. .‘-' . (r v— “3': "-3... :2 by willlllllllllllllllll 1293 01770 4374 This is to certify that the dissertation entitled SEROTONERGIC FUNCTION, SOCIOENVIRONMENTAL VARIABLES, AND BEHAVIORAL AND AFFECTIVE DYSREGULATION IN ALCOHOLICS AND THEIR MALE AND FEMALE OFFSPRING presented by Geoffrey Raymond Twitchell has been accepted towards fulfillment of the requirements for Ph- D - degree in lsychology. Q/ fir/749‘ Major profe or Date 5’3“ C] 6' MS U i: an Affirmative Action/Equal Opportunity Institution 0-12771 LIBRARY Michigan State University PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINE return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 1“ WWW“ SEROTONERGIC FUNCTION, SOCIOENVIRONMENTAL VARIABLES, AND BEHAVIORAL AND AFFECTIVE DYSREGULATION IN ALCOHOLICS AND THEIR MALE AND FEMALE OFFSPRING By Geoffrey Raymond Twitchell A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTORATE OF PHILOSOPHY Department of Psychology 1999 ABSTRACT SEROTONERGIC FUNCTION, SOCIOENVIRONMENTAL VARIABLES, AND BEHAVIORAL AND AFFECTIVE DYSREGULATION IN ALCOHOLICS AND THEIR MALE AND FEMALE OFFSPRING By Geoffrey Raymond Twitchell Serotonergic (5-HT) dysfunction has been implicated in both behavioral and affective dysregulation in clinically sampled adults. However, studies of these relationships in children /adolescents have produced inconsistent results; the relationship between S-HT dysfunction and affective dysregulation has been largely unexamined; social and environmental variables have been found to complicate relationships between 5-HT and behavior; and no studies have examined 5-HT’s potential role in the . development of children of alcoholics who are at increased risk for later problems such as alcoholism and aggressiveness. In part, this study examined relationships among biology [whole blood S-HT], environment [parental characteristics], and behavior [irritable impulsive aggressiveness and affective dysregulation]. The sample consisted of 50 families with 150 subjects having usable whole blood 5-HT samples, including 88 community-recruited adult alcoholic and control parents and their 45 male and 17 female Offspring (M = 10.88 i 2.03 years). The study also examined effects of potential moderating variables (e.g., pubertal status) on relationships between 5-HT dysfunction and behavioral and affective dysregulation in one of the largest samples of children to date. In adults, whole blood S-HT was positively related to affective dysregulation [current depression] (N = 88, 1: = .32, p < .01). In children, both maternal violence and maternal alcohol consumption were positively related to child behavioral dysregulation [CBCL Attack scores] ( 2 = .46, [F(4,41) = 8.75, p < .001]) and maternal alcohol consumption was positively related to child affective dysregulation [CBCL Anxious/Depressed scores] (R2: .53, [F(5,45) = 9.97, p < .001]). Neither relationships between whole blood 5-HT and either alcohol dependence or ASPD diagnosis in adults nor relationships between socioenvironmental characteristics and child whole blood S-HT were supported. Importantly, however, while few of the formal hypotheses were supported in the full data sets, the primary hypothesized relationships did emerge within subsets. In low SES ASPD men, whole blood S-HT was significantly and positively related to affective dysregulation [NED-FF I Neuroticism scores] (11 = 12, r = .73, p < .01). In children, results indicated that whole blood 5-HT was significantly and negatively related to both behavioral (n = 14, r = -.63, p = .02) and affective (n = 14, r =-. 57, p = .04) dysregulation in pubescent, but not in prepubescent children (n = 48, r_ = -.06, p = .69; n = 48, r = -.15, p = .31, respectively). For the relationships between parental characteristics and child behavior, both main and interaction effects were found. For example, maternal characteristics were related to child behavior in prepubescent, but not pubescent children. Some results and interaction effects were discussed within a developmental framework. Clinical and research implications and study limitations were discussed. It was recommended that future research evaluate moderating variables such as pubertal status, gender, social competence, and SES. To Clark, whose love and support have been the best things I’ve known. iv ACKNOWLEDGMENTS I am indebted to the following people for their instrumental assistance and support during the completion of this work: Dr. Hiram E. Fitzgerald, who perfectly balanced scientific rigor with the need to complete the task and move on with life. Dr. Robert A. Zucker, who has taught me to critically evaluate my thoughts and ideas. His mentoring has been most valuable. Dr. Robert Caldwell, who provided positive feedback when I needed it and it was appropriate. The ability to recognize and utilize these developmental windows to enrich a person is a skill I strive to obtain and utilize. Dr. Alexander von Eye, who modeled “good science” by emphasizing the importance of balancing hypothesis testing with exploratory analyses. His statistical expertise and his willingness to teach me more sophisticated strategies to examine my data was appreciated. Dr. Edwin Cook, Jr., Department of Psychiatry, University of Chicago, for his continued collaboration with this work, and his role in performing the sample assays. Dr. Gregory Hanna, Department of Psychiatry, University of Michigan, for his continued scientific collaboration. Susan Refior, whose willingness to facilitate my successful interactions with these families was greatly appreciated. My parents, who financially supported me during the writing of this dissertation. Without their help I would have floundered. Most of all, I am especially indebted to Dr. Tom L. Smith, who has been my best friend and mentor for the past decade. Tom selflessly gave me endless hours of invaluable statistical and interpretive guidance. Additionally, he effortlessly generated the motivation and hope that proved to be essential to my completion of the project. As always, Tom knew what I needed and never hesitated to graciously provide it. Tom’s scientific expertise, generosity, and wisdom are gifts that have made a lasting impact on me. vi TABLE OF CONTENTS LIST OF TABLES ..................................................... xiv LIST OF FIGURES ................................................... xvii INTRODUCTION ....................................................... 1 Background Of the Current Study ..................................... 3 Serotonergic Functioning ............................................ 5 Anatomy of the Serotonin System ............................... 6 Neurotransmission ........................................... 9 Clinical Advances .......................................... 12 Indices of Serotonergic Activity ............................... 15 REVIEW OF THE LITERATURE ......................................... 19 Serotonergic Function and Alcoholism ................................ l9 Serotonin and Alcohol Preference and Consumption ............... 19 Serotonergic Dysfunction Is Inconsistently Identified in Alcoholics . . . 21 Serotonergic Function and Aggression ................................ 28 Animal Studies of Overt Aggression ............................ 28 Human Studies of Aggression Directed Inward ................... 29 Human Studies of Overt Aggression ............................ 31 Is There a Relationship Between Serotonin and Impulsive Violence? . . 33 Personality Data Support a Relationship Between Serotonin and Impulsivity .......................................... 41 Early Onset Violent Alcoholics ................................ 43 vii Examining The Relationships Between 5-HT Function, Alcoholism, Impulsive Aggression, Major depression, and Suicide ....................................... 49 Limitations of Studies of Serotonin and Aggression .......... 53 Sociobiological Functions of Aggression .................. 53 Studies With Children And Adolescents ....... ' ........................ 54 Impulsive Aggression in Children and Adolescents ................ 54 Serotonergic Function and Phenotypic Expression ........... 60 Serotonergic Function in Children of Alcoholics ............ 60 Studies of Depression and 5-HT Function in Children .............. 62 Social Competence is Related to 5-HT Function in Non-Human Primates and Children ......................................... 63 Socioenvironmental Effects on Serotonergic Function .............. 66 Summary ....................................................... 68 STATEMENT OF THE PROBLEM ........................................ 7O HYPOTHESES ........................................................ 72 METHOD ............................................................ 74 Subjects ........................................................ 74 Exclusionary Criteria ........................................ 76 Family Composition ........................................ 77 Sampling Design ........................................... 77 Procedure ....................................................... 78 viii Participant Consent ......................................... 78 Materials and Preparation .................................... 79 Health History Questionnaire ........................... 79 Venipuncture ........................................ 80 Sample Storage and Transportation ....................... 80 Whole Blood 5-HT Assay .............................. 80 Measures ....................................................... 8] Demographic Variables ...................................... 81 Parental Occupation ................................... 81 Parental Education .................................... 81 Family Income ....................................... 81 Identifying Low SES and High SES Subjects ............... 82 Alcohol and Cigarette Smoking ................................ 82 Assessing Antisocial Personality Disorder ....................... 84 Assessing Parental Irritable Impulsive Aggression ................. 84 Assessing Parental Affective Modulation ........................ 85 NEO-F F I Neuroticism ................................. 85 Hamilton Rating Scale for Depression .................... 85 Assessing Child Behavioral and Affective Modulation .............. 86 Child Irritable Impulsive Aggression ...................... 87 Child Affective Modulation ............................. 87 Assessing Child Social Competence ............................ 87 ix Assessing Pubertal Status .................................... 88 Socioenvironmental Variables ................................. 89 Assessing Parental Alcohol Dependence Diagnosis .......... 89 Parental Physical Aggression ............................ 89 Measuring Low Parental Functioning ( Axis V DSM-IV Global Assessment of Functioning) ....................... 91 Assessing Parental Alcohol Consumption .................. 92 RESULTS ............................................................ 93 Methodological Considerations ...................................... 93 Potential Covariates for Adult Analyses ......................... 93 Season ............................................. 93 Body Mass Index (BMI) ............................... 93 Cigarette Smoking .................................... 94 Potential Covariates for Child Analyses ......................... 95 Age ................................................ 95 Diet and Diurnal Variation .............................. 95 Season ............................................. 96 Child Body Mass Index (BMI) .......................... 96 Demographic Characteristics, Independent, and Dependent Variables ........ 97 Hypothesis l-Parental Whole Blood S-HT, Antisocial Personality Disorder, and Alcohol Dependence ........................................ 97 Hypothesis 2-Parental Whole Blood 5-HT, Irritable Impulsive Aggressiveness, and Poor Affective Modulation ................................ 98 Potential Mediating and Moderating Relationships ................. 98 Gender ............................................. 98 Socioeconomic Status (SES) ............................ 99 ASPD as a Moderator ................................ 100 Hypothesis 3-Whole blood 5-HT and Both Child Irritable Impulsive Aggression and Poor Affective Modulation ............................... 102 Potential Mediating and Moderating Relationships ................ 103 Gender ............................................ 103 Pubertal Status ...................................... 103 Social Competence ................................... 105 Hypothesis 4-Socioenvironmental Variables and Child Whole Blood 5-HT . . 108 Potential Mediating and Moderating Relationships ................ 108 Gender ............................................ 108 Pubertal Status ...................................... 109 Social Competence ................................... l 10 Hypothesis 5-Socioenvironmental Variables and Child Behavioral and Affective Regulation ............................................... 1 12 Potential Mediating and Moderating Relationships ................ 115 Gender ............................................ 115 Pubertal Status ...................................... 1 19 xi Social Competence ................................... 124 Hypothesis 6-Socioenvironmental Variables and Child Whole Blood 5-HT as Independent Predictors of Child Irritable Impulsive Aggression and Poor Affective Regulation ....................................... 129 The Probability of Type 1 Versus Type 2 Error ........................ 129 Summary of Main Findings ........................................ 129 DISCUSSION ........................................................ 132 Relationships Between Adult Whole Blood 5-HT and Both Antisocial Personality Disorder and Alcoholism .................................... 132 Relationships Between Adult Whole Blood 5-HT and Both Affective Modulation and Irritable Impulsive Aggressiveness ......................... 132 SES Moderates the Relationship Between Whole Blood 5-HT and Depression ......................................... l3 3 ASPD Moderates the Relationship Between Whole Blood 5-HT and Affective Dysregulation in LSES Men ................... 133 Relationships Between Child Whole Blood 5-HT and Both Irritable Impulsive Aggressiveness and Poor Affective Modulation .................. 134 Puberty Moderates the Relationship Between Child Whole Blood 5-HT and Behavior ....................................... 134 Social Competence Moderates the Relationship Between Child Whole Blood 5-HT and Behavior in Boys ...................... 134 Socioenvironmental Variables and Child Whole Blood 5-HT ............. 135 xii Relationships Between Socioenvironmental Variables and Both Child Irritable Impulsive Aggression and Poor Affective Modulation ............. 135 Socioenvironmental Variables and Child Whole Blood 5-HT as Independent Predictors of Child Irritable Impulsive Aggressiveness and Poor Affective Regulation ....................................... 136 Contributions to the Literature ...................................... 136 The Importance of Moderating Variables ....................... 138 Results Within the Context of the Reviewed Literature ............ 138 Methodological Limitations ........................................ 142 Implications and Future Directions .................................. 144 APPENDIX A ........................................................ 151 APPENDIX B ........................................................ 219 APPENDIX C ........................................................ 252 LIST OF REFERENCES ................................................ 262 xiii LIST OF TABLES 1. Correlations Among Parental Whole Blood 5-HT, Potential Covariates, and Dependent Variables (N = 88) ............................................... 151 2. Correlations Among Paternal Whole Blood 5-HT, Potential Covariates, and Dependent Variables (_n_ == 45) ............................................... 153 3. Correlations Among Maternal Whole Blood 5-HT, Potential Covariates, and Dependent Variables(n = 43) ....................................... 155 4. Correlations Among Child Whole Blood 5-HT, Potential Covariates, and Dependent Variables (N = 62) ............................................... 157 5. Correlations Among Child Whole Blood 5-HT, Potential Covariates, and Dependent Variables For Boys (11 = 45) and Girls (11 = 17) ......................... 158 6. Means and Standard Deviations of Demographic Variables by Family Member for Subjects With Analyzable Whole Blood 5-HT (N = 150) ................. 159 7. Means and Standard Deviations of Independent and Dependent Variables by Family Member for Subjects with Analyzable Whole Blood 5-HT (N = 150) ....... 160 8. Correlations Between Whole Blood 5-HT, Irritable Assault, Neuroticism, and HRSD For Women (Q = 43) and Men (11 = 45) ............................... 161 9. Correlations Between Parental Whole Blood 5-HT and SES Indicators (N = 88) . . 162 10. Correlations Between Paternal Whole Blood 5-HT and SES Indicators (n = 45) . . 163 11. Correlations Between Maternal Whole Blood 5-HT and SES Indicators (_r_1 = 43) . 164 xiv 12. Correlations Between Parental Whole Blood 5-HT, Irritable Assault, Neuroticism, and HRSD in Low SES (n = 41) and High SES (n = 15) Subjects .......... 165 13. Correlations Between Paternal Whole Blood 5-HT, Irritable Assault, Neuroticism, and HRSD in Low SES (3 = 23) and High SES (n = 8) Men .............. 166 14. Correlations Between Maternal Whole Blood 5-HT, Irritable Assault, Neuroticism, and HRSD in Low SES (1; = 18) and High SES (3 = 7) Women ............ 167 15. Correlations Between Paternal Whole Blood S-HT, Irritable Assault, Neuroticism, and HRSD By ASPD Diagnosis and SES ............................. 168 16. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed Scores in Full Sample of Boys and Girls Combined (N = 62) .............. 170 17. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed by Gender ........................................................ 170 18. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in Prepubescent (n = 48) and Pubescent (r1 = 14) Children .................. 171 19. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in Prepubescent and Pubescent Boys and Girls ........................... 172 20. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in LSC (n = 9) and HSC (n = 53) Children .............................. 173 21. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in LSC and HSC Boys and Girls ...................................... 174 22. Correlations Between SE Variables, Child Whole Blood 5-HT, and Both Child Attack and Anxious/Depressed in Full Sample of Children ..................... 175 XV 23. Correlations Between SE Variables, Child Whole Blood 5-HT, and Both Child Attack and Anxious/Depressed in Girls (11 = 17) and Boys (11 = 45) ............... 179 24. Correlations Between Puberty and SE Variables in Full Sample of Children (N = 62) ................................................ 185 25. Correlations Between Puberty and SE Variables in Boys (n = 45) and Girls (n = 17) ................................................ 187 26. Correlations Between Child Whole Blood 5-HT, SE Variables, and Both Child Attack and Anxious/Depressed in Prepubescent (n = 48) and Pubescent (n = 14) Children ....................................... 190 27. Correlations Between Social Competence, SE Variables, Child Whole Blood 5-HT, and Behavior in the Full Sample (N = 62) ............................. 198 28. Correlations Between Social Competence, SE Variables, Child Whole Blood 5-HT, and Behavior in Boys (n = 45) and Girls (3 = 17) ....................... 202 29. Correlations Between SE Variables, Child Whole Blood 5-HT, and Both Child Attack and Anxious/Depressed in LSC (r; = 9) and HSC (n = 53) Children . . 210 30. Regression Analysis for Dependent Variable Attack ....................... 216 31. Regression Analysis for Dependent Variable Anxious/Depressed ............. 216 32. Regression Analysis for Dependent Variable Attack in Boys ................. 216 33. Regression Analysis for Dependent Variable Anxious/Depressed in Boys ...... 216 34. Regression Analysis for Dependent Variable Attack in Prepubescent Children ....................................................... 217 35. Regression Analysis for Dependent Variable Anxious/Depressed Prepubescent xvi Children ....................................................... 217 36. Regression Analysis for Dependent Variable Attack in HSC Children .......... 217 37. Regression Analysis for Dependent Variable Anxious/Depressed in HSC Children .................................................. 217 xvii LIST OF FIGURES 1. The Synapse ......................................................... 10 1A. Parental Whole Blood 5-HT and HRSD (N = 88) ......................... 219 2. Mechanisms of Action for Psychiatric Medications .......................... 14 2A. Whole Blood 5-HT and HRSD in Men (n = 45) ........................... 219 3. Whole Blood 5-HT and HRSD in Women (Q = 43) ......................... 220 4. Whole Blood 5-HT and HRSD in LSES Subjects (3 = 41) .................... 220 5. Whole Blood 5-HT and Neuroticism in LSES Men (r; = 23) .................. 221 6. Whole Blood 5-HT and Irritable Assault in LSES ASPD Men (n = 9) ........... 221 7. Whole Blood 5-HT and Attack in Girls (3 = 17) ............................ 222 8. Whole Blood 5-HT and Attack in Pubescent Children (n = 14) ................ 222 9. Whole Blood 5-HT and Anxious/Depressed in Pubescent Children (11 = 14) ...... 223 10. Whole Blood 5-HT and Attack in Pubescent Boys (3 = 9) ................... 223 11. Whole Blood 5-HT and Anxious/Depressed in Pubescent Boys (3 = 9) ......... 224 12. Whole Blood 5-HT and Attack in Pubescent Girls (11 = 5) ................... 224 13. Whole Blood 5-HT and Anxious/Depressed in Pubescent Girls (:1 = 5) ......... 225 14. Whole Blood 5-HT and Attack in LSC Children (n = 9) ..................... 225 15. Whole Blood 5-HT and Anxious/Depressed in LSC Children (3 = 9) .......... 226 16. Whole Blood 5-HT and Attack in LSC Boys (n = 7) ....................... 226 17. Whole Blood 5-HT and Anxious/Depressed in LSC Boys (3 = 7) ............. 227 18. Whole Blood 5-HT and Attack in HSC Girls (n = 15) ...................... 227 xviii 19. Whole Blood 5-HT and Anxious/Depressed in HSC Girls (n = 15) ............ 228 20. Maternal Violence and Whole Blood 5-HT in Girls (11 = 7) .................. 228 21. Paternal Violence and Child Whole Blood S-HT in Prepubescent Children (n = 36) ................................................ 229 22. Paternal Violence and 5-HT in Pubescent Children (n = 11) ................. 229 23. Maternal Violence and Child Whole Blood 5-HT in LSC Children (r; = 7) ...... 230 24. Paternal Violence and 5-HT in LSC Children (11 = 7) ....................... 230 25. Maternal Alcohol Consumption and 5-HT in LSC Children (11 = 9) ............ 231 26. Maternal Violence and Attack in Full Sample of children (N = 46) ............ 231 27. Maternal Violence and Anx/Dep in Full Sample of Children (N = 46) .......... 232 28. Paternal Functioning and Attack in Full Sample of Children (N = 60) ......... 232 29. Paternal Functioning and Anx/Dep in Full Sample of Children (N = 60) ....... 233 30. Maternal Functioning and Attack in Full Sample of Children (N = 62) ......... 233 31. Maternal Neuroticism and Attack in Full Sample of Children (N = 62) ........ 234 32. Paternal Alcohol Consumption and Attack in Full Sample of Children (N = 59) . 234 33. Maternal Alcohol Consumption and Attack in Full Sample of Children (N = 62) . 235 34. Maternal Violence and Attack in Boys (n = 39) ........................... 235 35. Maternal Violence and Anxious/Depressed in Boys (3 = 39) ................. 236 36. Paternal Functioning and Attack in Boys (11 = 44) ......................... 236 37. Maternal Functioning and Attack in Boys (3 = 45) ......................... 237 38. Maternal Neuroticism and Attack in Boys (_r_1 = 45) ......................... 237 39. Paternal Violence and Attack in Girls (n = 7) ............................. 238 xix 40. 41. 42. 43. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. Paternal Violence and Anxious/Depressed in Girls (3 = 7) ................... 238 Paternal Alcohol Consumption and Attack in Girls (3 = 15) .................. 239 Paternal Alcohol Consumption and Anxious/Depressed in Girls (r; = 15) ....... 239 Maternal Alcohol Consumption and Attack in Girls (n = 17) ................ 240 . Maternal Alcohol Consumption and Anxious/Depressed in Prepubescent Children (n = 17) ................................................ 240 Maternal Violence and Attack in Prepubescent Children (11 = 35) ............. 241 Maternal Violence and Anxious/Depressed in Prepubescent Children (n = 35) . . . 241 Maternal Functioning and Attack in Prepubescent Children (3 = 47) .......... 242 Paternal Functioning and Attack in Prepubescent Children (11 = 46) ........... 242 Maternal Neuroticism and Attack in Prepubescent Children (n = 48) ........... 243 Paternal Alcohol Consumption and Attack in Prepubescent Children (11 = 46) . . . 243 Maternal Alcohol Consumption and Attack in Prepubescent Children (n = 48) . . 244 Paternal Irritable Assault and Attack Pubescent Children (11 = 10) ............. 244 Paternal Functioning and Anxious/Depressed in LSC Children (n = 9) ......... 245 Maternal Functioning and Anxious/Depressed in LSC Children (r; = 9) ........ 245 Maternal HRSD and Anxious/Depressed in LSC Children (n = 9) ............. 246 Paternal Alcohol Consumption and Anxious/Depressed in LSC Children (11 = 9) . 246 Maternal Alcohol Consumption and Anxious/Depressed in LSC Children (I; = 8) 247 Paternal Irritable Assault and Attack (n = 8) .............................. 247 Maternal Violence and Attack in HSC Children (3 = 39) .................... 248 Paternal Functioning and Attack in HSC Children (n = 51) .................. 248 XX 61. Maternal Functioning and Attack in HSC Children (3 = 53) ................. 249 62. Maternal Neuroticism and Attack in HSC Children (r1 = 53) ................. 249 63. Paternal Alcohol Consumption and Attack in HSC Children (11 = 50) .......... 250 64. Maternal Alcohol Consumption and Attack in HSC Children (11 = 53) ......... 