodevelopmental disorder, often comorbid with learning, internalizing and externalizing features. Both diagnosis and treatment of ADHD remain controversial and there is a need for new objective assessment tools, complementing clinical information for making diagnostic and treatment decisions. We used a standardized approach to identify cognitive and brain function markers that define an objective ADHD profile to be used diagnostically. Patients and Methods: One-hundred-seventy-five (175) ADHD children/adolescents and 175 matched healthy controls were tested on a comprehensive battery of cognitive (both general and social) tests. They were also tested on electroencephalogram (EEG) measures of brain arousal and cognitive task-related brain activity. A new method for standardizing scores across age and sex was employed. We identified the measures that differentiated ADHD at the highest confidence levels. The combination of these measures, which classified ADHD with the greatest sensitivity, was then determined.
PEER VICTIMIZATION AND MULTIPLE MENTAL AND SCHOOL HEALTH INDICATORS AMONG ELEMENTARY SCHOOL-AGED YOUTH Melissa F. Peskin, PhD, Jaana Juvonen, PhD, Ryan Whitworth, MPH, Michael Windle, PhD, Patricia Dittus, PhD, Diana Paulk, PhD, Mark A. Schuster, MD, PhD, & Susan R. Tortolero, PhD. University of Texas at Houston; University of California at Los Angeles–RAND; University of Alabama-Birmingham; CDC Purpose: Studies of middle and high school youth reveal peer victimization to be associated with several mental and school health outcomes. Such studies among younger children, however, are limited. Peer victimization is prevalent among young adolescents; thus, mental and school health related consequences should be examined. Additionally, few studies have examined race/ ethnicity and perpetration (bullying) as moderators of the relationship between peer victimization and these outcomes. The purpose of this study is: 1) to examine the association between peer victimization and mental and school health indicators among early adolescents, adjusted for demographic covariates and perpetration and 2) to examine race/ethnicity and perpetration as moderators of these associations. Study Design: Cross-sectional. Setting: Data were collected at 3 geographic sites in the US for Phase I of the Healthy Passages study. Participants: A 2-stage probability sampling procedure was used to sample 650 5th-grade students and their primary caregivers. The African-American, Hispanic, and White participants were 10-14 years old, with a weighted mean age of 11.31 (SD ⫽ 0.51). Primary Outcome Measures: Negative affect (PANAS Negative Affect scale), Emotional symptoms (Strengths and Difficulties Emotional Symptoms scale), Hyperactivity (Strengths and Difficulties Hyperactivity scale), Global self-worth (Harter’s Global Self-Worth Scale), School functioning (PEDS QL School Functioning scale);
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Abstracts / 40 (2007) S1–S18
Multiple linear regression models were run to describe the association between peer victimization and each outcome. Results: Peer victimization was associated with greater negative affect, increased emotional symptoms, increased hyperactivity, lower global self-worth, and decreased school functioning (p ⬍ 0.05 for each). R2 values ranged from 0.10 to 0.27. Race/ethnicity and perpetration did not act as moderators of peer victimization for emotional symptoms, hyperactivity, or school functioning. However, perpetration was a moderator of peer victimization for negative affect (Adj Wald F ⫽ 8.97, p ⬍ 0.05). In addition, both race/ethnicity (Adj Wald F ⫽ 6.24, p ⬍ 0.05) and perpetration (Adj Wald F ⫽ 13.7, p ⬍ 0.05) were moderators of peer victimization when global self-worth was the primary outcome. Conclusions: Peer victimization is associated with mental and school health problems among early adolescents, even after adjusting for covariates including actual perpetration of bullying. Early intervention may reduce peer victimization among young people. Source of Support: Centers for Disease Control and Prevention.