250 xxi INTRODUCTION The precise ways that parental alcoholism affect the development of children are still largely unknown, but they are most likely multifactorial with biological, as well as psychosocial components (Sher, 1991; Sher, Walitzer, Wood, & Brent, 1991; Zucker & Gomberg, 1986). However, many psychosocial studies neglect to take into account the role of genetic contributions, the biological bases of transmission and association, and fail to examine the impact environmental variables have on biology and behavior. Similarly, many of the genetic studies focus primarily on biological factors at the exclusion of examining the psychosocial contributions to these systems. The current study attempts to address this void by exploring the relationships among biology, socioenvironmental variables, and behavior in the development of children of alcoholics who may be at increased risk for the development of behavioral and affective dysregulation. One model suggests that impulsivity in childhood can be precursive to the development of aggressiveness. and aggressiveness can be precursive to earlier and more severe alcoholism in later adolescence and adulthood (Zucker & Fitzgerald, 1991a; Zucker & Fitzgerald, 1991b). It has also been found that early difficulty with impulse control is the primary cause of early-onset aggressivity in children (Pulkkinen, 1982). Relatedly, early aggressivity measured as early as age 8 contributed indirectly, but specifically to adult problem drinking. This same group found that a high rate of early aggression preceded the development of conduct disorder at the age of 14 (Pulkkinen & Pitkanen, 1994). There is a large literature suggesting that serotonergic (5-HT) dysfunction is associated with impulsive aggression and early onset alcoholism in adults. Adults with early onset alcoholism exhibit high rates of co-morbid antisocial personality disorder (ASPD) a diagnosis which is preceded by the presence of conduct disorder (CD) in childhood. Both diagnoses are remarkable for the presence of increased aggressiveness. While some individuals will meet criteria for childhood CD, but will not continue to express violent behavior, ASPD individuals are those who have exhibited a sustained life trajectory marked by increased rates of aggressiveness and violence. Serotonergic deficits related to impulsive aggression and early onset alcoholism include lower whole blood serotonin (5-HT), lower cerebrospinal fluid monoamine metabolites of serotonin (5-HIAA), and increased serotonergic uptake (Moss, 1987). The current study was designed to examine the biologic contribution that serotonergic dysfunction may make to the development of irritable impulsive aggressiveness and alcoholism in adults, and to examine the socioenvironmental variables contributing to both low serotonergic function and problems in behavioral and affective regulation in their non-drinking children. Few studies have gathered data on serotonergic function in children, and none to date have examined children of alcoholics (COAs) to help determine what role serotonergic function may play in their later behavioral and affective development. Furthermore, studies of adults have been inconclusive as to whether serotonergic dysftmction in alcoholics is heritable or caused by previous alcohol consumption (Moss, 1987). Hopefully, data obtained from COAs both before and after the onset of alcohol use can provide data regarding the issue of the heritability of 5-HT dysfunction in alcoholics versus past use as the cause of this dysfunction. Historically, longitudinal studies of delinquency have focused on psychosocial measures to predict outcome (Loeber & Dishion, 1983). However, evidence suggests that biological variables may be more important than environmental variables in the development of a subgroup of conduct disorders that persist over the lifetime into adulthood (Rutter et al., 1990). Given the increased likelihood of conduct disorder in COAs as well as the increased risk for these children to develop ASPD, utilizing biological markers of risk in these children may be particularly helpful in early identification and treatment. k n t rre Earlier work by this author examined the relationship between serotonergic dysfunction and overt behavior problems in children of alcoholics to partially test a model which suggested that early serotonergic dysfunction might be involved in a life course trajectory consisting of increased rates of behavioral problems. Specifically, it was thought that a relationship between serotonergic dysfunction and overt behavior problems in children might indicate a phenotypic marker of biological vulnerability to early aggressiveness which is believed to be a risk factor for later antisocial alcoholism. One model supported by early data from the MSU/U of M family Study proposes that greater problems in behavioral control as evidenced by increased impulsivity in childhood will be precursive to the development of aggressiveness, and aggressiveness will be precursive to earlier and more severe alcoholism in later adolescence and 3 adulthood (Ellis, Bingham, Zucker, & Fitzgerald, under review; Jansen, Fitzgerald, Ham, & Zucker, 1995; Zucker & Fitzgerald, 1991a). The strongest comorbid association with alcoholism is the co-action of antisocial personality disorder. In adults, this comorbidity has been observed in 14% of alcoholics (Regier et al., 1990) and antisocial personality disorder is also 21 times more likely to be found in alcoholics than in the general population (Helzer, Bumarn, & McEvoy, 1991). Given the strength of this connection, it has been hypothesized that differences in aggressiveness should be observable in early childhood, before alcohol involvement has taken place (Zucker et al., 1996a). A number of studies indicating that antisocial and aggressive behavior is a risk pathway to the manifestation of alcoholism support this hypothesis. Moreover, an examination of early childhood behavioral differences in 3-5 year old children found that COAs exhibited elevated symptomatology in a number of CBCL behavioral areas, with the greatest differences occurring in the externalizing and aggression measures (Ellis et al., under review). This evidence of higher levels of externalizing behavior in early childhood parallels the evidence of later childhood and adolescent difficulty, and is presumptive evidence of the potential for a continuous lifetime process. Given the relationship between decreased serotonin neurotransmission and impulsive aggression in adult alcoholics and the greater risk for impulsivity, aggressiveness, and later alcoholism in their children, the previous study by this author was designed to examine the relationship between serotonergic function and problems in behavioral control in COAs. Because female as well as male children were available as 4 subjects, this work added to the sparse literature of children’s studies by examining serotonergic function and overt behavior problems in female as well as male children. Since the adult data suggest that S-HT’s role in behavior modulation is not limited to diagnostic categories, but rather is dimensional in nature, the prior study was designed to examine this relationship in a non-clinical community recruited sample. In this manner, results were believed to have greater generalizability to the establishment of risk in the general population. Results confirmed the hypothesis that greater serotonergic dysfunction would be found in high TBP children as compared to low TBP children. However, the hypothesis that paternal alcoholism subtype would be related to child serotonergic function, such that antisocial alcoholic fathers would have children exhibiting the greatest serotonergic dysfunction was not supported. As an extension of this work the present study seeks to examine the contribution socioenvironmental variables make to serotonergic function and behavior while continuing to explore the inconsistent relationship between serotonergic function and alcoholism that has been described in the literature. S i F ti n' Before describing the basic structure of the serotonin system, it must be noted that any attempt to isolate a single neurotransmitter system and to then propose to examine the behavioral or neuropsychological correlates of this system runs a great risk of oversimplifying the complexity of the phenomenon under examination as well as the complexity of neural functioning. First, this approach is problematic because neural circuits that produce any particular behavior also integrate a variety of activities of 5 different neurotransmitters and are unlikely to be subserved by a single neurotransmitter (Saver, Salloway, Devinskey, & Bear, 1996; Valzelli, 1986). Second, even if a behavior is affected directly by serotonergic transmission, this does not exclude the possibility that other neurotransmitter systems are also involved in the behavioral changes (Soubrie, 1986). Third, the specific receptor subtypes mediating a particular response are poorly understood (Saver et al., 1996). However, even with these caveats, it has been observed that specific behaviors have been shown to be associated with specific brain processes (Soubrie, 1986). For instance, feelings of hopelessness and despair have been shown to be alleviated by antidepressants, not anti-psychotics or neuroleptics. Therefore, although the risk for simplification is always present, the process of studying a single neurotransmitter and it’s relationship to behavior is arguably worthwhile as a starting point in gathering meaningful information. t ' ste The large majority of 5-HT cells in the CNS are located within the midbrain raphe nuclei. While there are approximately nine cell groups that have been described, activity of the dorsal and median raphe constitute about 80% of the forebrain S-HT (Azrnitia, 1978). Anatomically, these two areas are most salient in regard to the widespread nature of their projections (Spoont, 1992). There are six major ascending projections from the dorsal and median raphe. The dorsal raphe accounts for four of these projections and shares a fifth with the median raphe (Azrnitia, 1978). Tracts from both the dorsal and median raphe follow the medial forebrain bundle (Azrnitia, 1978). The dorsal raphe-medial forebrain bundle tract 6 innervates the lateral forebrain structures including the basal ganglia, amygdala, and nucleus acumbens, while the median raphe-medial forebrain bundle innervates the medial forebrain structures such as the cingulate cortex, septum, and hippocarnpus (Azrnitia, 1978). Within the four non-medial forebrain bundle tracts is the innervation of the periventricular system, which projects to the periaqueductal gray, the inferior and superior colliculi, and surrounds the periventricular portions of the thalamus and hypothalamus (Azrnitia, 1978). The two ascending non-medial forebrain bundle dorsal raphe tracts make up the cortical tract, which projects to the caudate-putamen as well as the cerebral cortices (most importantly the tempoparietal cortex), the arcuate tract which proceeds through the midbrain tegmentum and innervates such structures including the substantia nigra and the suprachiasmatic nucleus (Spoont, 1992). The last non-medial forebrain bundle begins in both the medial raphe and the dorsal raphe and innervates structures including the interpeduncular nucleus and the mammillary body (Azrnitia, 1978) It has been suggested that because the 5-HT system projects so widely to various brain structures, 5-HT neurotransmission can influence virtually all aspects of cortical functioning at several levels of information processing (Spoont, 1992). This author interprets the widespread and diverse nature of 5-HT projections as evidence that the 5- HT system performs a threshold function instead of performing mediating roles in specific behaviors. Spoont also interprets the fact that S-HT cells form relatively few classical synaptic connections (Azmitia, 1978), which allows for control over the 7 excitability of much more than discrete target cells, as further evidence that the 5-HT system’s role is one of a threshold capacity. Spoont argues that the modulatory role serotonin plays in aggressive behaviors is due to the fact that the 5-HT system innervates structures that are involved in aggressive behaviors. Specifically, she indicates that the 5- HT system modulates flight/fight response centers in the brain including the amygdaloid and hypothalamic nuclei. Many hypothalamic nuclei and especially the lateral hypothalamus have been implicated in triggering both instrumental and affective aggressive behavior. For example, animals who have had 5-HT turnover in the lateral hypothalamus decreased by social isolation exhibit intense irritable aggression (Kempf, Puglisi-Allegra, Cabib, Schleef, & Mandel. 1984). Additionally, S-HT has been found to play a specific role in inhibiting lateral hypothalamus related irritable aggression since infusions of 5-HT are found to produce inhibition, while infusions of Norepinephrine and Dopamine do not (Bell & Brown, 1975; Bell & Brown, 1976; Leroux & Myers, 1975). In relation to the appropriateness of comparing studies of 5-HT in animals with human studies, Spoont makes two important comments (Spoont, 1992). First, she notes that the fact that there are more synaptic connections formed by 5-HT cells in primates than in rodents suggests that there is greater specificity of 5-HT action with increasing cortical sophistication. However, she notes that with the exception of increased myelination of 5-HT fibers in humans and other primates in relation to structurally more primitive animals, the topographical and morphological properties of the 5-HT system appear largely similar across species. She interprets these findings to indicate that it is possible and not inaccurate to parallel the behavioral effects of 5-HT manipulations in animals to conceptually similar behavior in humans. The central serotonergic system reaches to the cortex and the limbic structures. The limbic system is an area of the brain implicated in the coordination of feelings and perception through its many connections to the frontal lobe. Consequently, the serotonergic system is involved in the regulation of several physiologic and affective functions. These include sleep, appetite, cognition, mood, sexual, and motoric activity (V ogt, 1982). Therefore, it has been suggested that any disturbance or dysfunction in this system may contribute to the development of various psychiatric behavior disorders involving abnormalities in these functions, such as affect (depression), anxiety (obsessive compulsive disorder, alcoholism), eating, and personality disorders (Coccaro & Murphys, 1990) Neumtransmissinu The basic function of the central nervous system is the transfer of information from one area of the brain to another. This system of intercellular communication is composed of billions of neurons which interact with one another through characteristic processes. Since these interconnections can work in synchrony, this system is capable of producing graded responses which result in a vast array of cognitive, affective, and behavioral responses (Gitlin, 1990). The synaptic unit is the functional building block of the central nervous system and consists of two neurons (presynaptic and postsynaptic) and a physical gap between them called the synapse, see Figure 1(Gitlin, 1990). For these neurons to communicate 9 with each other, a combination of bioelectrical and chemical processes must take place. Neurotransmitter is released when an electrical impulse called the action potential arrives at the axon terminal. This depolarizes the presynaptic terminal membrane, opening SYNAPTIC CLEFI' NERVE TERMINAL ELECTRICAL IMPULSE VESICLES . POSTSYNAP‘I’IC RECEPTORS WITH STORED NEUROTRANSMITTER Figure 1. The Synapse voltage gated calcium channels. The resulting elevation in the internal calcium ion concentration signals the release of neurotransmitter from the synaptic vesicles into the synaptic cleft in a process called exocytosis (Bear, Connors, & Paradiso, 1996). The neurotransmitter spreads across the gap and binds to specialized receptor sites on the 10 I :. 5111 ll "‘40.‘ '. ul‘ “fi‘” \ I‘. “.0. c . “.WI 151.} I‘; any 05 it“, lb‘ ~~lt~ £1,345. “Null I '1‘. ‘u ,.. .5. membrane of the postsynaptic neuron. The postsynaptic receptor then interprets the information within the neurotransmitter and begins a physiologic response that can be either inhibitory or excitatory (Martin, Owen, & Morihisa, 1987). The neurotransmitter serotonin is found in large quantities within blood platelets and the central nervous system and is synthesized within the presynaptic neuron from the common amino acid L-tryptophan (Levitan & Kaczmarek, 1997). Synthesis of serotonin occurs in two steps. First, tryptophan is converted into 5-HTP (5-Hydroxytryptophan) by the enzyme tryptophan hydroxylase. Next, 5-HTP is converted to S-HT (serotonin) by the enzyme 5-HTP decarboxylase (Bear et al., 1996). Serotonin is then packaged into secretory granules by special proteins embedded in the vesicle membrane called transporters and stored in the terminal bouton of the presynaptic neuronal axon. Once the released serotonin has interacted with the postsynaptic receptors, it must be cleared from the synaptic cleft to allow future transmission. Serotonin can be removed from the synaptic cleft by a specific transporter through reuptake into the presynaptic terminal where it can either be recycled and repackaged into synaptic vesicles or degraded by monoamine oxidase, resulting in the metabolite 5-Hydroxyindoleacetic acid (5-HIAA). As previously noted, central 5-HT neurons are localized in tracts within the brainstem, but affect most brain areas (Azrnitia, 1978; Levitan & Kaczmarek, 1997) and serotonin appears to be involved in several modulatory physiologic processes (Spoont, 1992; Tollefson, 1989). There is a widespread consensus that serotonin has an inhibitory effect on behavior. Specifically, decrements in serotonergic function (decreased 11 0;?" "y L,- d. ‘ “ELLA , ‘9 31.5. Dv4; ‘1} uh I -a 5“ "nth-I f--. ‘7‘! ”.1 2 .b} \Lfi‘; neurotransmission shown by lowered 5-HT turnover) have been linked to behavioral disinhibition (impulsivity), low frustration tolerance, (Goodwin, Schulsinger, Herrnansen, Guze, & Winokur, 1975; Jones, 1968; Moss, 1987; Robins, 1966) attention deficits, (Rydelius, 1983; Tarter, Hegedus, Goldstein, Shelly, & Alterrnan, 1984) increased motor activity, (Jones, 1968; McCord, McCord, & Gudeman, 1960) emotionality, (Rosenberg, 1969; Tarter, 1982) and aggressiveness (Guze, Goodwin, & Crane, 1969). As previously stated, serotonin has been implicated as serving a threshold function in relation to providing modulatory constraint, such that S-HT has a net inhibitory effect on information flow (Spoont, 1992). mm One of the most important clinical advances to date is the use of specific serotonergic re-uptake inhibitors (SSRIs) to treat depressive symptomatology. Several compounds such as fluoxetine (Prozac), citalopram, and zimeldine have been shown to have antidepressant effects through their ability to inhibit the serotonin uptake carrier (Fuller, 1992). While the antidepressant effects are clear, it is unknown how this specific alteration in the dynamic, homeostatic, and complex serotonergic system produces these positive effects. Data on enhancing serotonergic fimction from rat studies show that serotonergic uptake inhibitors increase serotonergic function by decreasing serotonin synthesis, but at the same time, increasing extracellular serotonin. It is believed that the increased extracellular serotonin leads to increased neurotransmission which causes positive functional changes and decreased serotonin synthesis and neuron firing (Fuller, 1992). 12 fiWJ} - but.) 9.33"?" wa‘ u I ‘4 -,N- s ' ‘a‘a bub-b I. rv'" RNA. it It; ’1‘3'9' .sh y g ;i_ A Lit ICC I'M. Null Uptake inhibitors increase serotonin concentration in the synaptic cleft which results in increased activation of all post-synaptic serotonin receptors. Most psychiatric medications work by affecting some aspect of the neurotransmitter/receptor system. The mechanisms of action can be explained by seven different effects of this system as diagramed in Figure 2 (Gitlin, 1990). 1.) First, a medication can directly bind to the receptor site. A receptor agonist is one that mimics the neurotransmitter by stimulating the receptor. Also, a medication can bind to the receptor causing no response and effectively block the neurotransmitter from binding to the receptor (antagonists). 2.) Medications can also cause the release of more neurotransmitter, functionally increasing the effect of the system. 3.) Medications can also block the reuptake of neurotransmitters back into the presynaptic neuron which allows the neurotransmitter to have more time in the synapse, increasing the possibility of stimulating the receptor in the postsynaptic neuron and thereby increasing neurotransmission. This is best illustrated by the action of selective serotonergic reuptake inhibitors (SSRIs) such as the widely used antidepressant, Prozac. 4.) Medications can also cause an increase or decrease in the number of receptor sites (up or down regulation). 5.) Medications may also alter the sensitivity of receptors, changing the magnitude of response that results from receptor stimulation. 6.) Medications can alter the metabolism of a neurotransmitter which changes the amount of neurotransmitter that is available for release. The monoamine oxidase inhibitors work as antidepressants primarily by decreasing the metabolism of a variety of neurotransmitters including serotonin, which are metabolized by the enzyme MAO. 7.) The amount of available neurotransmitter can 13 (D necema srre @ REUPTAKE Figure 2. Mechanisms of Action for Psychiatric Medications be altered by increasing the amount of the precursor ingredients that are used in synthesizing neurotransmitters. For example, a dietary increase in L-tryptophan, the amino acid synthesized into serotonin, can result in an increase in serotonin (Gitlin, 1990) The brain reacts to internal influences and external influences such as medications by trying to maintain homeostasis. For example, a medication such as Prozac that blocks the reuptake of serotonin, thereby functionally increasing the amount of available neurotransmitter, produces a decrease in the amount of serotonin released in an attempt to provide homeostasis (Gitlin, 1990). In essence, medications compete with a naturally l4 . Arro- 1L glut )- .. ;” I \ LI 5» 13'3”” hJskai I ‘SPJAI *- 8. I. . .I_ Hunt, 1 ‘Vvu. fin: xt~ adapting system whose goal is to prevent changes. Other than agonists which mimic the neurotransmitter by stimulating the receptor, medications appear to provide their clinical effects by exerting a continual influence over neurotransmitter systems for extended periods of time, thereby altering the regulatory mechanisms. Serotonergic activity in living subjects can be studied by measuring the concentration of the neurotransmitter, its metabolites, or metabolic enzymes, in plasma, cerebrospinal fluid, and urine. All studies using measures of 5-HT concentration are evaluating the presynaptic processes (e. g., metabolic turnover of the neurotransmitter; (Martin et al., 1987)). All but CSF monoamine metabolites are peripheral measures of brain serotonin, and as such provide only an indirect measure of brain levels of the neurotransmitter. In relation to the central index of serotonin function, CSF 5-HIAA, it is somewhat uncertain whether this measure adequately reflects brain serotonin function (Murphy, 1990). CSF samples are problematic because they reflect an average of brain and spinal cord CNS concentrations and, therefore, cannot provide information regarding localization of an observed abnormality (Martin et al., 1987). Importantly, the point has been made that it is possible that low CSF 5-HIAA levels might indicate depressed serotonin release without a similar decrease in overall serotonergic transmission (Soubrie, 1986). For instance, Soubrie acknowledges that compensatory mechanisms such as upregulation might result in increased density of serotonergic receptors which could conceivably overcome the deficit in presynaptic transmitter release. However, Soubrie concedes that despite the potential problems with using CSF 5-HIAA as a measure of 15 central serotonergic function, data exist that show CSF 5-HIAA is significantly correlated with 5-HIAA concentrations found in the frontal cortex of human brains at post-mortem (Stanley, Traskman-Bendz, & Dorovine-Zis, 1984). One important drawback to using this measure is that many subjects refuse to consent to the invasive and potentially painful spinal tap required to obtain CSF 5-HIAA. Since most of the body's serotonin is synthesized within the gastrointestinal tract, it has been suggested that measuring serotonin or its metabolites in urine or blood plasma are inadequate (Fuller, 1992). Blood platelets, however, contain common constituents with serotonin neurons such as serotonin storage granules and serotonin transporters (Pletscher, 1987). Thus, while whole blood 5-HTs relationship to brain serotonergic function remains an empirical question, one rationale for using this index is based on similarities in the metabolic control of serotonin synthesis, similarities in the serotonin reuptake systems of platelets and neurons, and the presence of 5-HT2A receptors on platelets (Moffitt et al., 1998). Measures from blood platelets such as serotonin content, serotonin transport, and radioligand-binding to transporter have been used successfully to study autism, aggression in males, and alcoholism, respectively (Fuller, 1992). Because of these benefits blood platelets have been called "models of brain serotonin neurons" (Da Prada, Cesura, Launay, & Richards, 1988). Additionally, since blood platelets have been found to contain serotonin receptors, blood platelet studies allow an examination of the less well understood connection between post-synaptic 5-HT functioning and suicidal and/or impulsive aggressive behavior (Coccaro, Kavoussi, Sheline, Berman, & l6 Csemansky, 1997). Blood platelets are also easily obtainable and accessible which increases the attractiveness of their use. Cook et al., have reported that whole blood 5-HT provides a measure of the function of the platelet 5-HT transporter and the 5-HT2A receptor (Cook, Stein, Ellison, Unis, & Leventhal, 1995). Therefore, this measure is most useful in delineating any relationships between a decrease in 5-HT function that is related to alterations in the fimction of the pre-synaptic 5-HT transporter or post-synaptic 5-HT2A receptor and behaviors. In a recent study, (Hanna, Yuwiler, & Coates, 1995) report that CSF 5-HIAA concentrations and platelet 5-HT concentrations were found to be positively correlated in a previous study (Kruesi et al., 1990). Relatedly, Cook et al., report that positive correlations have consistently been found between platelet (Kuperrnan, Beeghly, Burns, & Tsai, 1985) and whole blood 5-HT between autistic children and their first degree relatives (Abramson et al., 1989; Cook et al., 1990; Leventhal, Cook, Morford, Ravitz, & Freedman, 1990). However, this measure has been used infrequently since it is a peripheral measure and reports of it’s correlation to other indicators of 5-HT function are not consistent. For example, whole blood S-HT has been reported to be inversely related to fenfluramine (FEN) stimulated prolactin (PRL) response in a study of autistic adults (McBride, Murphy, Lumeng, & Li, 1989). Hence, the relationship between whole blood 5-HT and central serotonergic activity is still undetermined (Hanna, Yuwiler, & Cantwell, 1991) Blood platelets do differ from brain serotonin in significant ways. Since blood platelets do not synthesize serotonin but derive it completely by uptake, continuous 17 inhibition of the uptake carrier results in marked depletion of serotonin content in platelets. However, brain serotonin content is not decreased by uptake inhibition, and extracellular serotonin concentration in the brain is actually increased (Fuller, 1992). Given the similarities between blood platelets and serotonin neurons, the ease of obtaining such samples, and the ethical constraints of obtaining CSF measures in children, whole blood 5-HT was deemed the most promising measure of serotonergic function for this study. It is also possible to obtain post-synaptic measures from binding parameters of receptors (Coccaro et al., 1997). While both pre- and post-synaptic measures are helpful in indexing components of 5-HT function, the net or overall index of central 5-HT function that is characterized by PRL response to acute challenge with F EN has gained increasing prominence (Coccaro et al., 1989). As described by Coccaro et al. (1989), “fenfluramine is an indirect central 5-HT agonist that releases endogenous central stores of pre-synaptic 5-HT, blocks the reuptake of synaptic 5-HT, and stimulates both directly and indirectly, postsynaptic 5-HT receptors. The resulting enhancement in overall central 5—HT activity is reflected in the dose-related PRL response to the drug, which is blocked by 5-HT receptor antagonists. Thus, the PRL response to fenfluramine offers the advantage of reflecting the final effectance of central 5-HT function in the hypothalamic- pituitary axis.” Relatedly, studies of adults suggest that a lowered PRL response to FEN indicates decreased 5-HT functioning. l8 REVIEW OF THE LITERATURE t' Al h Ii e n o s m tio Data from animal studies have shown an association between low brain serotonin turnover and alcohol preference (Li et al., 1989). For example, increased serotonin uptake has been found in alcohol preferring rats (Daoust et al., 1985). Relatedly, serotonin reuptake inhibitors and monoamine uptake inhibitors reduced ethanol consumption in rats (Daoust et al., 1984; Murphy et al., 1985; Rockman, Amit, Carr, Brown, & Orgen, 1979; Waller, Murphy, McBride, Lumeng, & Li, 1985). The concentration of 5-HT has also been linked to alcohol preference and consumption in animal studies, but the results are somewhat contradictory. One group found lower 5-HT levels in brains of inbred alcohol preferring rats versus non alcohol preferring rats (Murphy, McBride, Lumeng, & Li, 1982). However, one researcher found no difference in voluntary alcohol consumption in rats after lowering brain serotonin by three different methods (Kiianamaa, 1976). Therefore, evidence for the link between serotonin and alcohol in the animal literature is strongest in regard to decreased serotonin turnover in relation to alcohol preference and consumption. The link between serotonin and alcohol consumption is less strong in regard to 5-HT concentration's connection to voluntary consumption of alcohol. One reviewer has suggested that rat strain differences, methodologic considerations, and differential food intake could be responsible for some of the discrepancies in the animal 19 literature (Moss, 1987). Please refer to LeMarquand, Pihl, & Benkelfat (1994b) for a more comprehensive review of the animal literature. In humans, less research has been conducted on the relationship between serotonin and both ethanol preference and consumption. Human studies are also less conclusive than animal studies since ethical guidelines prohibit the use of an experimental design which would allow the manipulation of serotonin levels to examine the impact on alcohol consumption. Instead, human studies have used the alcohol challenge paradigm in healthy subjects to examine the serotonin system’s response to ethanol. In response to Ballenger’s hypothesis that alcohol initially increases 5-HT turnover, but produces further depletion of the 5-HT system, LeMarquand (1994a) argues that there is little data from alcohol challenge studies to support this hypothesis for samples of healthy controls. Acute doses of ethanol lowered blood tryptophan, CSF tryptophan, blood 5-HT, and increased platelet 5-HT uptake, all of which suggest decreased levels of 5-HT and decreased 5-HT neurotransmission (LeMarquand, Pihl, & Benkelfat, 1994a). However, it should be noted that given Ballenger’s hypothesis, it does not necessarily follow that acute ethanol exposure should produce transient increased neurotransmission in those individuals who do not have a pre-existing serotonergic deficit. Similarly, while the acute effects of alcohol appear to decrease serotonergic transmission in normal controls, findings from studies of problem drinkers and alcoholic men are mixed regarding the effectiveness of SSRIs in decreasing alcohol consumption and increasing days abstinent. While earlier studies of the administration of citalopram, 20 fluoxetine, viqualine, and zimeldine showed a decrease in alcohol consumption and an increase in days abstinent (Naranjo, Kadlec, Sanhueza, Woodley-Remus, & Sellers, 1990; Naranjo, Poulos, Bremner, & Lanctot, 1992; Naranjo et al., 1984; Naranjo et al., 1987; Naranjo et al., 1989) recent results from clinical trials in primary alcoholics do not indicate S-HT pharmacotherapy as effective in reducing days drinking or increasing days abstinent (Dundon, 1998; McGrath, 1998; Numberg, 1998). Strengths of these findings include the fact that many of the studies utilized random assignment of subjects, screened out subjects with major affective disorders, used controls, and administered placebo. Thus, unlike the animal data, the human data are mixed regarding the hypothesis that decreased serotonergic neurotransmission might facilitate alcohol intake, whereas increases in 5-HT function may inhibit alcohol intake. The association between serotonergic function and alcoholism has been examined with somewhat inconsistent results. While the results from the majority of these studies provide evidence of a relationship between serotonergic dysfunction and alcoholism, these results may be differentially found depending on the particular subsets of alcoholics in the studies (e.g., ASPD, affective disorders. other personality disorders related to impulsive aggression). ‘ Some research suggests that alcohol consumption and preference in humans may be related to decreased serotonergic neurotransmission as measured by the presynaptic measures of increased serotonin uptake and higher mean maximal-velocity-of-serotonin- transport (Vmax, density of platelet uptake sites; (Boismare et al., 1987; Bokii, Kiseleva, 21 “we" \ 35. ~. '~\' SCI: it’ll 3511.- ‘,.;- .. not WI Lapin, Prakhe, & Rybakova, 1984; Daoust et al., 1991; McBride et al., 1989; Naranjo, Sellers, & Larwin, 1986; Naranjo et al., 1984; Naranjo et al., 1987; Neiman, Beving, & Malmgren, 1987; Rausch, Monteiro, & Schuckit, 1991). In what has been called the “serotonin hypothesis of alcoholism,” (LeMarquand et al., 1994a) it is suggested that a serotonergic dysfunction is passed on genetically to offspring, and which, if expressed, results in a brain deficit in 5-HT. It has also been suggested that a pre-existing serotonergic deficit may be transiently alleviated by alcohol consumption, but eventually leads to further depletion of the 5-HT system (Ballenger, Goodwin, Major, & Brown, 1979). Hence, a cycle is instituted that reinforces further depletion of the pre-existing serotonergic deficit. If this is true, it would be expected that proximal alcohol consumption would produce acute elevations in serotonergic functioning at least within those individuals with a pre-existing serotonin deficit. One strategy to examine the relationship between alcohol and 5-HT is to study 5- HT functioning in alcohol dependent subjects. It should be noted that these studies are inherently problematic in that they may be confounded by the long term effects of alcohol abuse on the serotonergic system. However, while these studies restrict an examination of the possible role of serotonin in the development of alcoholism prior to alcohol consumption, they do provide information regarding serotonergic function in alcoholics. One study showed increased Vmax of serotonin uptake, indicating an increased capacity to remove 5-HT from the synaptic cleft, thereby lowering the availability of 5-HT for neurotransmission, in severe alcoholics versus non-alcoholic healthy controls (Daoust et al., 1991). In a previous study, this same group also noted an increase in platelet 3H- 22 serotonin uptake in currently alcoholic subjects as well as former alcoholics with eleven years abstinence versus non-alcoholics (Boismare et al., 1987). D'aoust et al., (1991) suggest that serotonin uptake is altered during chronic alcohol consumption. It must be noted that neither of these studies provided information on co-morbid diagnoses (depression, antisocial personality disorder, intermittent explosive disorder) or alcoholism subtype of subjects (Type 11, early onset) which precludes an examination of the effects of potential subsets of alcoholics. In contrast to the previous studies of increased serotonergic uptake in alcoholics, Neiman et al found no difference in Vmax between 7 middle aged alcoholic males (mean of 13 years abusing alcohol) and 7 age and sex matched non-alcoholic controls, both before and after an 8 day detoxification (Neiman et al., 1987). Additionally, one study found decreased platelet serotonin uptake in 19 male in-patient alcoholics (age = 24-55) in comparison to 19 age and sex-matched non-alcoholic control patients described as “free of serious medical or psychiatric illness” two weeks following detoxification (Kent et al., 1985). However, both studies were handicapped by small sample sizes. Given Ballenger’s hypothesis that alcoholics have a pre-existing low brain serotonin level that can be transiently raised by alcohol consumption, but in the long run, actually leads to further depletion, it has been suggested that the alcoholic may drink repeatedly to pharmacologically modify a serotonin deficiency in the brain (Ballenger et al., 1979). D'aoust etal., (1991) cite their previous study of former alcoholics with 11 years abstinence where serotonin uptake was always increased (Boismare et al., 1987) as supporting evidence of this hypothesis. 23 Given the use of whole blood 5-HT in the present study, the finding of decreased whole blood 5-HT content in'20 unmedicated female chronic alcoholics (Banki, 1978) is of interest. However, this group suffered from a variety of co-morbid diagnoses and was sampled from inpatients currently under aversion therapy for “asocial, aggressive behavior, suicidal manifestations, atypical intoxications, etc..” Given the relationship between serotonergic dysfunction and suicidality it is possible that the finding of decreased whole blood 5-HT in this sample of alcoholics is a function of the alcoholic subtype under examination. Similarly, the presence of impulsive aggression in this sample may have also been a function of the sample’s alcoholic subtypes. Further contributing to the inconsistent findings in alcoholics are findings from our own work with a sample of middle aged Caucasian men characterized by presence or absence of alcoholism and subtyped by level of antisociality. No differences in whole blood S-HT were found among 13 antisocial alcoholic men, 13 non-antisocial alcoholic men, and 12 non-alcoholic control men who were categorized by lifetime indexes of alcoholism and antisociality about 6.5 years prior to whole blood sample collection (Twitchell, 1997). Relatedly, no difference was found between alcoholic (AAL + NAAL) and non-alcoholic control men. Additionally, later analyses using current lifetime measures of alcoholism and antisociality to subtype the men also failed to indicate any differences in whole blood 5-HT. In this study, co-morbid diagnoses were not controlled for and it is possible that affective disorders and antisocial personality disorder were present and influenced these results. 24 Studies of platelet 5-HT content have also described an association between serotonin deficits and alcoholism. Lower mean platelet 5-HT levels were found in 47 patients with alcoholism in comparison to 11 healthy controls (Rolf, Matz, & Brune, 1978). Similarly, reduced platelet 5-HT content was found in a sample of 30 alcoholic patients (21 men, 9 women; mean age = 27.7) at day one of withdrawal and after 2 weeks of abstinence versus a group of 26 non-alcoholic controls (13 men, 13 women; mean age = 26.6) (Bailly et al., 1990). Additionally, results indicated that there was no difference in platelet 5-HT level from day 1 to day 15 in alcoholic subjects. While these authors indicated that their alcoholic sample had no “clinically detectable psychiatric or organic disease” they later indicated that several subjects were diagnosed with major depressive disorder at day 15 of abstinence. In any case, results indicated that the presence of major depression did not influence platelet 5-HT measure. However, these authors indicated that those alcoholics with an impulse control disorder were found to have higher platelet S-HT content than alcoholics without an impulse control disorder. Studies of central serotonergic function in alcoholics may indicate that lowered serotonergic function is associated with alcoholism. One study has shown abstinent alcoholic men to have lower CSF-S-HIAA levels than personality disordered patients (PD; (Ballenger et al., 1979)). Ballenger studied alcoholic military men entering an inpatient program for treatment (mean age = 29) and measured CSF 5-HIAA in the immediate post-intoxication period and after 4 weeks of abstinence. While CSF 5-HIAA measures in alcoholics could not be differentiated from PD controls in the post- intoxication period, there was a difference shown after four weeks of abstinence, with the 25 alcoholic group having lower concentrations of CSF 5-HIAA. The fact that a reduction in CSF 5-HIAA was only present in alcoholics following cessation of alcohol consumption lends further strength to Ballenger’s hypothesis that alcohol produces acute elevations in 5-HT, but in the long term result in further depletion of the 5-HT system. However, the Ballenger study did not report the presence of other psychiatric disorders in their alcoholic sample and may have over sampled individuals with antisocial personality disorder, intermittent explosive disorder, and depression, which may complicate these results. In contrast to this study, no difference in C SF 5—HIAA was found in 48 male alcoholics in comparison to 14 male non-alcoholic men (Limson et al., 1991). It should be noted that within the sample of alcoholics, several subjects made diagnosis for major depression, panic disorder, antisocial personality disorder, and obsessive compulsive disorder. Another study found decreased mean CSF 5-HIAA in non-alcoholic depressed patients with a family history of alcoholism in comparison to equally depressed patients free of a family history of alcoholism. (Rosenthal, Davenport, Cowdry, Webster, & Goodwin, 1980). While these studies are important, they are appropriately cited for being potentially confounded by the possible effects of chronic alcohol abuse on the serotonergic system. Perhaps more importantly, the results from many of these studies are limited in interpretability by the fact that they have not taken into account co-morbid psychiatric diagnoses which may complicate the observed relationships. One paradigm that does not have the potential confound of chronic effects of ethanol on the serotonergic system is the family history study. This paradigm studies serotonergic functioning in non-alcoholic individuals who are at increased risk for 26 alcoholism by virtue of a positive family history of alcoholism in a first degree biological parent, usually a father. Higher mean density of platelet serotonin uptake sites was found in young adult men (mainly college students) with a positive family history of alcoholism in comparison to men with a negative family history of alcoholism (Rausch et al., 1991). Importantly, this study only sampled men who were free of any psychiatric diagnosis themselves (including alcoholism, major affective disorders, and antisocial personality disorder) and who had alcoholic fathers who were free of any other psychiatric diagnosis. Similarly, in a study of abstinent adult alcoholics and their adult and younger offspring, increased serotonergic uptake (Vmax) was found in the alcoholics in comparison to controls, as well as in the alcoholic’s children (mean age = 11 i 1.1 years), most of whom had not ever drunk alcohol, in comparison to age and sex matched control children (Emouf et al., 1993). Importantly, subjects in this study were free of clinical depression, alcoholics had been abstinent between 1 month to 22 years, and no subjects were taking any antidepressant medications. These studies are particularly compelling and suggest that there is a relationship between serotonergic dysfiinction and alcoholism and furthermore, that altered platelet serotonin transport may be inherited. In summary, while the link between low 5-HT and alcoholism has been identified inconsistently, the most convincing evidence of a serotonergic deficit in alcoholism comes from the family history studies since these studies are not confounded by alcohol use and they carefully sampled non-pathological samples thereby decreasing potential bias related to associations between co-morbid diagnoses and 5-HT. Also, since whole blood 5-HT has been cited as a particularly good measure of the serotonin transporter, 27 these studies of increased transport indicate that the present measure of whole blood 5- HT should be useful in detecting differences between alcoholic and non-alcoholic subjects. For a comprehensive review of the human literature regarding serotonin and alcohol intake, abuse, and dependence, please refer to (LeMarquand et al., 1994a). rtn iF tinnA ein i s f A essi n Data linking low serotonin with aggressive behavior in animals have existed since a 1959 study which showed that the administration of 5-HT reduced isolation-induced aggression in mice (Yen, Stangler, & Millman, 1959). Currently, there exists a large literature of animal studies supporting the hypothesis that central 5-HT is involved in the regulation of aggressive behavior (Eichelman, 1979; Soubrie, 1986; Valzelli, 1981). Data cited by Soubrie show an inverse correlation with central 5-HT activity and shock- induced fighting (Kantak, Hegstrand, & Eichelman, 1981; Sewell, Gallus, Gault, & Cleary, 1982), muricidal (mouse killing) behavior (Katz, 1980; Waldbilllig, 1979), and filicidal (pup killing) behavior (Copenhaver, Schalock, & Carver, 1978). It appears that each of these behaviors can be increased or decreased by neurochemical manipulations of central 5-HT activity. An association between violence and a low 5-HIAA to serotonin ratio was found in studies of isolation-induced fighting in male mice and mouse-killing behavior in rats (V alzelli, 1969; Valzelli, 1971). A low ratio indicates a low serotonin turnover rate, and reducing CNS serotonin by diet or pharmacological means leads to increased shock induced fighting or mouse-killing behaviors (Kantak et al., 1981; Katz, 1980). Further 28 evidence of this was shown when mouse-killing behavior that is produced by p- chlorophenylalanine, a chemical that decreases the synthesis of serotonin, was reduced by the serotonin reuptake inhibitor fluoxetine (Berzenyi, Galateo, & Valzelli, 1983). Correlational and experimental studies of vervet monkeys have demonstrated that increased serotonin inhibits destructive aggression and facilitates many positive prosocial and affilliative behaviors (Raleigh & McGuire, 1994). In non-human primates, reduced levels of CSF 5-HIAA early in life have been found to be highly predictive of future excessive unrestrained aggression, risk taking, and premature death (Higley et al., 1996a). In free ranging monkeys, 4 years following initial evaluation, 46% of the subjects with low CSF 5-HIAA were dead or presumed dead while none of the subjects from the highest CSF 5-HIAA quartile were dead or missing. Those animals who had died were found to have initiated unrestrained aggression more frequently than other animals, EXhibited greater impulsivity as measured by taking more life threatening, unprovoked, Spontaneous, long leaps between treetops, and were repeatedly captured with greater frequency than high 5-HT functioning animals. These findings suggest that high mortality in low CSF 5-HIAA primates may result from impaired impulse control and excessive risk taking. For a comprehensive review of the literature regarding the role of Serotonin in animal aggression please refer to (Soubrie, 1986). Some of the very first studies examining the relationship between aggression and 5-HT were of violent suicide. Postmortem studies have been inconsistent, but evidence of a serotonergic deficit in violent suicide attempters has generally been found by the 29 indices of decreased brain 5-HT (Stanley & Stanley, 1990; Stanley, Virgilio, & Gershon, 1982) and increased post-synaptic receptor binding (interpreted as upregulation in response to a pre-synaptic deficit; Arango, Emsberger, Marzuk, & al., 1990; Arora & Meltzer, 1989; Mann, Stanley, & McBride, 1986; Owen, Cross, Crow, & a1, 1983; Stanley & Mann, 1983). In a review of studies of suicidal behavior, impulsivity, and serotonin, Roy and Linnoila (1988) cite one early study that found lower CSF 5-HIAA in those patients who made violent suicide attempts (hanging drowning, shooting, gassing, several deep cuts) versus those suicides that were non-violent (overdose) (Traskman, Asberg, Bertilsson, & Sjostrand, 1981). Additionally, they cite studies that also found lower levels of the dopamine metabolite (CSF HVA) in both violent and non-violent suicide attempters in comparison to controls and note that this study found a significantly greater reduction in CSF HVA in the depressed attempters, but not in the non-depressed attempters. Traskman et al., (1981) interpreted this finding to indicate that low CSF HVA levels may be more related to depression than suicidal behavior. Overall, results Suggest that reduced pre-synaptic 5-HT functioning is associated with suicidal behavior. While the increased number of post-synaptic receptor binding found in brain has typically been interpreted as evidence of upregulation in response to reduced pre-synaptic activity, there is the possibility that increased post-synaptic activity either separately or in Conjunction with pre-synaptic deficits is associated with suicidal and/or impulsive aggressive behavior. For a comprehensive review of the literature on suicide, impulsivity, and serotonin, please see Asberg et al., 1987. Further studies of serotonergic dysfunction in suicide in several clinical populations are reported below. 30 e si The connection between 5-HT dysfunction and impulsive aggressive behavior in humans is one of the most widely accepted findings in psychiatry today. Results from human studies have largely supported the findings from animal studies and suggest a relationship between serotonergic dysfunction and reactive aggression towards others. Human studies have consistently shown reduced levels of CSF 5-HIAA in patients with a history of aggressive behavior as manifested by outward violence. To determine if this relationship was specific to diagnostic categories Brown et al.