3. THE EFFECT OF SCHOOLS ON TEENAGE DEPRESSION AND PROBLEM BEHAVIOURS Simon Denny, FRACP, MPH, Susan Morton FAPHM, PhD, Peter Watson, FRACP. Department of Paediatrics, University of Auckland, Auckland, New Zealand Purpose: The objectives of this study are to describe the schoollevel variation in student depression scores and conduct problems using data from a nationally-representative youth health survey in New Zealand (Youth 2000). Methods: Data were collected from a random selection of high school students during 2001 using laptop computers with multimedia graphics and audiofiles. The overall response rate was 64.3% (n ⫽ 9570). The main outcome variables were the Reynolds Adolescent Depression Scale (RADS) and a conduct problem scale based on DSM IV criterion. Possible scores for RADS range from 30 to 120 with higher scores indicating higher levels of depressive symptomatology. Possible scores for the conduct scale range from 0 to 11 with higher scores indicating more problem behaviours. Random effects models were used to examine the school-level variance in outcomes and the effect of schools on student level outcomes. Results: Among the 114 high schools the average RADS score was 59 and average conduct score was 1.2. There was a wide range of average scores between schools with a range of 48.9 to 72.6 for the RADS and 0.27 to 2.35 for the conduct problem scale. For the depression score, the between-school variance was 7.474 and the variance between students within schools was 231.45. The intraclass correlation was 0.031 meaning only 3.1% of the total variance in the depression score could be attributable to differences between schools. For conduct problems the between-school variance was 0.077 and the variance between students within schools was 2.33 with 3.2% of the total variance attributable to differences between schools. When age, sex and socio-economic student-level variables were controlled for the intra-class correlation was reduced even further to 1.1% and 1.3% respectively. Conclusion: While the range of average scores between schools in outcomes like depression and conduct problems is high, the actual variance that may be attributable to differences between schools is low. This is even further reduced after controlling for student level demographic variables that may influence school selection. Caution needs to be taken when interpreting individual school averages in student-level outcomes when intra-class correlations are
low as differences between schools may reflect underlying between-student variation. This suggests that interventions in school settings where intra-class correlations are low should target students rather than schools themselves. Sources of Support: This research was supported by grant 00/208 from the Health Research Council of New Zealand. Portables Plus and the Starship Foundation provided support with laptop computers.
4. EFFECTS OF MENSTRUAL FUNCTION AND WEIGHT RESTORATION ON COGNITIVE FUNCTION IN FEMALES WITH ADOLESCENT-ONSET ANOREXIA NERVOSA Harold T. Chui, BSc, Bruce Christensen, PhD, Robert B. Zipursky, MD, and Debra K. Katzman, MD. Institute of Medicine Science, University of Toronto, Toronto, Ontario, Canada Purpose: Cognitive dysfunction is a common feature reported in patients with anorexia nervosa (AN). While current evidence suggests that cognition improves with weight gain, it remains unclear whether cognition recovers fully or equally across all neuropsychological domains. The purpose of this study was to understand whether cognitive functioning was associated with clinical measures of recovery such as the resumption of regular menstrual function. Methods: This cross-sectional study included 67 women (age ⫽ 21.3 ⫾ 2.3 years) with a history of adolescent-onset AN treated in a tertiary care facility 6.5 ⫾ 1.7 years earlier and 42 healthy controls (age ⫽ 20.7 ⫾ 2.5 years). All participants underwent an MRI scan of the brain as well as a clinical and cognitive evaluation. Subjects were grouped by 1) weight recovery (body mass index (BMI) ⱖ 19.5 kg/m2 (n ⫽ 53) and ⬍19.5 kg/m2 (n ⫽ 14) and 2) menstrual status (n ⫽ 20 regular menses, n ⫽ 29 oral contraceptive pill (OCP), n ⫽ 18 irregular or absent menses). Scores from the Woodcock Johnson III - Tests of Cognitive Abilities and Tests of Achievement, Hopkins Verbal Learning Test and Wechsler Memory Scale - Revised were compared among subject and control groups using analysis of variance. Results: Post-hoc analysis (Tukey HSD) revealed that compared to controls, subjects with a history of AN who had irregular or absent menses at the time of study had significant deficits across a range of cognitive domains including oral language (p ⫽ .009), verbal ability (p ⫽ .027), cognitive efficiency (p ⫽ .029) and working memory (p ⫽ .045). Subjects who had return of normal menses or were on OCP did not differ significantly from controls on any cognitive measures. Cognitive functioning was not associated with the degree of weight recovery. Conclusions: This study suggests that failure to resume normal menses may contribute to persistence of cognitive deficits in patients with adolescent-onset AN. Estrogen is known to affect diverse brain functions including learning and memory. Some studies suggest that estrogen may reduce the risk of cognitive decline in postmenopausal women. Like postmenopausal women, women with AN are amenorrheic and have low circulating estrogen levels. It is thus biologically plausible that an amenorrhea-associated decline in estrogen may be associated with cognitive impairment in AN, while the return of menses and therefore normal circulating serum estrogen levels may contribute to the recovery of cognitive function. Our results underscore the importance of weight gain and resumption of menses in patients with AN. Sources of Support: The Ontario Mental Health Foundation, Ontario Graduate Scholarship and RESTRACOMP, Research Institute, Hospital for Sick Children.