(1982) studied 12 active duty military men with borderline personality disorder who were free of any history of affective disorder. A non-significant negative correlation was found between lifetime history of aggression and CSF 5-HIAA. Additionally, subjects with a history of suicidal behavior exhibited significantly lower levels of CSF 5-HIAA than those without a history of suicidal behavior. Also, a negative relationship was found between CSF 5-HIAA and the psychopathic deviate scale of the MMPI-2. However, it should be noted that it is unclear if these subjects were screened for a diagnosis of alcoholism which could make these findings difficult to interpret. This same study also reported similar results from a previous study of 24 male patients with personality disorder. The similarity in results of these two studies suggests that the relationship between decreased serotonergic function and aggressive behavior (both self directed and overt) is not related to diagnostically homogenous groups. Several studies of murderers have also been conducted. One study found lower CSF 5-HIAA in male violent offenders whose crimes were impulsive (unpremeditated; 31 Linnoila et al., 1983). Another study of men convicted of criminal homicide, men who had attempted suicide, and healthy male controls found decreased CSF 5-HIAA in those men who had killed a sexual partner or spouse (almost always in a rage suggesting reactive or impulsive behavior) in comparison to those men who had killed someone of less emotional significance (Lidberg, Tuck, Asberg, Scalla-Tomba, & Bertilson, 1985b). Importantly, this study raised the possibility that decreased serotonergic function may be related to decreased ability to control violent tendencies in states of heightened affective dysregulation. This suggests that the combination of poor behavioral inhibition in conjunction with poor affect modulation may be responsible for violence. In another study by this group, very low levels of CSF 5-HIAA were found in three individuals who had attempted to commit suicide and who had killed or attempted to kill his or her child (Lidberg, Asberg, & Sundqvist-Stensman, 1984). In one review, Coccaro (1989) cites various studies of clinical samples comprised largely of male subjects in their 20's giving evidence that CSF SHIAA levels are negatively correlated with both clinician and self-reported aggression (Brown et al., 1982; Brown, Goodwin, Ballenger, Goyer, & Major, 1979; Lidberg, Modin, Oreland, Tuck, & Gillner, 1985a; Linnoila et al., 1983), irritability and hostility (Brown & Goodwin, 1984; Roy, Adinoff, & Linnoila, 1988; Rydin, Schalling, & Asberg, 1982; van Praag, 1986) as Well as criminal behavior (Lidberg et al., 1985b; Linnoila et al., 1983; van Praag, 1983; Virkkunen, Nuutila, Goodwin, & Linnoila, 1987). Coccaro (1989) also cites evidence from peripheral measures of 5-HT functioning (whole blood 5-HT and plasma tryptophan/neutral amino acid ratio) which also indicate 32 an inverse correlation with aggressive behaviors. Both studies showed a negative correlation between 5-HT function and clinician rated measures of current aggressive behavior or historic accounts of serious aggressive acts that led to jail time. One study found an inverse relationship between whole blood 5-HT and hyperactivity and aggression in a sample of 30 mentally retarded patients (age 4-39; (Greenberg & Coleman, 1976)). However, a recent study found a positive relationship between whole blood 5-HT and violence in a large epidemiological sample of young adult men (Moffitt et al., 1998). This study suggests that while the relationship between whole blood 5-HT and brain 5-HT function is still unclear, these results indicate that whole blood 5-HT is related to behavior and as such, whole blood S-HT warrants more research. Interestingly, in this same study, no relationship was observed in a comparison group of females. Another study found a low ratio of tryptophan to amino acids, signifying lowered serotonin synthesis, in male alcoholics with histories of aggression in comparison to male alcoholics without such histories (Branchey, Branchey, Shaw, & Lieber, 1984). A more detailed review of the literature documenting the relationship between serotonin and aggression in humans can be found in Soubrie, 1986. Since serotonin has been implicated in behaviors and disorders ranging from alcoholism, personality disorders, obsessive compulsive disorder, depression, and obesity, much debate has centered around the possibility that the relationship between these diverse disorders and serotonin may be mediated by a core component shared by each of these conditions. In relation to the spectrum of disorders marked by 33 aggressiveness, the most parsimonious and supported hypothesis suggests that serotonin neurons play a central modulatory role in behavioral inhibition with aggression being one result of a serotonergic deficit. One early proponent of this hypothesis, Soubrie (1986), argues that serotonin acts as an endogenous inhibitor for various behaviors. In his comprehensive review of animal and human data, Soubrie provides the interpretation that the serotonin system is primarily involved in modulating overall level of responsiveness. In relation to aggression, he suggests that deficits in the serotonergic system decrease the ability to tolerate delayed responding and thus result in the facilitation of impulsive responding to noxious stimuli. This construct has most frequently been described as impulsivity, but has also been described as hyper-reactivity. In regard to the relationship between aggression and serotonin, Soubrie suggests that reduced serotonin does not lead directly to aggressive behaviors but rather, may be a catalyst for the expression of aggressive impulses through a primary effect on inhibition. This model suggests that serotonin depletion results in a primary increase in impulsiveness, and that an increase in aggressiveness is just one of the resulting behavioral changes. Similarly, this same deficit could produce emotional disinhibition resulting in lowered ability to cope with or tolerate negative affect, thereby leading to depression and irritability. While the most convincing evidence to date centers around studies of aggression, the possible relationship between decreased serotonin and an increase in other normally suppressed behaviors is promising. Similarly, it has been hypothesized that the relationship between decreased 5-HT and alcoholism is merely another manifestation of poor behavioral control (Pihl & Peterson, 1993). 34 Substantiating the relationship between decreased serotonergic transmission and impulsive aggression are studies suggesting that central S-HT activity is associated more with reactive aggression than with aggressive behavior in general (Coccaro, 1989). When rats were previously exposed to mice the muricidal response produced by decreased 5-HT was prevented (Marks, O'Brien, & Paxinos, 1977). Additionally, in a study of non- human primates who had 5-HT functioning lowered by tryptophan depletion, no aggression was found unless conditions of increased arousal were present as occurs upon the insertion of a nasogastric tube (Chamberlain, Ervin, Pihl, & Young, 1987). These findings suggest that when sufficient arousal is not present, central 5-HT may not be associated with aggression. This data may also support the hypothesis that increased levels of negative affect in combination with increased motoric disinhibition may be necessary for the exhibition of violent behavior. Many of the human studies on serotonergic dysfunction have focused on impulsive aggression (Asberg, Schalling, Traskman-Bendz, & Wagner, 1987; Coccaro, 1 989; Roy et al., 1988). Of particular importance to the hypothesis that impulsivity might be the underlying behavioral construct in aggressive behavior are a series of studies by Linnoila and Virkkunen (Linnoila et al., 1983; Virkkunen, DeJong, Bartko, & Linnoila, 1989a; Virkkunen, DeJong, Goodwin, Linnoila, & Bartko, 1989b; Virkkunen et al., 1987). In a study of 36 male murderers and attempted murderers under forensic evaluation, lower levels of CSF 5-HIAA was found to discriminate between those offenders whose crimes were impulsive versus those offenders whose crimes were premeditated (Linnoila et al., 1983). It should be noted that all subjects met criteria for 35 alcohol abuse, 20 were diagnosed with intermittent explosive disorder, 7 were diagnosed with antisocial personality disorder (2 disorders which may signify poor affective modulation; all were impulsive offenders), and 9 met criteria for paranoid or passive- aggressive personality disorder. Interestingly, further analyses found that those offenders who had committed more than one violent crime had significantly lower CSF 5-HIAA levels than the offenders who had committed only one violent crime. Additionally, the impulsive offenders who had attempted suicide had significantly lower CSF 5-HIAA levels than in violent offenders who had not attempted suicide. These results were interpreted to indicate that low CSF 5-HIAA is associated with a tendency for repeated, impulsive violent behavior towards others or the self, as well as with early onset alcohol abuse. These authors further suggest that there may be certain individuals who may have a central serotonin metabolism defect, who abuse alcohol early in life, and then go on to become violent psychopaths later in life. Most importantly, these findings support the hypothesis that low CSF 5-HIAA may be associated with impulsivity rather than Violence. A second study was conducted of 20 incarcerated male arsonists (mean age =29.8 i 9.6 years) to further determine whether low CSF 5-HIAA levels were associated with aggressiveness or impulsivity (Virkkunen et al., 1987). Arsonists whose crimes were motivated by uncontrollable impulsive urges to set fires were selected because they show high levels of impulsivity, but little interpersonal aggressiveness. Using a subset of the male violent offenders from the previous study (Linnoila et al., 1983) as well as a control group of 10 community recruited healthy subjects (3 female, 7 male) who were free of 36 any history of mental illness, CSF 5-HIAA levels were found to be lower in the arsonist group than either the violent offenders or controls. Neither of the monoamine metabolites 5-HIAA or MHPG was correlated with the severity of repeated fire setting behavior. However, low blood glucose nadir, a measure of hypoglycemia which has been related to impulsive fire-setting, violent behaviors, and suicide attempts in depressed patients, was found to be related to severity of repeated fire setting behavior. The authors interpret these findings as further evidence that low CSF 5-HIAA and hypoglycemia are associated with violent behavior primarily through poor impulse control. In the third study by this group, Virkkunen and Linnoila examined their ability to discriminate recidivists from non-recidivists in a sample of 58 male violent offenders and impulsive fire setters (Virkkunen et al., 1989b) using the psychobiological variables of CSF S-HIAA, HVA, and hypoglycemia. In all, 13 subjects had been found to have perpetrated new crimes as indicated by the criminal register in Finland during the 3 year follow-up period since release from prison. Diagnostic characteristics of the sample are as follows: all subjects with the exception of two arsonists met criteria for alcohol abuse, the majority of impulsive violent offenders and arsonists (also impulsive) met criteria for intermittent explosive disorder (suggesting poor affect modulation in combination with behavioral under control), 25% of the impulsive offenders met criteria for ASPD (again, potentially suggestive of poor affective modulation and behavioral under control), while only 14 percent of arsonists and none of the non-impulsive offenders met ASPD criteria. Furthermore, major depression or dysthymia was diagnosed in 13% of impulsive offenders, 50% of non-impulsive offenders, and 82% of arsonists. 37 Results of linear discriminant analysis found that blood glucose nadir during oral glucose tolerance test correctly classified 81% of the subjects as recidivists or non- recidivists. Adding the CSF 5-HIAA measure increased the percentage of correct classifications to 84%. When using the C SF 5-HIAA concentration alone, all subjects were classified as non-recidivists, producing a 77% correct classification rate. Consequently, CSF 5-HIAA by itself was not a good predictor of recidivism. These authors conclude that the strongest predictors of recidivism are the combination of hypoglycemia and low levels of CSF 5-HIAA. Furthermore, these authors indicate that these psychobiological variables either alone or in combination had greater predictive power for recidivism than any combination of behavioral variables. They stress that the utility of psychobiological variables in comparison to the utility of behavioral and diagnostic variables in predicting long-term outcome in dangerous criminals should not be ignored. Importantly, these authors note that almost without exception each new offense perpetrated took place while the offender was under the influence of alcohol. They note that the offenders behaved well in prison where alcohol is not available, were released early for good behavior, and upon release from prison drank excessively and committed new offenses. These authors suggest that since all offenders have low CSF 5- HIAA which can be ameliorated with serotonergic drugs, and given that serotonergic enhancing drugs have been shown both to reduce alcohol consumption in humans and to improve glucose metabolism in experimental animals, serotonergic enhancing medications might be useful in these populations. 38 The fourth study examined the relationship between a history of suicide attempts serious enough to result in a hospital visit (the behavioral variable of impulsivity), and the psychobiological variables of CSF S-HIAA, low CSF HVA, and hypoglycemia (V irkkunen et al., 1989a). While CSF 5-HIAA and low CSF MHPG were significantly lower in the subjects with a history of suicide attempts (27 subjects) than in those without such a history (31 people), no differences were found for blood glucose nadir or HVA. Linear discriminant analyses revealed that CSF S-HIAA correctly identified 72% of the subjects having a positive or negative history for suicide. Adding the diagnosis of dysthymic disorder increased correct classification to 79%. Using only MHPG resulted in correct classifications for 79% of the subjects. Interestingly, while hypoglycemia was previously found to be a strong predictor of violent offenses, the lack of an association between a history of suicide attempts and hypoglycemia in the current study “suggests that biochemical concomitants of suicidal behavior and outward directed violence though similar, may not be identical.” Peripheral measures of 5-HT function have also been used in studies of aggression. A recent study found an inverse relationship between Bmax (maximal number of platelet tritiated binding sites) of the 5-HT transporter (pre-synaptic measure) and both a lifetime measure of aggression (Life History of Aggression total score) and the Buss-Durkee Hostility Inventory assault score in 24 personality disordered individuals (18 men, 6 women), suggesting decreased numbers of platelet S-HT transporter sites (Coccaro, Kavoussi, Sheline, Lish, & Csemansky, 1996). However, no similar relationship was found in a group of 12 healthy controls (6 men, 6 women). Unlike many 39 studies, this group partialled out the effects of depression, global adaptive functioning, and history of alcoholism or drug use. No difference was found between Bmax values in personality disordered versus healthy subjects suggesting that personality disordered subjects as a group do not have an abnormality in the platelet 5-HT transporter. Rather, there may be a relationship between the dimension or irritable aggression related to the platelet 5-HT transporter site. Recently, post-synaptic measures of 5-HT have begun to be examined in relation to impulsive aggression. Coccaro et a1. (1997) found that increased post-synaptic platelet 5-HT2A receptor density was associated with increased assaultiveness as measured by the Buss-Durkee Hostility Inventory in 22 personality disordered subjects (14 men, 8 women). Furthermore, they reported that this relationship was independent of life history of depression, alcoholism, drug abuse, current depressive symptoms, or GAF scores. No difference was found in receptor density between PD and control subjects again suggesting that there is no receptor site abnormality in PD subjects as a group. Rather, there appears to be a relationship between a dimension of assaultive aggression and variables related to platelet 5-HT2A receptor characteristics. They argue that while studies show increased numbers of postsynaptic 5-HT receptors, the fact that most S-HT pharmacochallenge studies show reduced physiological response to stimulation of post- synaptic 5-HT receptors in suicidal and/or impulsive aggressive individuals suggests that decreased post-synaptic functioning, with or without pre-synaptic dysfunction may also be related to suicide. This is contrary to the usual interpretation that increased post- 40 synaptic receptors are merely a sign of compensatory action for decreased pre-synaptic function through upregulation. Given that the serotonergic system is also implicated in affect modulation, it is possible that these studies of behavioral disinhibition (impulsive aggression towards others or the self) and emotional dyscontrol (depression, intermittent explosive disorder, and ASPD) stem from problems in behavioral under control in conjunction with poor affect modulation. Lidberg states that those subjects who killed a lover did so in a state of intense negative affect (jealousy, frustration, or fear; (Lidberg et al., 1984)). Relatedly, when put together with the low CSF 5-HIAA found by Linnoila in impulsive offenders, and the impulsive violent character of the suicide attempts reported by Asberg, it is possible that serotonin turnover is important in the control of tendencies to violence in states of emotional turmoil (poor affect regulation). Similarly, given that many studies showing decreased S-HT in alcoholics sampled alcoholics with ASPD or with intermittent explosive disorder it is possible that the combination of negative affect and behavioral under control which is suggested by these two diagnoses, not alcoholism, is primarily related to low 5-HT functioning. For an early comprehensive review of the literature regarding the relationship between serotonergic dysfunction and impulsive aggression please refer to (Coccaro, 1989). "Mia's I: z-.nu1.1‘;tufirt 3' 'e! .6. iii, 2.10.1”. ° 5 Data from personality inventory scores have also produced evidence that serotonin is related to impulsivity. A negative correlation between CSF 5-HIAA and psychotocism was found in a study of psychiatric patients and healthy volunteers 41 (Schalling & Asberg, 1985). Schalling argues that not only is the construct of psychotocism related to the susceptibility to psychosis, but that there is also evidence that there is a strong association between psychoticism and both impulsiveness and criminality (Eysenck & Eysenck, 1976). Psychotocism can also be conceptualized as a combination of poor behavioral and affective modulation. Additionally, Schalling draws the parallel between the relationship between low CSF 5-HIAA and psychotocism and the observed relationship between low CSF 5-HIAA and the Psychopathic Deviate scale of the MMPI that was reported by Brown (Brown et al., 1982). Furthermore, a negative relationship was found between CSF 5-HIAA and elevated scores in scales found to be correlated with impulsivity, sensation seeking, and psychopathy, but only in non- depressed patients (Schalling, Asberg, Edman, & Levander, 1984). In analyses by this author using the larger sample, increased levels of neuroticism as measured by the NEO-FFI (negative affect as measured by the subscales of Anxiety, Angry Hostility, Depression, Self-Consciousness, Impulsiveness, and Vulnerability) were found in 29 Antisocial Alcoholic (AALs) men in comparison to 69 Non-Antisocial Alcoholic (NAALs) men (Twitchell et al., 1996). Significantly lower levels of Agreeableness (measured by the subscales of Trust, Straightforwardness, Altruism, Compliance, Modesty, and Tenderrnindedness) was found in AALs in comparison to NAALs and Non-Alcoholic Controls (N Cs; n = 70). Additionally, alcoholics (AALs and NAALs) scored significantly higher than NCs on Openness (measured by the subscales of Fantasy, Aesthetics, Feelings, Actions, Ideas, Values). While 5-HT was not measured in this sample, the greater levels of neuroticism and lower level of agreeableness in 42 alcoholic subtypes suggest that there may be an underlying dimension of irritable impulsive aggressiveness combined with poor affect modulation in ASPD alcoholics who have a more severe life course marked by both alcoholism and antisociality. However, it should be noted that while one study found higher Neuroticism scores in alcoholics versus controls as measured by the Eysenck Personality Questionnaire Revised, and for Psychopathic deviancy, Depression, Psychasthenia, and Anxiety as measured by the MMPI, CSF 5-HIAA was not correlated with these personality scores in either the sample of alcoholics or the controls (Limson et al., 1991). These authors explain these results by surmising that the personality inventories they used may not adequately or specifically measure the constructs of impulsivity, hostility, and aggression, which are the variables most commonly associated with serotonergic dysfunction. This group further argues that future research into the neurobiology of aggression and hostility will need to develop specific measures of these personality dimensions. EIQ |V°I lllll° Given the consistent relationship that has been observed between serotonergic dysfunction and impulsive aggression and the less consistent, but suggestive evidence of a potentially similar deficit in alcoholics, research has focused on examining serotonergic function in early onset, antisocial alcoholics. This subtype of alcoholic is remarkable for the prominence of early impulse control problems and aggressiveness as well as the early emergence of alcohol related life problems and greater life difficulty related to such alcohol abuse. Cloninger’s Type II alcoholism is limited to males, is largely genetically transmitted and has been characterized by Cloninger as involving early impaired impulse 43 control, early onset of alcoholism (typically in adolescence), antisocial traits, problems in social relationships, physically aggressive acting out behavior, and is thought to be related to a serotonergic deficit. While there are numerous studies documenting overlap in Cloninger’s schema (Irwin, Schuckit, & Smith, 1990; Anthenelli, 1994), the age of onset of alcoholism has been found to be perhaps the most important factor in differentiating alcoholic course and outcome (Irwin, Schuckit, & Smith, 1990). It should also be noted that there is consensus that within this subgroup of alcoholics, there is a large proportion of individuals who fulfill criteria for antisocial personality disorder (ASPD; (Virkkunen & Linnoila, 1997). While antisocial personality has a very high co-morbidity with alcoholism, one group has noted that there is strong evidence that antisocial personality disorder and alcoholism are distinct entities (Schuckit, Klein, Twitchell, & Smith, 1994), and others stress that alcoholism accompanied with antisocial personality disorder should be differentiated from alcoholism outside the context of antisocial personality disorder (Von Knorring, Von Knorring, Smigan, Lindberg, & Edholm, 1987). In fact, ASPD may carry it’s own primary relationship with decreased serotonergic function given that ASPD is marked by increased impulsivity, aggressiveness, and high levels of negative affect. An early review of the studies of serotonergic function in alcoholics and samples with problems of behavioral dysregulation suggested that serotonergic dysfunction might play a role in the dimension of disinhibitory psychopathy seen in some alcoholics (Moss, 1987). This author noted that serotonergic deficits appeared to be related to a spectrum of disinhibited behavior disorders, and were not restricted to diagnostic categories. 44 Relatedly, he suggested that alcoholism itself might be a form of behavioral disinhibition. In one study, low CSF 5-HIAA was found in subjects with a paternal history of alcoholism in comparison to subjects without a paternal history of alcoholism in a group of 54 alcoholic incarcerated male violent offenders and fire setters (Virkkunen et al., 1989b). These data were interpreted to indicate that this group of subjects represented a subgroup of Type II alcoholism. Given the role of the serotonin system in affect and behavioral regulation, the relationship between problems with mood and aggression control and onset of alcoholism were studied in a sample of early (< age 20 years) and late (2 20 years) onset male alcoholics (Buydens-Branchey, Branchey, Noumair, & Lieber, 1989). Low tryptophan ratio was found in early onset alcoholics in comparison to late onset alcoholics, suggesting a decreased availability of tryptophan for synthesis into serotonin in the brain. Additionally, a significant effect was found for depression and aggression only in the group of early onset alcoholics after controlling for age, years of regular drinking, and consumption of alcohol. These authors conclude that early onset alcoholism is marked by alterations in the availability of tryptophan produced by alcohol use, which could place the alcoholic at greater risk for affective disorders and/or the expression of aggression. Blunted PRL response to m-chlorophenylpiperazine (m-CPP), a serotonin agonist, was found in 15 male subjects with ASPD and substance abuse in comparison to 12 healthy controls without personal or family history of psychiatric condition (including alcoholism or substance abuse; Moss, Yao, & Panzak, 1990). The PRL response was 45 inversely related to measures of assaultive aggression from the BDHI and hypophoria (negative affect), again suggesting a relationship between decreased 5-HT functioning and the combination of increased affective dysregulation and disinhibited violence. However, impulsivity as measured by response latencies to pictorial stimuli in a matching figures task was not related to prolactin response. These authors recognized the difficulty in understanding whether the blunted response in ASPD substance abusers was related to dispositional characteristics of ASPD which may either predispose them to or coexist with substance abuse, the effects of substance abuse, or characteristics related to ASPD substance abusers. Notably, this author pointed out that the high number of ASPD subjects with alcoholic fathers, brought up the recurrent question of whether ASPD substance abusers were a unique category (Type II alcoholism/antisocial alcoholics) or represented a co-morbid diagnostic condition. In summarizing the early data, Virkkunen and Linnoila suggest that male patients exhibiting early onset alcoholism, impaired impulse control, violence while intoxicated, and paternal alcoholism may have reduced central serotonin turnover (Virkkunen & Linnoila, 1990). In a follow-up study of recidivism in 114 male alcoholic violent offenders and fire setters, low CSF 5-HIAA was associated with a family history of paternal alcoholism and violence, but not with paternal alcoholism without violence (Virkkunen, Eggert, Rawlings, & Linnoila, 1996). Additionally, alcoholic recidivists who committed new crimes after release from prison had significantly lower CSF 5-HIAA and CSF MHPG (central metabolite of norepinephrine) and had a positive developmental history of early paternal absence from the home as well as the presence of brothers in the home. These 46 authors believe the high rates of absent alcoholic and violent fathers suggests that there is a heritable component to the transmission of violent alcoholism which may be present in Type II alcoholics. It should be noted that this study did not take into account the effects of co-morbidity; many of the impulsive violent offenders and impulsive fire setters met criteria for intermittent explosive disorder and antisocial personality disorder again suggestive of emotional under control/negative affective experience. Therefore, it is possible that the relationships observed may be carried by a relationship between reduced S-HT function and impulsivity in combination with poor affect modulation. Most importantly, the observed relationship between low CSF 5-HIAA and a combination of paternal alcoholism with paternal violence suggests that there is a stronger relationship between low CSF S-HIAA and violent alcoholism (as seen in antisocial alcoholics or in Type 115) than between low CSF 5-HIAA and alcoholism without violence. Importantly, decreased S-HT has been found in subjects without ASPD or intermittent explosive disorder. Low CSF 5-HIAA was found in early onset alcoholics (< age 25) in comparison to late onset alcoholics (> age 25) in a sample of 131 abstinent subjects (mainly male and Caucasian; abstinent 3 weeks) free of antisocial personality disorder (Fils-Aime et al., 1996). No differences were found in CSF 5-HIAA between alcoholics with only paternal alcoholism, only maternal alcoholism, or either maternal or paternal alcoholism. However, lower CSF 5-HIAA was found in the 12 alcoholics with both paternal and maternal alcoholism. While this could offer evidence for an additive genetic contribution from both parents, it could also point to the increased role of a negative environment in the development of serotonergic dysfunction by having two 47 parents who are alcoholic. While the majority of the alcoholics fulfilled current or past psychiatric diagnoses, alcoholics with a diagnosis of depression did not have lower CSF S-HIAA levels. Additionally, no difference in CSF 5-HIAA was found in 19 alcoholics who had attempted suicide. While subjects were free of ASPD, early onset alcoholics exhibited greater antisocial behavior as summed across four criteria for ASPD. However, childhood, adult, occupational, and summed antisocial behavior scores were not correlated with CSF S-HIAA in the full sample or in the early and late alcoholics. There was no relationship between paternal alcoholism status and antisocial traits in the offspring. While early onset alcoholics had more extensive drinking and alcohol related problem histories, alcohol-related behaviors or alcohol consumption did not correlate with CSF 5-HIAA. Overall, psychiatric co-morbidity and family history for paternal alcoholism was not correlated with CSF 5-HIAA in this group of treatment seeking, non- ASPD alcoholics. It’s possible that S-HT level may be dimensionally related to impulsive aggression since the levels of CSF 5-HIAA were higher in the Fils-Aime study of alcoholics in comparison with the violent offenders in Linnoila’s studies. Given that many of the reviewed studies suggesting an association between early onset antisocial alcoholics are potentially complicated by the presence of emotional under control as seen in depressive disorders and intermittent explosive disorder, replication of findings from studies like the Fils-Aime study are necessary. For a more extensive review of the literature regarding the role of serotonin in early onset violent alcoholism, please refer to (Virkkunen & Linnoila, 1997) 48 WWW As the literature so far reviewed indicates, there are four clinical characteristics that have been reported to be associated with 5-HT dysfunction: major depression. suicide attempts, impulsive aggression, and alcoholism. However, most of these studies have examined the relationship between 5-HT and one characteristic, for example 5-HT and alcoholism, while ignoring the frequent co-morbidity of depression or impulsive aggression (frequently found in antisocial personality disorder) found in alcoholics, and their effects on the primary relationship under examination. This strategy results in confusion when interpreting results due to different characteristics of particular subsets and mediating relationships. To ameliorate this deficit, studies need to take into account simultaneously, all factors currently suspected to be related to 5-HT dysfunction and examine the possibility of an underlying clinical construct (a dimensional not categorical approach) such as impulsive aggression that may underlie these somewhat diverse characteristics. Perhaps a design that allows the examination of these factors simultaneously in a large sample is needed. Such a design would allow an examination of the possibility that one factor underlies each of the observed relationships. One study has provided such a design strategy and reported results from a prolactin response to fenfluramine study with a sample of 45 male VA patients [25 with primary major affective disorder (MAD), 15 currently diagnosed, 10 previously diagnosed; 20 with primary personality disorder (PD) many of whom had past or present MAD- borderline, schizotypal, paranoid, histrionic, or compulsive] and 18 healthy male 49 controls who were free of any personal or family history of Axis I or Axis II disorder (Coccaro et al., 1989). Results found that both PD and MAD patient groups exhibited decreased prolactin response to fenfluramine challenge in comparison to the control group. No differences in PRL(FEN) were found when MAD and PD subjects were broken into the following groups: current, ever, or never diagnosed with MAD. Within MAD subjects, decreased PRL(FEN) was found in the group with acute MAD, and the group with past or present MAD in comparison to controls. However, the difference between PRL(F EN) response in MAD patients in remission was not different from controls, nor present MAD patients suggesting that the relationship between 5-HT and depression reflects a state, not a trait marker. Within the PD group, no PRL(FEN) response difference was found in those subjects with a present or past history of MAD in comparison to those without any history of MAD. Analyses revealed that those patients who had attempted suicide (14) had reduced PRL (FEN) response in comparison to those patients who had not attempted suicide (31) and healthy controls (1 8). Further analyses found that this main effect for history of suicide was not specific for diagnostic group (MAD or PD). Because alcoholics have been reported to have lower 5-HT and exhibit increased rates of suicide, analyses were performed to determine if alcoholism contributed to the main effect for suicide. Results found that peak PRL(FEN) response was lower in those who had alcoholism (n=13) than in those who had no history of alcohol abuse (n=32); no main effect was found for suicide attempt. However, a significant effect for suicide history was observed in patients without a history of alcohol abuse (patients who had attempted suicide and who didn’t 50 have a history of alcohol abuse; n=8) in comparison to patients who have not attempted suicide or who do not have any history of alcohol abuse (n=24). Inverse correlations were found between peak PRL (F EN) response and the clinician rated Brown Goodwin aggression, self-rated Buss-Durkee motor aggression, and Bar'ratt Total Impulsiveness Scale. These relationships were accounted for by the strong relationships among PD patients. Importantly, this study examined the possibility that PRL(FEN) response might correlate non-specifically with psychopathology factors from other nonaggressive/impulsive self ratings of psychopathology not hypothesized to be related to decreased 5-HT. Results found no relationships between PRL(FEN) and the Spielberger State Trait Anxiety Inventory, the Zuckerman Sensation Seeking Inventory, and MMPI inventory scores (other than the PD scale). Stepwise regression analyses of the aggression and impulsivity measures in PD subjects found that the majority of the variance was accounted for by the Buss-Durkee assault and irritability score alone. Within the PD group there were strong correlations between alcohol abuse, history of suicide, and impulsive aggression in borderline patients. Analyses covarying for the Buss-Durkee Inventory score as a covariate found no relationship between these characteristics, once irritable impulsive aggression was partialled out. These authors interpret these findings to suggest that in PD subjects, irritable impulsive aggression is the most powerful behavioral correlate of reduced peak PRL(FEN) response which is believed to be an index of “net” central 5-HT function. Overall, these findings suggest that 5-HT dysfunction is associated with self and other directed irritable impulsive aggression in PD patients and to self-directed 51 aggression in MAD patients. These findings indicate that decreased 5-HT is present in some patients with MAD and PD, but that the behavioral correlates in these populations differ. In PD patients, reduced 5-HT is associated with both a history of suicide attempt and impulsive aggression. In MAD patients, decreased 5-HT is associated only with a history of suicide attempt. These authors interpret the lack of an association between 5- HT and severity of depression and the fact that PRL(FEN) did not differ in PD or MAD subjects as a function of past or present depression to indicate that depression is not a central correlate of decreased 5-HT. History of suicide attempt was related to reduced 5- HT function, but the finding of elevated scores of irritable aggression in the suicidal patients, but not with violent means of the attempt is similar to the finding of decreased CSF 5-HIAA in impulsive, but not premeditated violent offenders by Linnoila. Coccaro et al., interpret this to suggest that a general history of irritable impulsive aggressive behavior, not violent/non-violent method, is more strongly associated with decreased 5- HT function in patients who attempt suicide. Additionally, results indicate that the association between a history of alcohol abuse and decreased 5-HT is attributable to the presence of impulsive aggression. Coccaro et al., interpret the strong correlations between motoric or physical aspects of impulsive aggression and 5-HT, the lack of correlation between ideational measures of aggression, and the animal data of increased aggressiveness only in response to noxious stimuli in relation to decreased 5-HT, as suggesting that reduced 5-HT is related to reactive physically aggressive behavior that is irritable-impulsive rather than generally physically aggressive. Additionally, these findings suggest that a dimensional 52 rather than a categorical model is most useful when examining the association between decreased 5-HT and behavioral correlates. In summary, (Coccaro, 1989) suggests that reduced S-HT function in the CNS makes an affected individual vulnerable to responding to noxious stimuli in an exaggerated manner. Thus, the individual strikes out at the noxious stimuli (the self in cases of suicide) at a lower threshold. W. The studies reviewed have several limitations. First, most studies to date have been conducted on largely male samples. Therefore, endocrine and neurochemical factors that influence aggression in females have as yet not been fully evaluated (Saver et al., 1996). Second, many studies have not yet taken into account the distinction between state and trait responses and as such fail to deal with the likelihood that the neurochemical substrates for responses related to quickly changing behavioral states and those related to more enduring trait like dispositions may differ (Saver et al., 1996). Third, and most importantly, there is a lack of precision and consensus in defining and measuring concepts related to aggression, impulsivity, and particularly impulsive aggression. Sgcigbiglggigal Eungtigns of Aggression. While it is agreed that impulsive, poorly modulated aggressiveness is maladaptive, aggression in certain circumstances is an adaptive strategy favored by natural selection. Agonistic behavior to defend ones tenitory, obtain food, protect offspring, or to win a mate is essential for individual survival and genetic propagation (Saver et al., 1996). More specifically, evolutionary theory suggests that it is not only adaptive aggression, but the ability to regulate a mixture of aggressive and peacemaking behaviors that natural selection favors. While consistent 53 unregulated aggression would quickly reduce the support among an individual’s conspecifics and reduce reproductive success, the same result would occur if an individual used uniformly submissive and avoidant behavior (Saver et al., 1996). Therefore, in regard to social behavior, natural selection pressures organisms to adopt flexible behavioral strategies that allow aggressive and affilliative behaviors depending on an array of environmental variables. Consequently, social animals have a greater need for a neurobiological substrate to help regulate aggression than do solitary animals. W' 'l n ssi i il ren an A l ent Several studies have examined central and peripheral indices of serotonergic function (CSF S-HIAA, neuroendocrine challenge; platelet 5-HT uptake, whole blood 5- HT, respectively) in children and adolescents from clinical settings who exhibit a variety of overt behavior problems and aggressiveness. Lower CSF 5-HIAA was found in children (27 male/2 female) with disruptive behavior disorders (DBDs) versus age, sex, and race matched controls both at assessment (mean age = 11.3 i 3.6 years of age) and at two year follow-up (mean age = 13.8 i 3.9 years of age; Kruesi et al., 1992; Kruesi et al., 1990) Additionally, age corrected analyses revealed negative correlations between CSF 5-HIAA and three measures of aggression. The first study found inverse relationships between the Aggression Towards People subscale of the Diagnostic Interview for Children and Adolescents (Herjanic & Campbell, 1977) and a measure of Expressed Emotionality of the subject towards the mother (Magana et al., 1986). The second study found an inverse relationship between CSF 5-HIAA and the Physical Aggression 54 subscale from the Modified Overt Aggression Scale (Kay, Wolkenfield, & Murrill, 1988). Measures of impulsivity did not differentiate between the two groups (Kruesi et al., 1990). Conversely, a similar study conducted in the same laboratory reported a positive correlation between CSF S-HIAA and aggression in 29 younger male children with attention-deficit hyperactivity disorder (ADHD; X = 9.2 i 1.8 years of age), who differed from the previous sample in that they exhibited much lower levels of aggression (Castellanos et al., 1994). In all of these studies. parental alcoholism status was not reported. Neuroendocrine challenge tests have also been used as a non-invasive method to assess net responsivity of the serotonergic system. No difference in prolactin response to fenfluramine challenge was observed in 8 male adolescent patients with DBDs (X = 14.7 i 1.4 years of age) in comparison to 8 age, race, and SES matched community recruited healthy males (X = 15.3 i 1.2 years of age Stoff et al., 1992) Similarly, no relationship was observed between prolactin response and the Brown-Goodwin Assessment for History of Lifetime Aggression or the Buss-Durkee Hostility Inventory. In a separate group of 15 pre-pubertal males with one or more DBDs (X = 10.2 1; 2.5 years of age), prolactin response to fenfluramine was not significantly correlated with measures of aggression or impulsivity from the Child Hostility Inventory or the Inventory for Antisocial Behavior. Conversely, aggressive behavior was found to be positively correlated with prolactin response to fenfluramine in 34 younger brothers (X = 10.0 i 1.5 years of age) of convicted delinquents (Pine et al., 1997). However, while an elevated prolactin response 55 to fenfluramine was also found in 10 aggressive boys with ADHD (X = 8.6 i 1.3 years of age) in comparison to 15 non-aggressive ADHD boys (X = 8.5 i 1.1 years of age; Halperin et al., 1994) this same group was unable to replicate this finding in an older sample of 13 aggressive (X = 9.5 i 1.4 years of age) and 12 non-aggressive ADHD boys (X = 9.5 i 1.3 years of age; Halperin et al., 1997). Analyses combining the original and replication samples divided into older and younger subgroups found that young aggressive boys had a significantly greater prolactin response to fenfluramine than young non-aggressive boys, but no such difference existed in the older boys. Importantly, the difference in prolactin response to fenfluramine challenge across the age groups was entirely accounted for by a difference across the two non-aggressive groups; younger and older aggressive children had almost identical prolactin responses to fenfluramine. Consequently, these authors suggest that age-related developmental changes in 5-HT function may be important to consider when interpreting data regarding the relationship between aggression and 5-HT in children and adolescents. Studies of 5-HT uptake measured by platelet imipramine binding density more consistently support a relationship between serotonergic dysfunction and overt behavior problems and aggressiveness. A significant reduction in the density of imipramine binding sites was found in 17 conduct disordered (CD) plus ADHD diagnosed children (14 boys/3 girls; 16 African American/l Caucasian; mean age = 10.8 i 1.8 years of age) in comparison to matched normal controls (Stoff, Pollock, Vitiello, Behar, & Bridger, 1987). Additionally, a negative correlation between platelet imipramine binding density and both externalizing behavior and aggressiveness as measured by the CBCL was found 56 in the combined sample. Similarly, an inverse correlation between number of imipramine binding sites in platelets and CBCL TBP, Extemalizing, Hostility, and Aggressiveness scores was found in a sample of 23 males (X = 12.6 i 2.2 years of age) recruited from an inpatient psychiatric unit; all subjects fulfilled criteria for CD, and 16 also fulfilled criteria for ADHD (Birrnaher et al., 1990). Post-synaptic indices have also been used in studying these relationships. Decreased SHT2 receptor binding was found on platelets of 28 incarcerated male delinquent adolescents (16.1 i 1.6 years of age) who had committed violent crimes in comparison to a group of non-violent age matched controls (Blumensohn et al., 1994). Due to ethical constraints, the majority of child and adolescent studies have been restricted to studies of peripheral indices of 5-HT function such as whole blood 5-HT. While whole blood 5-HT shares similar receptor, release, and transport mechanisms with serotonin neurons (Pletscher, 1987), the precise relationship of whole blood 5-HT to central serotonergic functioning is unclear (Stoff & Vitiello, 1996). Unfortunately, since adult studies of aggression have focused largely on central measures of 5-HT function, findings from child and adolescent whole blood 5-HT studies cannot be directly compared to adult findings. Consequently, these studies of children and adolescents are more exploratory in nature. In addition, less consistent results have been reported in studies of whole blood 5- HT. Reduced levels of whole blood 5-HT were found in 6 children with both obsessive compulsive disorder (OCD) and a DBD (all male; X = 14.1 i 2.2 years of age) in comparison to 12 children with only 0CD (7 male. 5 female; X = 13.0 i 0.9 years of age; 57 Hanna et al., 1995) Additionally, a negative relationship between whole blood 5-HT concentration and CBCL TBP, Extemalizing. and Aggressive Behavior scores was found in analyses of the complete sample. Conversely, a positive correlation between clinician CD ratings and whole blood 5-HT was observed in a more behaviorally disturbed and older sample of 27 recently incarcerated middle adolescent males and 17 community mental health recruited like aged male adolescents (Pliszka, Rogeness, Renner, Sherman, & Broussard, 1988). Additionally, a positive correlation between whole blood 5-HT and aggression as measured both by total offense points and the degree of violence of the offense leading to incarceration was found in a sample of 43 male conduct disordered juvenile offenders (13-17 years of age) incarcerated for violent crimes such as murder, rape, and armed robbery (Unis et al., 1997). However, this same study found a negative correlation between whole blood 5-HT and a self report index of impulsivity in 31 of these adolescents. While a positive correlation between CBCL TBP scores and whole blood 5- HT was also found in 10 behaviorally disturbed boys in residential treatment for unmanageable behavior (12-15 years of age), no correlation was observed in 11 younger similarly disturbed boys (7-11 years of age; Gabel, Stadler, Bjorn, Shindledecker, & Bowden, 1993). Similar to the findings of Halperin et al., these findings also suggest that age related developmental changes may be important factors in examining these relationships in non-adult samples. No difference in whole blood S-HT concentration was found between 25 conduct disordered children and adolescents in comparison to 20 normal controls (Rogeness, 58 Hernandez, Macedo, & Mitchell, 1982). Similarly, no difference in whole blood 5-HT level was found between 30 children with ADHD plus CD or oppositional defiant disorder (X = 8.2 i 2.4 years of age) and 22 children with ADHD only 0( = 9.9 i 2.6 years of age; Cook et al., 1995). This study also found no correlation between whole blood 5-HT and the CBCL Aggression and Delinquency subscales in 41 of these children. Relatedly, a recent review concluded that there is insufficient data to implicate a relationship between ADHD and 5-HT (Zubieta & Alessi, 1993). The discrepancies in the reviewed studies may be related to methodological differences, differences in the serotonergic system unique to the particular clinical populations studied, co-morbidity effects, varying definitions and measures of overt behavior problems, aggression, and impulsivity. Additionally, results of studies of whole blood S-HT highlight the possible importance of age related developmental changes in the serotonergic system (puberty) to the relationship between 5-HT and behavior. Studies of whole blood 5-HT in young children found no relationship, but results from studies of older children and adolescents did find a relationship between whole blood 5-HT and behavior. Additionally, many of these studies were hampered by the use of small samples, initial level of stress (e. g. relating to incarceration or hospitalization) and baseline level of aggression varied across studies, and the majority failed to take the effect of seasonal rhythms on serotonergic function into account (Pine et al., 1996). Overall, the CSF 5-HIAA studies of central 5-HT function and peripheral studies of platelet imipramine binding are most consistent with the adult studies and suggest a relationship between impulsive aggression and low CSF turnover. However, 59 neuroendocrine challenge and whole blood 5-HT studies in children and adolescents to date have produced inconsistent and frequently conflicting results. For further review of the literature regarding the role of serotonergic function in aggression of children and adolescents, please refer to Stoff & Vitiello (1996). Serotonergic Function and Phenogpic Expression. The most systematic finding in the child and adolescent literature is of a relationship between decreased 5-HT function and overt behavior problems of a variety of different kinds. Aggressive disorders and level of aggression within other disorders has been shown to have varying and sometimes hard to interpret relationships to the serotonin system. In a previous study upon which the present project was built, this author attempted to replicate this finding in a sample of COAs. That study used a global index that was believed to be the best general measure of behavioral under control, but that also had strong positive relationships to more explicitly externalizing and aggressive behavior was chosen, namely the Total Behavior Problem scale from the CBCL. Results of this study are presented below. anwmflflmm Interestingly, while it is generally accepted that deficits in serotonergic functioning are related to alcoholism and impulsive aggression, there is a paucity of data examining the possible role this dysfunction may play in the development of children of alcoholics (COAs) who are at increased risk for both of these behavioral problems. To our knowledge, only one study other than our own has examined the role of serotonergic function in young COAs. In a study of abstinent adult alcoholics and their adult and young children, increased 60 serotonergic uptake (Vmax) was found in the alcoholics in comparison to controls, as well as in the alcoholic’s young children (mean age = l l i 1.1 years), most of whom had not ever drunk alcohol, in comparison to age and sex matched control children. On the basis of these findings, the authors suggested that altered platelet serotonin transport may be inherited (Emouf et al., 1993). In a less violent, less disordered community based sample of Caucasian COAs, our own research group found lower whole blood 5-HT content in 6 COAs classified as exhibiting overt behavior problems as measured by clinical range CBCL TBP scores (5 sons, 1 daughter; mean age = 10.78 i 0.64) in comparison to 38 COAs (27 sons, 11 daughters; mean age = 10.42 i 1.78) with CBCL TBP scores in the normal or borderline range (Twitchell et al., 1998). Overall, a 34% reduction in whole blood 5-HT was found in the high problem behavior group. Correlational analyses of the full sample found significant negative correlations between whole blood 5-HT and the CBCL TBP and Anger scores. Additionally, moderate non-significant negative correlations between CBCL Aggression, Extemalizing, and Delinquency scores were observed, suggesting that the relationship between low whole blood 5-HT and TBP scores reflects some aspects of more aggressive and impulsive behavior. Relatedly, whole blood 5-HT was significantly negatively correlated with early impulsivity in 38 of these children as measured by Conner’s Impulsivity/Hyperactivity scale scores which were taken when the children were approximately 4 years old. Importantly, exploratory correlational analyses revealed significant relationships between whole blood 5-HT and several indicators of poor emotional modulation; CBCL Depression, Intemalizing, Somatic, and Withdrawal scales. 61 The presence of associations among whole blood S-HT, behavioral under control (behavioral impulsivity and aggressiveness) and poor emotional modulation (depression and internalizing problems) may suggest a link between decreased 5-HT and both behavioral and emotional control problems in children at risk for antisociality, alcohol problems, and greater psychiatric difficulty. i 11 -HT un ti i h'l While it has been debated that depressive disorders do not exist in children and adolescents, recent data suggest that depression in children may be highly prevalent, although under identified, under reported and until very recently, under treated (Ambrosini, 1987). Currently there is much debate surrounding the concern that the increased use of antidepressants for children and adolescents may be unnecessary, and potentially damaging, particularly in regard to the potential effects psychopharmacological intervention may have on the develOping affective modulation system. Given the relative recency of the surge in using selective serotonergic reuptake inhibitors for childhood depression and behavioral problems, the long term effects of these drugs on the serotonergic system and other neurotransmitter systems is unknown. Interestingly, high rates of co-morbid depression have been found in children with conduct disorder (Reich RSA presentation, 1997 (Dadds, Sanders, Morrison, & Rebgetz, 1992; Field et al., 1987; Kazdin, Esveldt-Dawson, Sherick, & Colbus, 1985; Kovacs, Paulauskas, Gatsonis, & Richards, 1988; Sanders, Dadds, Johnston, & Cash, 1992). Given the co-occurrence of CD and depression it is possible that an underlying biological substrate may be involved in the expression of these disorders through problems in both 62 behavioral and affective regulation. Therefore, the present study examined these relationships in hopes of gaining a more comprehensive understanding of the relationship of the serotonergic system to problems in both behavioral and affective modulation. _. _=. 11-1.0'nl__‘.\1’!" F citininN - - .2, -‘u =_ -~=. Childten Social factors such as social competence and dominance have been associated to 5—HT function in non-human primates and humans (Kruesi et al., 1990; Raleigh, Brammer, & McGuire, 1983; Raleigh, Brammer, McGuire, & Yuwiler, 1985). In free ranging primates, CSF 5-HIAA was found to be positively related to prosocial affilliative behaviors as measured by time spent grooming others, time in close proximity to group members, and mean number of neighbors within a 5 mile radius, and with timing of emigration (Mehlman et al., 1995). Additionally, these authors reported that low CSF 5- HIAA males exhibited impaired impulse control and underdeveloped social networks which may have contributed to “isolation. ostracism, or aggressive eviction,” factors that could lead to early emigration. Furthermore, they surmised that when these less socially competent animals leave their groups they may be exposed to unfavorable outcomes such as early mortality. Interestingly, these authors draw the connection that low CSF 5-HIAA may be a marker for behavioral traits like social competence, aggression, and impaired impulse control. Other studies have been conducted of prosocial affilliative behavior in non-human primates. The administration of serotonergic enhancing drugs increased positive social behavior such as grooming and approaching (Raleigh et al., 1983; Raleigh et al., 1985; Raleigh et al., 1980) in monkeys. 63 The relationship between aggression and 5-HT function appears to be moderated by social factors such as dominance. Dominant male vervet monkeys have been found to have basal whole-blood levels that are twice that of non-dominant monkeys (Raleigh et al., 1983). Additionally, the ascent to the dominant status has been associated with an acute elevation of 5-HT (Raleigh & McGuire, 1991). Consequently, serotonergic enhancing drugs have been found to increase dominance while serotonergic depleting drugs have produced a descent in status (Raleigh, McGuire, Brammer, Pollack, & Yuwiler, 1991). Additionally, dominant males are more responsive to serotonergic altering drugs and exhibit increased behavioral responses to such drugs than non- dominant animals (Raleigh et al., 1985). Experimental data firrther indicate that social factors constrain the link between aggression and serotonin (Raleigh & McGuire, 1994). For example, in high dominant animals, serotonin depleting drugs produce small changes in behavior, but small depletions of serotonin in subordinate animals produce greatly increased rates of aggression. Relatedly, he suggests that high social status might protect those individuals with low CSF 5-HIAA from exhibiting maladaptive impulsive aggression. Dominance and aggression are not synonymous. Dominance refers to the increased ability to consistently displace another animal in an approach-retreat interaction and the success in agonistic encounters (Raleigh & McGuire, 1994). Interestingly, while many early studies suggested that morphological differences or aggressiveness were correlated with dominance, this is untrue. In fact, measure of physical strength are not different between dominant and non-dominant animals (canine length, weight, testes 64 volume, length of animal). Interestingly, dominant animals have been found to exhibit less aggressivity, more reconciliation, greater ability to recruit allies, and increased rates of defending the group than subordinate animals. This suggests that dominant animals are more able to maintain social bonds. engage in appropriate aggressive behavior, and to inhibit unprovoked attacks. In general, it appears that dominant males are more able to navigate social systems, integrating appropriate aggressiveness and peace-making behaviors. Raleigh suggests that social skills, not physical strength or prowess, are essential to attaining and maintaining high dominance ranking (Raleigh & McGuire, 1994). Taken together, it has been suggested that increased serotonergic function is an important factor in mediating behaviors which permit a male to achieve high dominance status (Raleigh et al., 1991). The possibility of a relationship between social competence and 5-HT has begun to be explored in human studies. (Kruesi et al., 1990) found a significant positive correlation between CSF 5-HIAA and social competence as defined by the CBCL in a sample of boys with DBDs. This data, while preliminary, suggests that similar to the monkey studies, social competence and serotonergic systems may be linked. Relatedly, in order to adequately examine the relationships between 5-HT and acting out, impulsive aggressive behaviors in humans and affective disturbances as seen in depression, it may be necessary to take into account the possible mediating and/or moderating effects of social status on these relationships. 65 t r i i Serotonergic ftmction as measured by CSF S-HIAA has been found to be highly heritable and exhibits intra individual stability (trait, not state marker) in non-human primates (Raleigh, Brammer, McGuire, Pollack, & Yuwiler, 1992) as well as in humans (Riddle et al., 1986). However, data suggest that this dysfunction, when inherited, can be exacerbated or dampened by experience. Non-human primate studies have found that the peer rearing of infants, an analog of early parental neglect, leads to lower CSF S-HIAA in infants as early in life as 14 days of age (Higley, Suomi, & Linnoila, 1996b). Furthermore, this deficit continues into adulthood. In humans, the psychobiological consequences of neglect and isolation have been found to be more severe than those related to abusive environments. Neglected children have been found to be aggressive, depressed, and socially unskilled (Cicchetti, 1989 from Lewis ). Behavioral correlates of parental neglect and low 5-HT function in peer reared non-human primates have also been identified. For example, peer reared monkeys were found to drink more alcohol than mother reared monkeys and exhibited less social dominance. Both low CSF 5-HIAA and social competence were correlated with excessive alcohol consumption. These authors concluded that peer reared monkeys exhibited several behaviors that made them good animal models of Cloninger’s Type II alcoholism, including low serotonergic function, increased alcohol use, decreased social competence, and increased impulsive aggression. When monkeys from both peer reared and mother reared environments who exhibited low serotonergic function were followed into adulthood, the peer reared 66 monkeys exhibited more socially inept behaviors and more frequently were thrown out of their social groups for exhibiting excessive aggression and deviant social behaviors (Higley et al., 1996b). These authors concluded that the experience of peer-rearing aggravated the negative consequences associated with low serotonergic function. Importantly, this study found that the immediate environment could also influence behavior above and beyond serotonin level. The observable difference in alcohol intake between the two groups disappeared when the mother reared animals were faced with the stressful situation of separation from their social group. At that point, the mother reared monkeys drank similar amounts of alcohol. Relatedly, one human study found that the parental characteristics of harsh , parenting, parental alcoholism, and parental incarceration were associated with low serotonergic function as measured by reduced 5-HT2A receptor density on platelets in a study of 34 younger brothers of convicted delinquents (mean age = 8.3 it years; Pine et al., 1996). Additionally, this same group found that adverse rearing was positively correlated with prolactin response to fenfluramine challenge independent of the relationship of prolactin response to fenfluramine with aggression in a separate study of 34 younger brothers of convicted delinquents (X = 10.0 3: 1.5 years of age; Pine et al., 1997). In light of this finding, these authors warn that parental characteristics and early familial experiences may confound the relationships between a child’s behavior and serotonergic profile. Consequently, early behavioral and environmental intervention may positively modify existing serotonergic functioning. These psychosocial human and non- human primate data together suggest that while serotonergic function is partly heritable, 67 4 l experiential factors can impact this neurotransmitter system in ways above and beyond the genotypic contribution. Relatedly, the expression of a genetic trait is multiply determined, such that individuals with the genetic potential for a particular trait or disorder may not express the trait or disorder. For example, individuals with a positive family history of alcoholism who are at three fold increased risk for the development of alcoholism themselves will not express the phenotype (reduced penetrance) if they do not expose themselves to alcohol and thus select themselves out of an environment necessary for the expression of the phenotype (Schuckit, 1994). While analyses of the present author’s own study of alcoholics and their offspring did not find any relationship between paternal alcoholism subtype and child serotonergic function, an association was found between current paternal alcohol consumption and child whole blood 5-HT. Given that current heavy drinking might be a proxy for negative environmental variables that co-exist with heavy alcohol use, this relationship may indicate the untoward effects of a negative home environment on the child. Summary Serotonergic dysfunction has been implicated in both behavioral and affective modulation. Importantly, the data reviewed suggest that the combination of behavioral and affective disinhibition may be an important contributor to the expression of violent behaviors. While results from several studies suggest that reduced serotonergic function is associated with alcoholism, data from other studies suggest that this relationship might be complicated by the presence of irritable impulsive aggression which is highly co- morbid with the Type II or early onset subtype of alcoholism. 68 In contrast to the adult studies, an association between serotonergic function and impulsive aggression in children and adolescents has not been clearly or consistently found. Additionally, social and socioenvironmental variables have been found to complicate the observed relationships between serotonergic function and behavioral correlates in children and adolescents and both parental characteristics and child social competence have been found to share relationships with child serotonergic function. Additionally, the findings of a relationship between low serotonergic functioning and both aggression and depression in adults, in combination with the high prevalence of co- morbid depression in conduct disordered children may suggest that serotonergic dysfunction is involved in both behavioral and affective regulatory problems. 69 STATEMENT OF THE PROBLEM While a vast literature indicates a clear relationship between serotonergic dysfunction and irritable impulsive aggression in adult samples, data suggest that the less consistently observed relationship between serotonergic dysfunction and alcoholism may be complicated by the presence of irritable impulsive aggression. Given that previous work by this author failed to find any differences in serotonergic function between alcoholics and non-alcoholic controls, the present study examined the possibility that irritable impulsive aggression, not alcoholism is primarily related to serotonergic deficits. Additionally, evidence suggests that the less examined combination of irritable impulsive aggression and affective dysregulation may be particularly relevant to the expression of violent behavior. Therefore, the present study sought to explore the relationships between serotonergic function and both poor behavioral and affective modulation (irritable impulsive aggression and affective dysregulation, respectively) in a sample of alcoholics and non-alcoholic controls. Results from studies of behavioral problems in children have been less consistent than adult studies. While findings suggest that serotonergic dysfunction is related to overt behavioral problems and aggressive/violent behaviors, a relationship between serotonin and irritable impulsive aggression is unclear. Similar to adult studies, results from children and adolescents suggest that decreased serotonergic functioning may be related to problems in behavioral and affective modulation. While our own study of COAs found a negative relationship between whole blood 5-HT and overt behavior problems, the role of serotonergic function in affective problems in these children has not 70 yet been formally examined. In response to the data suggesting that serotonergic dysfunction is similarly involved in both behavioral and affective modulation and the findings of high co-morbidity of depression in conduct disordered children, the present study sought to examine the role serotonin might play in both the expression of behavioral under control and poor affective modulation in COAs. Additionally, given that recent data have indicated that social and socioenvironmental factors may influence the relationship between serotonergic function and child behavior, the relationships among child whole blood 5-HT, social and socioenvironmental factors, and both child behavioral and affective modulation were examined. 71 HYPOTHESES H1. Both ASPD and Alcohol Dependence diagnoses will be related to serotonergic dysfunction, though the whole blood 5-HT and alcohol relationship will be a function of ASPD. H2. Serotonergic dysfunction in adults will predict irritable impulsive aggressiveness (composite of Buss Durkee Irritability and Assault scales) and poor affective modulation (Neuroticism factor of the NEO-FFI and the Hamilton Rating Scale for Depression). H3. Low serotonergic function in children will predict irritable impulsive aggressiveness (Attack subscale of the CBCL) and poor affective modulation (Anxious/Depressed scale of the CBCL). H4. Socioenvironmental variables of high parent to child physical aggression (Conflict Tactics Violence scale), low parental functioning (Global Assessment of Functioning), parental irritable impulsive aggressiveness (composite of Buss-Durkee Irritable and Assault subscales), poor parental affective modulation (Neuroticism and Hamilton Rating Scale for Depression). and high current parental alcohol consumption (standardized quantity X frequency) will predict low child whole blood 5-HT. H5. Socioenvironmental variables of high parent to child physical aggression, low parental functioning, parental irritable impulsive aggressiveness, poor parental affective modulation, and high current parental alcohol consumption will predict child irritable impulsive aggression and poor child affective modulation. 72 H6. Socioenvironmental variables and child whole blood 5-HT will be independently related to child irritable impulsive aggression and poor affective modulation. 73 METHOD Sum Subjects for the present study were drawn from an already existing longitudinal data set from the Michigan State University/University of Michigan Family Study (Fitzgerald, Zucker, & Yang, 1995; Zucker, 1987; Zucker, Ellis, Bingham, & Fitzgerald, 1996b; Zucker, Ellis, Fitzgerald, Bingham, & Sanford, 1997). This project is following a population based sample of children of alcoholics, both biological parents, and an ecologically comparable, but non-alcoholic group of control families at 3 year intervals, beginning when the male target children were ages 3-5. and the female target children were between ages 3 and 11. Wave One involved 215 alcoholic families and 96 non-alcoholic control (NAC) families. All families were of non-Hispanic Caucasian background, which was dictated by the low base rate for non-Caucasian families in the area (less than 10%), and the concern that inclusion would add variance that could not be evaluated. Inclusion criteria for the larger study included having a biological son between age 3.0 and 6.0 living in an intact family with both biological parents. Fetal alcohol syndrome was an exclusionary criterion (Fitzgerald et al., 1993). Maternal alcoholism was neither inclusionary nor exclusionary, although a subset (41%) made a lifetime DSM-III-R alcohol abuse/dependence diagnosis. Alcoholic families were identified in one of two ways: (a) from the population of all convicted drunk drivers in a four county area of mid-Michigan. All men meeting the family recruitment criteria involving child's age and coupling status who had a blood 74 alcohol concentration (BAC) of 0.15% (150mg/100 ml) or higher when arrested, or a BAC of 0.12% if a history of prior alcohol-related driving offenses existed, were asked for permission to have their names released for contact by study staff. Seventy-nine percent agreed to have their names released, and of those, 92% agreed to participate. All of these men met a “definite” or “probable” criterion for alcoholism using the Feighner Diagnostic Criteria (Feighner, 1972) with 92% making a “definite” diagnosis. Later, DSM-III-R diagnoses were also established although this was not a basis for study inclusion; 73% of the alcoholic men met either moderate or severe alcohol dependence criteria. (b) from the same neighborhoods where drunk driver alcoholic fathers resided. These families provided an ecologically comparable subset of high risk families drawn out of the same social stratum as the drunk drivers, but where the alcoholism was identified by way of community survey rather than by way of legal difficulty. These alcoholic fathers also met Feighner criteria (with 85% making a definite diagnosis), had children and partners who met the same inclusion criteria as the drunk driving group, but had no drunk driving or drug involved arrest record occurring during the lifetime of the 3 to 5 year old male target child. In addition to alcoholic families, a control group of community families was recruited via door-to-door community survey techniques. These families were recruited out of the same census tract as alcoholic families and were homogenous with them for age of the male target child (+/- 6 months). However, neither parent met Feighner criteria for alcoholism. or for other drug abuse/dependence. Ninety-three percent of families who met eligibility criteria as controls agreed to participate. 75 To insure demographic comparability, non-alcoholic control families were recruited through door to door canvassing which started one block away from each alcoholic family and stayed within the same census area. Other criteria for control families included the presence of a male biological child who was within 6 months of the same age as the experimental target child. Feighner criteria were used for both fathers and mothers to rule out probable or definite alcohol or other drug abuse/dependence. 't ri Of the 50 families who participated in this study, blood samples were successfully drawn from 161 subjects (49 fathers, 47 mothers, 47 sons, 18 daughters). Prior to data analysis, those subjects taking any potentially serotonergic altering medications were identified from the self report data in the Health History Questionnaire. The whole blood 5-HT value for each of these 8 individuals was then excluded from analyses (5% of total samples). The composition of these exclusions by medication status were as follows: Fathers (l-Pamelor, l-Zoloft, l-Calan), Mothers (l-Effexor and Parnelor, l-Eskalith and Prozac, l-Prozac, 1-Paxil), Sons (l-Tofranil). Given that this study examined whole blood S-HT only in biological family members, one daughter’s whole blood 5-HT value was excluded from analyses based on her father’s report of questionable paternity. Additionally, one boy’s whole blood 5-HT sample and one father’s whole blood S-HT sample (unrelated subjects) were also excluded from analyses. The boy’s blood sample was the only sample to be drawn at a commercial laboratory and results were anomalous to all other data. Given these findings, his whole blood 5-HT value was dropped from all analyses. The father’s whole 76 blood S-HT value was found to be over three standard deviations above the mean of all fathers and was deemed an outlier. Overall, a total of 11 individual whole blood 5-HT values (7% of total samples drawn) were excluded from analyses. This resulted in a total of 150 analyzable whole blood 5-HT values (F athers-45, Mothers-43, Sons-45. Daughters-l 7). As mentioned earlier, given this study’s primary focus on the relationships between behavior and the potentially inherited biochemical serotonin, the author attempted to gather data from intact, biologically related families. Nonetheless, due to other study design issues, data were collected from one family where the biological father was unavailable (committed suicide at T2; stepfather currently living with family), one family where the children lived with the biological father and a stepmother, and one family where the divorced parents shared joint custody of the children. In each of these families, biochemical data were collected from each available biological family member, but not the stepparent. In analyses examining the relationships between socioenvironmental factors and both child behavior and biology, stepparent data were utilized when appropriate. W The present study is an extension of previous work by this author which compared serotonergic functioning in 11 AAL, 13 NAAL, and 9 NC fathers and serotonergic functioning between their high and low overt behavior problem children (Twitchell, 1997). This previous study included 114 analyzable blood samples (including 38 fathers, 77 32 mothers, 32 sons, and 12 daughters) which were included in the present analyses. Using this diagnostic schema, the subjects from the original report included eight fathers who met diagnosis for ASPD and 30 fathers who did not meet criteria for ASPD. Therefore, in order to test the hypothesis that ASPD men have lower serotonergic functioning than non-ASPD men, ASPD men and their family members were selected for inclusion in the present study. To increase the overall sample size for child analyses an attempt was made to select ASPD fathers who had both a son and a daughter. An attempt was also made to match the recruited children on the variable of age with the previous sample to reduce possible age related differences. Similar to the previous study, biochemical data were collected only from biological family members and an attempt was made to sample non-divorced intact families where the biological mother and father were currently living with the child. Mrs MIME—Cum In accordance with the procedures used in the previous study, prior to sample collection, the study coordinator contacted each new participating family and give an introduction to the proposed study. Then a follow-up phone call was made by the author, outlining detailed procedures of this separate in-home session and the voluntary nature of participation. Participants were then asked to give written consent to this procedure with the understanding that they could withdraw at any time without risk of penalty. 78 Materialsanflrenaranon Each subject had 24ml of whole blood collected by venipuncture in polystyrene ethylenediaminetetraacetic acid (EDTA) Vacutainer brand collection tubes by the author who is a trained phlebotomist. Twenty-one gauge Vacutainer brand needles were used to insure platelet integrity. All Vacutainer tubes were labeled beforehand with an indelible marker with the subject's 6-digit identification number, date, and time of blood draw. All identifying information, collection time, and number of tubes were logged in a lab book immediately following venipuncture. MW. While the MSU/U of M Longitudinal Study already has a self reported life history of physical health for each study participant, a general medical screen in the form of a health history questionnaire was administered to each participant prior to venipuncture to ascertain any current medications, illnesses, or difficulties that might confound sample results (please see Appendix C). Relatedly, this health screen inquired about recent alcohol consumption of the respondent and their spouse as well as recent cigarette use. All family members were informed that they would be paid $10 for participating while their blood samples would be donated to MSU. Each family member was informed that if they were injured as a result of participation in this study, Michigan State University would provide emergency medical care if necessary. Sample collection proceeded following a full review and approval by Internal Review Boards at Michigan State University and at the collaborating institution, University of Michigan. 79 Xenipuncturg. Each subject was seated in a comfortable supine position for the single blood draw. The antecubital area of the most appropriate arm for draw was prepared for venipuncture with alcohol pad and tourniquet. Venipuncture proceeded with a single needle stick. A total of 24 mls of whole blood was collected into (6), 4ml EDTA Vacutainer tubes. As soon as a steady flow of blood was apparent, the tourniquet was undone to prevent any subject discomfort. Following venipuncture completion and needle withdrawal, the puncture site was observed, and the subject was instructed to place sterile gauze with pressure to the site to prevent any further bleeding. The site was then covered with a band-aid to prevent any irritation of the area. All tubes were gently inverted approximately 5-6 times to thoroughly mix blood with EDTA anti-coagulant. MW Blood for whole blood serotonin assay was immediately frozen in dry ice pellets, then stored in a -70° C freezer upon arrival at Michigan State University. Later, these samples were batch shipped in dry ice to the University of Chicago for laboratory analysis. WW Whole blood 5-HT was analyzed by high pressure liquid chromatography with fluoremetric detection (Anderson, Young, Cohen, & Schlicht, 1981). 5-Hydroxytryptophan was used as an internal standard. Assays were performed blind to all demographic and diagnostic information at the Laboratory of Developmental Neuroscience, Department of Psychiatry. University of Chicago under the direction of Edwin H. Cook, Jr., M.D.. 80 Meaflres Denmarauhislariahies The families in this study were characterized by the current wave demographic measures of parental occupation, parental educational degree, parental years of education, family income, and age. All measures were reported by respondents on a demographic instrument administered as part of the protocol of the parent study except the variable of age which was calculated using date of birth and date of blood draw. W. Information regarding parental occupation was measured by the Revised Duncan Socioeconomic Index (TSE12, Stevens & F eatherrnan, 1981). The TSE12 is a measure of occupational attainment which has been suggested as a more contemporary indicator of SES than measures based solely on income. Current wave data were utilized for this indicator. MW. Two measures of education were used to describe the sample. The first measure, years of education, denotes the number of years of academic or vocational education achieved. The second measure denotes the highest degree achieved. Scores range from 0 to 4 (0=high school diploma or less, 1=vocational or technical degree, 2=Bachelors degree, 3=Masters degree, 4=Doctorate, Medical degree, or Veterinarian degree). Current wave data were utilized to describe parental education. W- Family income was measured as each family’s current gross annual income in dollars as reported by father. Subjects responded to a lO-point scale in which a score of 1 represented income of $4,000 or less; 2=$4,00I-$7,000; 3=$7,001- $10,000; 4=$10,001-$13,000; 5=$13,001-$16,000; 6=$16,001-$20,000; 7=$20,001- 81 $30,000; 8=$30,001-$50,000; 9=$50,001-$75,000; 10=$75,001-$100,000; l 1=Over $100,000. The midpoint dollar level of each interval was used in computing mean income level for the sample. For example, an interval score of 3 was coded as $8500. ldgnfifying Low SES and High SES Subjects. Similar to Dabbs and Morris (1990) current median family income and median educational attainment were utilized for identifying LSES and HSES subjects. Subjects were classified as LSES or HSES if they were, respectively, below or above both the 1996 Michigan population median in income ($56,174) and the 1997 US. population median in educational attainment (high school diploma). This dual criterion excluded 20% of the subjects (mixed SES), who were high in income and low in education, or vice versa. However, this criterion produced a relatively clear distinction between LSES and HSES groups. r t m kin Quantity and frequency measures of alcohol and cigarette use for all subjects were gathered at the time of blood draw through subject responses to related items on the Health History Questionnaire (see Appendix C). Parents were asked to provide a self report of their own alcohol consumption and a collateral report of their spouse’s alcohol use in an attempt to reduce possible reporting bias. These data were coded such that the highest report of alcohol use (self report by subject or collateral report by subject’s spouse) was used for analyses. Children were asked to report on their own alcohol and cigarette use in an abbreviated version of this instrument which was administered privately. 82 Parental cigarette smoking was evaluated by the variables of average days smoking in the last month and average cigarettes smoked per day. Analyses indicated that the standardized quantity X frequency procedure that was used for alcohol consumption produced an interaction term for the smoking variable that was unique to the two individual variables. Given this finding it was decided to use the individual variables of quantity and frequency of cigarette smoking for analyses. Children were asked to report on their own alcohol and cigarette use in an abbreviated version of this instrument which was administered privately and confidentially. Of the 60 children with health history questionnaire data, 5 subjects indicated that they had smoked cigarettes at least once or twice (2 boys, 1 girl) or occasionally but not regularly (1 boy, 1 girl). Two of the smokers indicated that they had not smoked in the past 4 weeks ( 1 boy, 1 girl) and 3 smokers indicated that they had smoked between 1-10 days on average in the past 4 weeks (2 boys, 1 girl). Average cigarettes smoked per smoking day for the 3 children/adolescents who had smoked in the past 4 weeks ranged between 1-10 cigarettes. Thus, it appears that 8% of the children had exposure to cigarette smoking and that 5% of the children in the sample who are currently smoking are best categorized as infrequent and non-heavy cigarette smokers. In regard to alcohol use, data from the 60 children with health history questionnaire data indicated that 9 children (6 boys. 3 girls) self reported themselves as having consumed some alcohol at some point in their lives (15%). However, all of these children denied having consumed any alcohol within the past 4 weeks. Based on the available information it appears that the children who have had exposure to alcohol are 83 most likely not yet drinkers. Therefore, the present sample is comprised of COAs who have not yet begun regular drinking. i r l' i Antisocial Personality Disorder was assessed via the NIMH Diagnostic Interview Schedule- Version 111 at wave 1 (DIS; (Robins, Helzer, Croughan, & Ratcliffe, 1981). The DIS is a structured interview that allows trained lay interviewers to gather extensive physical, alcohol and drug related, and mental health (symptomatic) information. The DIS utilizes DSM—IV criteria in ascertaining the presence or absence of Antisocial Personality Disorder. Lifetime ASPD diagnoses at entry into the parent study (Wave 1) were used to classify fathers and mothers. 1 I ive A r i Parental irritable impulsive aggression was measured by summing total scores on the Buss-Durkee Hostility Inventory (BDHI) Irritability and Assault subscales at Wave 1 (Buss & Durkee, 1957). The BDHI is a widely used self report true or false questionnaire. The 75 items compose 2 main factors (Motor Aggression and Hostility) and 8 subscales. The motor aggression factor is composed of 4 subscales: assault [direct (against people), indirect (assault against objects), verbal, (assault through vocalization), and irritability (readiness to react with negative affect). The Hostility factor is composed of the 2 subscales, resentment and suspiciousness. Additional subscales include negativism and guilt. 84 i e t' Wm, Parental affective modulation was assessed with current wave scores from the Neuroticism factor (N F) of the NEO-F F I (Costa & McCrae, 1985) and the Hamilton Depression Rating Scale (Hamilton, 1960; Hamilton, 1967). The NEO Five Factor Inventory (N EO-FFI) is the short form of the NBC Personality Inventory (NEO-PI) and consists of 60 items (12 items per factor) designed to assess Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. Each of these domains is composed of six subscales (facets). Neuroticism is composed of the following facets: Anxiety, Hostility, Depression, Self-Consciousness, Impulsiveness, and Vulnerability. Thus, Neuroticism is believed to assess adjustment vs. emotional instability and to identify individuals who are prone to psychological distress, unrealistic ideas, excessive cravings or urges, and maladaptive coping responses. High scorers are characterized as worrying, nervous, emotional, insecure, inadequate, and hypochondriacal. Low scorers are characterized as calm, relaxed, unemotional, hardy, secure, and self-satisfied. Factor analytic studies have documented strong correspondence between the NBC factor structure and those of the California Q-sort, the Interpersonal Adjective Scales, the Personality Research Form, the Guilford-Zimmerman Temperament Survey, and Eysenck Personality Questionnaire. Internal consistency coefficients for Form S range from .76 to .93 for domain scales and from .60 to .86 for facet scales. NEO-FFI scales yield correlations of .75 to .89 with the NEO-PI (long form). MW The Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1960; Hamilton, 1967), is a 21 item instrument for the 85 clinical rating of depression. The HRSD was coded by a clinician following the administration of the DIS. This rating covers a variety of behavioral, affective, somatic, and psychological dimensions associated with depression, and the score is based on the subject’s responses as well as the clinician’s judgments. The clinician makes both a current depression rating and a rating of the level of the subject’s depression at the point in the past three years when they were most depressed. HRSD interrater reliabilities have ranged from .80 to .90 (Hamilton, 1967). HRSD worst ever depression ratings were utilized for the present study. v' If 'v I i The 4-16 year old version of the Child Behavior Checklist (Achenbach, 1991) was used to gather behavioral data for children in the present study. Maternal ratings of their children at the most recent wave of data collection were used to assess child behavioral and affective modulation. The CBCL includes 113 items regarding prevalence and frequency of child problem behavior and is the most commonly used questionnaire for clinical classification of child behavior problems in the United States. The CBCL is completed by each parent independently. This provides an objective assessment of the target child's social and emotional functioning. The instrument has been normed on children 4 to 16 years of age and yields standardized scores on eight narrow band subscales including the Anxious/Depressed scale which will be one focus of the present study, two broad band subscales concerning externalizing and internalizing behavior, and a total behavior problems score. Achenbach and Edelbrock demonstrated test-retest reliability of item scores on the CBCL ranging from .95 at a one-week interval, to .84 at a 86 three-month interval. Parent agreement in the item scores was .99. Similar reliabilities were established on scale scores and total problem score with one week test-retest of .89. The median parent agreement on scale scores was .66. Adequate construct validity was established by correlations between CBCL scores and scores on a wide range of other measures of child behavior problems. Analysis of data from the MSU-U of M Longitudinal Study indicated that goodness of fit indices exceeded .95 in all cases, and internal consistency reliabilities, through somewhat lower, were generally comparable to those reported by Achenbach (Achenbach & Edelbrock, 1983). The Total Behavior Problems Score from Wave 1 to Wave 2 had a stability coefficient of r = .59. The Broad Band and Narrow Band scores from Wave 1 to Wave 2 had stabilities ranging from r = .31 to r = 65. Child Irrjtahlg Impulsive Aggression. The CBCL Attack subscale was used to measure child irritable impulsive aggression as an index of poor behavioral modulation. This scale contains five items that measure reactive, physically aggressive and violent behavior (Cruelty, bullying, or meanness to others; Gets in many fights; Physically attacks people; Sudden changes in mood or feelings; Threatens people). W. Similarly, the CBCL Anxious/Depressed scale was used to assess poor affective modulation. This 14 item scale contains items assessing negative affect (i.e., Lonely, Cries, Worthless, Nervous, Sad, Worries). Assessing Child Sggia! Competengg To examine the potential mediating and/or moderating effects of social competence on the relationships under examination it was necessary to identify low and 87 high socially competent children. Current wave Social Competence maternal rating T- scores of 30 through 33 identified children scoring in the borderline clinical range which spans from about the second to fifth percentiles of the CBCL normative sample (Achenbach, 1991). These children were classified as low in social competence (LSC). Children with CBCL Social Competence T-scores of 34 and above represented non- referred children from the normative sample and were classified as being high in social competence (HSC). Assessingflbertaifitatus In order to examine the developmental effects of puberty on the relationships in question, it was necessary to determine which children had entered puberty (pubescent) and which children had not (pre-pubescent). Data for this classification were obtained from the Naomi Morris Scale of Physical Development (N MS; Morris & Udry, 1980), a self report instrument which was administered to each child during routine data collection for the larger study. The NMS is a self report measure of physical growth and development during puberty. There are separate versions for boys and girls. Children select from a sample of 5 line drawings which most closely resembles their current Tanner-based stage of development as indexed by development of the genitalia and pubic hair. They then answer 23 questions that assess secondary sexual characteristics, vision, height and weight. In addition, questions assess the degree of satisfaction individual's have about their physical development and physical appearance. Instruments are administered by same-sex examiners. 88 Pubescent children were identified as those children who rated both their genital and pubic hair development as being at or above the Tanner Stage 3 of development at the current wave of assessment. Those children who rated both their genital and pubic hair development below Tanner Stage 3, or who rated either their genital or pubic hair development as below Tanner Stage 3 were classified as pre-pubescent. This classification is similar to that used by another group in their study of major depression in prepubertal children (Ryan et al, 1992). Va i le WWW Parental alcoholism classification was assessed via the DIS. Those men and women who met DSM-IV criteria for alcohol dependence at the most recent wave of assessment were classified as alcoholic and those who did not meet criteria at any time point were classified as non- alcoholic. Eatgntgl Physigal Aggression. Parental physical aggression toward child was assessed by the current wave score from the Violence subscale of the Conflict Tactics Scale (CTS; (Straus, 1979). The CTS examines spousal violence, parent's violence towards children, children's violence towards parents, and sibling violence. It measures family violence by asking about the ways in which conflict is resolved by family members. The eighteen items utilized can be grouped into three methods of resolving conflicts: (A) Reasoning-the use of rational discussion and agreement; (B) Verbal Aggression-the use of verbal and non-verbal expressions of anger and hostility; and (C) 89 Violence-the use of physical force or violence. Data from the Violence Scale (items 11 through 15) were used for the current study. Parents were asked independently to indicate the number of times they used each tactic during the past year on the target child. The items become gradually more violent toward the end of the list. The CTS can be interviewer-administered or self-administered; for the proposed study a self-administered questionnaire format was used. The 15 items of the CTS were revised in the MSU-UM Longitudinal Study with minor changes in some of the wording. The respondent is asked to rate how often he or she used each of the listed tactics during the past 12 months (A = never, B = once, C = 2 - 3 times, D =4 - 6 times, E = 7 - 11 times, F = monthly, G = about twice a month, H = weekly, I = about twice a week, I = more than twice a week but less than daily, and K = daily). Straus (1979) reported high reliability with item-total correlations ranging from .70 to .88 using the first version, Form A (14 items). Cronbach alphas for the Reasoning, Verbal Aggression, and Violence scales of the Form N (19 items) ranged from .77 to .88, .62 to .88, and .50 to .76, respectively. Correlations between the CTS and other measures relevant to family violence are also shown to be high. Past studies have collapsed all items from the verbal aggression, minor violence, and severe violence subscales into a global dimension of maltreatment, for which parallel-fonns reliability was estimated at .77 (Muller et al., 1994). Based on the most recent theories that view maltreatment as a continuum, parents’ physical aggression toward children were assessed according to ‘degree’. To determine degree of parental physical aggression, responses to the Violence Subscale of the Conflict 90 Tactics Scale (items 11 through 15) were weighted according to frequencies indicated by response categories and summed together to produce a weighted summed score. Straus’ (1979) form N had response category ranges from 0 to 6; for scoring purposes, he suggests substituting for the 0 to 6 scale, 0, 1, 2, 4. 8, 15, and 25. The items of the CTS in the MSU-UM Longitudinal Study were revised to include a greater range of responses for number of times the action occurred during the past 12 months. The respondent was asked to rate how often he or she used each of the listed tactics, ranging from never to daily. Extending Straus’ suggested weighting method to the Longitudinal Study version of the CTS, scores were weighted according to frequency, along the following dimensions: (0) never, (1) once, (3) 2 - 3 times, (5)4 - 6 times, (9) 7 - 11 times, (12) monthly, (24) about twice a month, (52) weekly, (104) about twice a week, (156) more than twice a week but less than daily, and (365) daily. Each parent received a summed weighted frequency score, indicating the overall level of physical violence reported during past 12 months. ental F n i nin Axi V - V e mm), The Axis V DSM-IV, global assessment of functioning score (GAF);Association, 1994) is an instrument to measure the current and highest level of global assessment of functioning in the last year. GAF scores at the most recent wave of assessment were coded by a clinician following administration of the DIS. Information necessary to code this rating scale includes social, occupational and leisure time functioning. This measure is especially important because it is an index of social/personal competence that may be semi-independent of symptomatic status. 91 Interrater reliability for the DIS interviewer and another listener to the DIS recording on this measure has already been evaluated and is an acceptable F.85. WWW Parental alcohol consumption was evaluated by quantity X frequency of alcohol consumption as measured by the standardized score of average days drinking in the last month multiplied by the standardized score of average drinks per drinking day. This information was obtained via the Health History Questionnaire which has been described above. 92 RESULTS Meth d l ical onsider i ns WWW 5mm], Since seasonal effects in whole blood serotonin have been found in adults (Moffitt et al., 1998) this potential covariate was examined in the present sample where blood samples were collected across three seasons (no samples were drawn during Summer). An Analysis of Variance was conducted to allow an examination of the relationship between the 3 seasons and whole blood 5-HT. Results failed to find a significant relationship between Season and parental whole blood 5-HT [(E(2,85) = 1.52, p = .22; Winter, 3 = 40, M = 177.53 ng/ml, SD = 56.02; Spring, 11 = 26, M = 164.27, SD = 60.05; Fall, 11 = 22, M = 152.82 ng/ml, SD = 43.28; r = -.19, p = .08]. Next, analyses were run for mothers and fathers separately. Again, results failed to indicate a significant effect for seasonality [Mothers: (E(2,40) = .92, p = .41; Winter, 11 = 19, M = 185.47 ng/ml, SD =62.50; Spring, n = 13, M = 177.31, SD = 72.86; Fall, n = 11, M = 152.91 ng/ml, SD = 54.22, r = -.20, p = .20; Fathers: (F(2,42) = .98, p = .38; Winter, 11 = 21, M = 170.33 ng/ml, SD = 49.90; Spring, 11 = 13, M = 151.23, SD = 42.85; Fall, 11 = 11, M = 152.73 ng/ml, SD = 31.52, r = -.18, p = .23]. Given the lack of a significant relationship between Season and the independent variable of whole blood 5-HT, Season was not used as a formal covariate in analyses of adults. WM BMI has been found to be weakly, but significantly negatively related to whole blood S-HT in an epidemiological sample of young adult men (Moffitt et al., 1998). Thus, body mass (weight in kilograms/height in metersz) was also 93 evaluated as a potential covariate in the present study. Results of analyses of the full sample of men and women found no relationship between BMI and whole blood 5-HT (see Appendix A, Table 1). Thus, BMI was not used as a covariate in adult analyses. W Among drinking alcoholic men and women, cigarette smoking has been found to be related to increased levels of whole blood 5-HT (Schmidt, Dufeu, Heinz, Kuhn, & Rommelspacher, 1997). Additionally, cigarette smoking has been found to be negatively correlated with platelet monoamine oxidase activity levels in alcoholics (Anthenelli, Smith, Craig, Tabakoff, & Schuckit, 1995). Given these findings, cigarette smoking was evaluated as a potential covariate. Results of analyses with the combined sample of men and women found no relationship between whole blood 5-HT and cigarette smoking (average day smoked in past month and average number of cigarettes per smoking day in past month; see Appendix A, Table 1). While no relationship was found between cigarette smoking and whole blood 5-HT for women (see Appendix A, Table 3), results indicate that cigarette smoking is significantly and positively related to whole blood 5-HT (average days smoked, n = 45, r = .44, p < .01; average cigarettes per day, n = 45, r = .39, p < .01) and that it is highly and significantly correlated to ASPD diagnosis in this sample of men (average days smoked, n = 45, r = .60, p < .01; average cigarettes per day, n = 45. r = .67, p < .01). Similarly, findings suggest that there also exists a significant positive relationship between quantity of cigarette use and paternal alcohol dependence diagnosis (3 = 45, r = .34, p = .02). Given these findings, cigarette smoking was identified as a covariate for any 94 tela llOl rela (see Res 116g: H0“ imp] analyses examining whole blood 5-HT, ASPD diagnosis, or alcohol dependence diagnosis in the sample of men. WW Age, Age has been found to be related to whole blood 5-HT in 10-12 year old children. Blood 5-HT content declines moderately between the ages of 10 and 12, but after this time period there is no correlation between whole blood 5-HT and age (Ritvo et al., 1971). Given that the present sample of children was within this age range this relationship was analyzed to determine if the association between age and whole blood 5- HT should be controlled in analyses. Using the complete sample of sons and daughters no relationship was found (see Appendix A, Table 4). However, the frequently reported relationship between age and whole blood 5-HT has been observed more often among samples of boys, so this relationship was also examined within the two gender subsets (see Appendix A, Table 5). Results for daughters revealed no significant relationship. Results of analyses with sons alone revealed a moderately sized, but non-significant negative relationship between age and whole blood 5-HT (11:45, i: = -.26, 3; =08). However, age was not related to either of the dependent variables, child irritable impulsive aggressiveness (n = 45, r = .01 , p = .92) or poor affective modulation (9 = 45, r = -.06, p = .69), and thus, was not used as a covariate. W911, Whole blood 5-HT is not affected by ordinary changes in diet; therefore, fasting prior to venipuncture was not required (Anderson, Teff, & Young, 1984; Badcock, Spence, & Stern, 1987). An early study found that after acute loading with tryptophan, the precursor of 5-HT, changes in blood 5-HT were transient 95 with a return to baseline levels within 8 hours (Yuwiler et al., 1981) . A more recent study found no detectable changes in blood 5-HT levels after either oral or intravenous administration of tryptophan (Cook et al., 1981). Additionally, prior work has shown that there is no significant diurnal variation in blood 5-HT content in adults (Kremer, Goekoop, & Van Kempen, 1990). Season, Seasonal effects on platelet 5-HT content have been described in children and adolescents with OCD and matched normal controls (Brewerton, F lament, Rapoport, & Murphy, 1993). In the present study, as with adult samples, child blood samples were collected across three seasons (no samples were drawn during Summer). Analysis of the full sample of children found no significant relationship between season of blood draw and child whole blood 5-HT [(F(2,59) = 1.06, p = .35; Winter, n = 29, M = 206.14 ng/ml, SD =64.05; Spring, 11 = 18, M = 233.94, SD = 74.08; Fall, 11 = 15, M = 219.27 ng/ml, SD = 48.63]. Next, analyses were run for seasonality for boys and girls separately. Again, results failed to indicate a significant effect for seasonality [boysz (E(2,42) = .82, p = .45; Winter, n = 22, M = 214.23 ng/ml, SD =66.26; Spring, 11 = 13, M = 244.08, SD = 82.68; Fall, 11 = 10, M = 217.40 ng/ml, SD = 53.53; Girls: (E(2,14) = 1.27, p = .31; Winter, 11 = 7, M = 180.71 ng/ml, SD =52.78; Spring, n = 5, M = 207.60, SD = 40.22; Fall, 11 = 5, M = 223.00 ng/ml, SD = 42.46]. WM), Similar to adults, BMI was also evaluated as a potential covariate in children. Analyses of all children combined found no significant relationship between child BMI and the independent variable of child whole blood 5-HT (see Appendix A, Table 4). Similarly, analyses of boys and girls alone also found no 96 relationship between BMI and whole blood 5-HT (see Appendix A, Table 5). Therefore, body mass was not used as a covariate in any child analyses. hi haracteristic Ind en ent and D V ' l The demographic variables of age, family income, years of education, academic degree, and current occupation of the families in the present study are provided in Appendix A, Table 6. See Appendix A, Table 7 for the means and standard deviations of independent and dependent variables. hlBll‘III -HT nti ' Ingmar J IrI° 2II o cII‘_ -I_'1'I. Algghgl Dependengg To test the hypothesis that serotonergic dysfunction is related to ASPD and not to alcohol dependence diagnosis, correlations and a linear regression analysis with the full satnple of adults were planned. However, since no women in the sample met criteria for a diagnosis of ASPD, it was only possible to test this hypothesis for the sample of men. Results of correlational analyses in men failed to reveal statistically significant relationships between the independent variable of whole blood 5-HT and the dependent variables of ASPD and Alcohol Dependence diagnosis (see Appendix A, Table 2). Thus, the planned regression analysis with paternal ASPD diagnosis and Alcohol Dependence diagnosis as independent variables and paternal whole blood 5-HT as the dependent variable was abandoned. Though the relationship between whole blood 5-HT and ASPD did approach a medium effect size (r = .27, p = .08), effect size estimates in small Smples are unreliable. 97 I II I -.’=. 'I . WI‘IIB III '1 I" :II' in- ‘ ‘af'd iv 0 ul i To test the hypothesis that parental whole blood 5-HT would predict irritable impulsive aggressiveness as measured by the combination of Buss Durkee Irritable and Assault scales (IA) and poor affective modulation as measured by both the NEO N euroticism factor (NF) and Hamilton Rating Scale for Depression (HRSD), correlational and regression analyses were planned. Results of correlational analyses in the fllll sample indicated a significant positive relationship between the independent variable whole blood 5-HT and the dependent variable HRSD (N = 88, r = .32, p < .01), but no relationships were observed between whole blood 5-HT and IA (N = 75, r = -.09, p = -46) or NF (N = 88, r = .10, p = .35). Evaluation of the scatterplot for the observed relationship between whole blood 5-HT and HRSD did not suggest that a single subject or a subset of subjects was responsible for the relationship (see Appendix B, Figure 1). Since the zero order correlations for whole blood 5-HT and both NF and IA reported above were non-significant, regression analyses were not conducted. d ra ' lat' hi mm Next, to determine if the relationships under examination differed by gender, analyses were run on the samples of men and women separately. While a Sigtlifrcant relationship was observed between whole blood 5-HT and HRSD in both male (11 § 45, r = .32, p = .03) and female subjects (n = 43, r = .32, p = .04), no relationships were observed between whole blood 5-HT and both IA or NF in men or women (see Appendix A, Table 8). These relationships did not differ by gender. Furthermore, 98 evaluation of the scatterplots for the observed relationships between whole blood 5-HT and HRSD in male and female subjects did not suggest that a single subject or a subset of subjects was responsible for the relationships (see Appendix B, Figures 2 and 3). Socioeconomic Status (SES). Next, the potential mediating and moderating effects of socioeconomic status (SES) on the relationships between parental whole blood 5-HT and both irritable impulsive aggressiveness and poor affective modulation were examined. First, a correlation was run between parental whole blood 5-HT and SES as measured by the variables of educational attainment (years of education and degree), occupation, and family income. Results of the full sample of men and women failed to Show a significant relationship between various individual indicators of SES and whole blood 5-HT (see Appendix A, Table 9). Similarly, results from separate analyses of men and women failed to indicate a relationship between individual indicators of SES and whole blood S-HT (see Appendix A, Tables 10 and 11). SES has been found to moderate the relationship between another biochemical, te5"1i()sterone, and aggression (Dabbs & Morris, 1990). Thus, to examine the potential moderating effects of SES on the relationships between whole blood 5-HT and both irritEible impulsive aggressiveness and poor affective modulation, correlations were conducted among whole blood S-HT, IA, NP, and HRSD in low and high SES subjects (LSES and HSES). Again, analyses were first conducted with the combined sample of men and women and these were then followed up with analyses of men and women alone. First, correlations were run between the independent variable whole blood 5-HT and the dependent variables IA, Neuroticism, and HRSD in the combined sample broken 99 down by SES status. Results indicated a significant positive relationship between whole blood 5-HT and HRSD in LSES subjects (n = 41, r = .37, p = .02) and no such relationship in HSES subjects. Evaluation of the scatterplot for the relationship suggested that one subject might be primarily responsible for the relationship (see Appendix B, Figure 4). However, deletion of this subject left the relationship unchanged (3 = 40, r = .3 7, p = .02). Also, no relationships were observed between whole blood 5-HT and either IA or Neuroticism within LSES or HSES groups. See Appendix A, Table 12 for complete results. Next, a similar correlational analysis was run within LSES and HSES men and women separately. The only significant relationship was a positive one between the independent variable whole blood 5-HT and the dependent variable NF (n = 23, r = .45, p = - 03 ) in LSES men (see Appendix A, Table 13 for complete results). Next, to examine the obtained relationship further, a scatterplot of the relationship between paternal whole blood 5-HT and Neuroticism was created (see Appendix B, Figure 5). Evaluation of this scatterplot suggested that one subject might be primarily responsible for the relationship bet‘I’Veen whole blood 5-HT and Neuroticism in LSES men. To examine this possibility, the Subject was excluded and the correlation was re-run. Results of this analysis were n()1'1‘-Significant (n = 22, r = .23, p = .30,), limiting the interpretability of this possible finding. mm Since previous research has found relationships between 5 ‘HT dysfunction and impulsive aggression in personality disordered subjects but not cotltrols (Coccaro et al., 1997; Coccaro et al., 1996) an attempt was made to replicate this 100 finding in the present sample of ASPD men. However, it was observed that all ASPD men but 1 were in the low SES grouping. Thus, while the sampling design prohibited an examination of the potential moderating effects of SES on the relationships between whole blood 5-HT and the variables IA, Neuroticism, and HRSD in ASPD men, it was possible to examine moderating effects of SES within non-ASPD men and moderating effects of ASPD within low SES men. Results from a correlational analysis within each of the three available cells indicated a significant relationship between the independent variable whole blood 5-HT and the dependent variable IA only in LSES ASPD men (n = 9, g = -.80, p < .01; see Appendix A, Table 15 for complete results and Appendix B, Figure 6 for scatterplot). It is important to note that this relationship is a negative one and as such is contrary to the existing literature (Moffitt et al., 1998) and the general pattern of results in the present study. Next, the relationship between whole blood 5-HT and Neuroticism in LSES ASP D and non-ASPD men as well as between LSES and HSES non-ASPD men was examined. Results of a correlational analysis indicated a significant relationship between Whole blood 5-HT and Neuroticism in LSES ASPD men (n = 12,; = .73, p < .01) and no moderating effect of SES (see Appendix A, Table 15 for complete results). These results Suggest that ASPD moderates the relationship between whole blood 5-HT and I\Ie‘llt‘oticism in LSES men, but SES does not moderate the relationship between whole blood 5-HT and Neuroticism in non-ASPD men. Finally, the relationship between whole blood 5-HT and HRSD in LSES ASPD and non-ASPD men and as well as within LSES and HSES non-ASPD men was 101 examined. While results of these correlational analyses did not reach significance, the relationship between whole blood 5-HT and HRSD in LSES non-ASPD men (u = 11, r = .52, p = .10), and in HSES non-ASPD men (u = 7, r = .64, p = .12) were both of large effect size (see Appendix A, Table 15 for complete results) and the relationship between whole blood 5-HT and HRSD in LSES ASPD men was not present (u = 12, r = .22, p = .49). Thus, though it appears that ASPD and not SES may be moderating the relationship between whole blood 5-HT and HRSD, these nonsignificant results are difficult to interpret. An interesting finding that did emerge for adult men was that of an effect of one of the previously identified potential covariates, cigarette smoking. Cigarette smoking (frequency) was positively related to whole blood 5-HTI(u = 45, r_= .44, p = .003). c . I .~ -W II- Iood -HT anI Both hildI r' 2.. up at: -_ ‘|.l oud Poor Afl'ootive Modulation Correlations and regression analyses were planned to test the hypothesis that low chi 1d whole blood 5-HT would predict both child irritable impulsive aggressiveness and poor affective modulation. First, zero order correlations were run between child whole blOOd 5-HT and both the CBCL Attack and Anxious/Depressed scales for the combined Sal'I'TIIDIe of boys and girls. Results failed to show any significant relationships (See Appendix A, Table 16). Since the zero order correlations were non-significant, r . egl‘essron analyses were not conducted. 102 Gouda; Next, given that the literature suggests that the relationships under examination may be different in males and females, analyses were run on samples of boys and girls separately. Results of girls alone found a significant correlation between whole blood 5-HT and Attack score (u = 17. r = -.48, p = .05). To examine this relationship further, a scatterplot was created. Evaluation of this scatterplot did not indicate that a single subject or a subset of subjects is responsible for the observed relationships (see Appendix B, Figure 7). All other results revealed non-significant relationships (see Appendix A, Table 17). W Results from the child and adolescent literature, particularly whole blood 5-HT studies, strongly suggest that age related developmental factors need to be taken into account when examining the relationships between serotonergic function and behavior in non-adult samples. To examine this issue, the potential mediating and moderating effects of puberty on the relationships between whole blood 5-HT and both itTitiible impulsive aggressiveness and poor affective modulation were tested. First, a correlation was run between whole blood 5-HT and pubertal status in the full sample of Chi ldren. Results of the full sample failed to show a significant relationship (N = 62, r = - ‘ 1 2: D = .37). Similarly, results from boys alone (u = 45, r = -.17, p = .28) and girls alone (I1 § 1 7, r = .10, p = .69) failed to indicate a relationship. Next, the potential moderating effects of pubertal status on the relationships betWeen child whole blood 5-HT and both irritable impulsive aggressiveness and poor affective modulation were examined. Again, analyses were first conducted with the 103 combined sample of boys and girls and these were then followed with analyses of boys and girls alone. Results from correlational analyses in the full sample revealed significant relationships between whole blood 5-HT and both Attack (n = 14, r = -.63, p = .02) and Anxious/Depressed (n = 14, r = -.57, p = .04) in pubescent children. However, for prepubescent children there were no significant relationships nor were the relationships of reasonable magnitude (see Appendix A, Table 18). To examine the observed relationships further, scatterplots were created. Evaluation of these scatterplots did not suggest that a single subject or a subset of subjects was primarily responsible for the relationships between whole blood 5-HT and both Attack and Anxious/Depressed (see Appendix B, Figures 8 and 9). This pattern of relationships was the same within boys and within girls (see Appendix A, Table 19). For pubescent boys the relationships between whole blood S-HT and both Attack ([1 = 9, r = -.61, p = .08) and Anxious/Depressed (n = 9, r = -.54, p = .13 ) While non-significant were of large magnitude. However, for prepubescent boys, the relationships between whole blood 5-HT and both Attack (n, = 36, r = -.08, p = .63) and AnXious/Depressed (n = 36, r = -.16, p = .35) were neither significant nor of reasonable magnitude. Evaluation of the scatterplots for the relationships between whole blood 5- HT and both Attack and Anxious/Depressed in pubescent boys does not suggest that a Single subject or a subset of subjects is responsible for the observed relationships (see Appendix B, Figures 10 and 11). Nonetheless, interpretation of results would be difficult beCause effect size estimates with small samples are unreliable. 104 The same general pattern was observed within girls such that, for pubescent girls a significant relationship between whole blood 5-HT and Attack was observed (11 = 5, r = - .88, p = .05) and the relationship of whole blood S-HT to Anxious/Depressed (_n_ = 5, r = - .80, p = . 11) while not significant, was of large magnitude. An interpretation of nonsignificant, but large magnitude relationships is questionable since effect size estimates with small samples are unreliable. However, for prepubescent girls there was no relationship between whole blood 5-HT and either Attack (11 = 12, r = -.26, p = .41) or Arvcious/Depressed (Q = 12, r = -. l 6, p = .63). Evaluation of the scatterplots for the significant relationship between whole blood 5-HT and Attack (see Appendix B, Figure l 2) as well as the nonsignificant, but large effect size relationship between whole blood S-H T and Anxious/Depressed (see Appendix B, Figure 13) do not suggest that either a single subject or a subset of subjects is controlling either relationship. Given the similar Pattern for boys and girls and the difficulty in interpreting nonsignificant large effect size relationships in small samples, only the significant relationships within the full sample Wil 1 be interpreted. Social competence. Next, the potential mediating and moderating effects of chi 1d social competence on the relationships between child whole blood 5-HT and both Chi 1d irritable impulsive aggressiveness and poor affective modulation were examined. F irSt, a correlation was run between child whole blood 5-HT and CBCL Social ColTnpetence raw scores. Results of the full sample failed to show a significant re=lationship (bl = 62, r = -.03, p = .82). Similarly, results from boys alone failed to itltli<:ate a relationship (it = 45, r = -.15, p = .33). Results with girls alone revealed a 105 moderately sized positive relationship between whole blood 5-HT and Social Competence that nearly reached significance (n = 17, r = .47, p_ = .06), but no relationship was observed between social competence and either Attack (n = 17 r = -.09, p = .73) or Anxious/Depressed (n = 17, r = -. l 8, p = .49). Next, the potential moderating effects of Social Competence on the relationships between child whole blood 5-HT and both irritable impulsive aggressiveness and poor affective modulation were examined. Analyses were first conducted with the combined sample of boys and girls within LSC and HSC groupings, and these were then followed wi th analyses of LSC and HSC boys and girls alone. First, correlations were run between child whole blood 5-HT and both Attack and Anxious/Depressed scores in the full sample (see Appendix A, Table 20). While results found no significant relationships between child whole blood 5-HT and both child Attack or Anxious/Depressed scores, the Correlations for LSC children (Attack, n = 9, r = -.53, p = .15; Anxious/Depressed, n = 9, I = - -48, p = .20) are of a much higher magnitude than those within the HSC children (Attack, n = 53, r = -.13, p = .36; Anxious/Depressed, n = 53, r = -.l4, 2 = .32;). EValLlation of the scatterplots for these relationships (see Appendix B, Figures 14 and 15) Suggested that one subject might be primarily responsible for the relationship between Whole blood 5-HT and Anxious/Depressed. However, even after re-running the c()l‘l‘elation following deletion of the suspect subject, this relationship remained mehanged (n = 8, r = -.42, p = .31). Though these results may suggest that social c0Inpetence moderates the relationships between child whole blood 5-HT and both 11iritable impulsive aggressiveness and poor affective modulation in children (see 106 Appendix A, Table 20), any such interpretation is difficult given the unreliability of estimates of effect sizes in small samples. Next, a similar correlational analysis was run within HSC and LSC boys and girls separately. For LSC Boys, results indicated a significant negative relationship between whole blood 5-HT and CBCL Attack score (11 = 7, r = -.77, p = .04) and an examination of the scatterplot revealed a reasonable pattern (see Appendix B, Figure 16). Additionally, the relationship between whole blood 5-HT and poor affective modulation as measured by CBCL Anxious/Depressed score while not significant, was of large magnitude ([1 = 7, r = -.58, p = .17). While an evaluation of the scatterplot suggested that this relationship might be carried by one subject (see Appendix B, Figure 17), correlational analysis following deletion of the subject still revealed a large effect size relationship (11 = 6 , r = -.48, p = .34). However, there were no such relationships for HSC boys (Attack, n = 38, r = -.09, p = .58; Anxious/Depressed, n = 38, r = -.09, p = .57). Results for boys suggest that social competence moderates the relationship between whole blood 5-HT and irritable impulsive aggressiveness such that the impact of whole blood 5-HT is allowed expression only for LSC boys (see Appendix A, Table 21). Though a similar moderating effect may be present for the relationship between whole blood 5-HT and Anxious/Depressed, any such interpretation is difficult due to the unreliability of estimates of effect sizes for small samples. Next, similar analyses were conducted within LSC and HSC girls. Since there were only two LSC girls, results were not produced for this cell. For HSC Girls, 3 significant negative relationship was found between whole blood 5-HT and CBCL Attack 107 score (n = 15, 1; = -.52, p = .05). Additionally, the relationship between whole blood 5-HT and poor affective modulation as measured by the CBCL Anxious/Depressed scale while not significant, was of moderate magnitude (3; = 15, r = -.37, p = .18; see Appendix A, Table 21). Evaluation of both of these scatterplots suggested reasonable patterns (see Appendix B, Figures 18 and 19). For girls, whether social competence moderates the relationship between whole blood 5-HT and both irritable impulsive aggressiveness and poor affective modulation cannot be formally tested without more LSC girls. . H ,..._ ,...p-,H!.1, 113.. ,H J, H . g H. _ To test the hypothesis that the socioenvironmental variables (SE) of parent to child physical aggression, low parental functioning, parental irritable impulsive aggressiveness, poor parental affective modulation, and parental alcohol consumption would predict child serotonergic functioning, correlational and regression analyses were planned. Results of correlational analyses in the full sample failed to indicate any significant relationships between SE and child whole blood 5-HT (see Appendix A, Table 22). Since the zero order correlations between SE variables and child whole blood 5-HT were all nonsignificant, regression analyses were not conducted. gender, In separate correlational analyses of boys and girls alone (see Appendix A, Table 23), results indicated a nonsignificant, but large effect size relationship between maternal violence and child whole blood 5-HT in the sample of girls (3 = 7, r = -.63, p = .13). Next, to examine the obtained relationship further, a scatterplot of this relationship between maternal violence and child whole blood 5-HT in girls was created. Evaluation 108 of this scatterplot indicated that the observed relationship between maternal violence and whole blood 5-HT in girls was due solely to one subject (see Appendix B, Figure 20). Additionally, for the sample of boys, there was neither significant nor large effect size relationships between SE variables and whole blood 5—HT (see Appendix A, Table 23). REM Next, the potential mediating and moderating effects of pubertal status on the relationships between SE and child whole blood S-HT were examined. First, a correlation was run between pubertal status and SE variables. Results of the full sample failed to show any significant relationships (see Appendix A, Table 24). Similarly, results from separate correlational analyses of boys and girls alone failed to indicate any relationships between pubertal status and SE variables (see Appendix A, Table 25). Next, the potential moderating effects of pubertal status on the relationships between SE and child whole blood 5-HT was examined. Correlational analyses of SE variables and whole blood 5-HT indicated a significant positive relationship between the SE variable of paternal violence and whole blood S-HT in prepubescent children (n = 36, r = .42, p = .01; see Appendix A, Table 26). To examine this finding further a scatterplot of the relationship was created. Evaluation of the scatterplot did not indicate that a subject or subset of subjects was responsible for the observed relationship between paternal violence and child whole blood S-HT in the prepubescent children (see Appendix B, Figure 21). This relationship is positive in direction and as such is inconsistent with the general findings among children in this study. making interpretation difficult. 109 Additionally, in pubescent children, a non-significant, but large effect size negative relationship was observed between paternal violence and whole blood 5-HT (n = 11, r = -.58, p = .06). To examine this potential finding further a scatterplot of the relationship was created. Evaluation of the scatterplot does not suggest that one subject or a subset of subjects is primarily responsible for the observed relationship between paternal violence and child whole blood S-HT in pubertal children (see Appendix B, Figure 22). Please see Appendix A, Table 26 for complete results. Again, it is important to note that interpreting this finding is questionable because estimates of effect size are unreliable in small samples. MW Next, the potential mediating and moderating effects of child social competence on the relationships between SE and child whole blood 5-HT were examined. First, a correlation was run between SC and SE variables. Results of the full sample indicated a significant relationship between paternal functioning and child social competence (n = 60, r = .28, p = .03). However, no relationship between paternal functioning and child whole blood 5-HT was observed (see Appendix A, Table 27 for complete results) making formal testing of mediation unnecessary. Next, similar correlational analyses were conducted on boys and girls separately. Results from separate analyses of boys and girls alone failed to indicate any relationships between SC and SE variables (see Appendix A, Table 28 for complete results). Next, the potential moderating effects of SC on the relationships between SE and child whole blood S-HT were examined (see Appendix A, Table 29 for complete results). Results of correlational analyses of SE variables and child whole blood S-HT indicated a 110 nonsignificant, but large effect size relationship between maternal violence and child whole blood S-HT (n = 7, r = -.63, p = .13) in LSC children. To examine this relationship further a scatterplot was created. Evaluation of this scatterplot did not indicate that a single subject nor a subsample of subjects was primarily responsible for either observed relationship (see Appendix B, Figure 23). Additionally, it should be noted that while there was a similar nonsignificant positive relationship between paternal violence and child whole blood 5-HT in LSC children, evaluation of the scatterplot of this relationship indicated that one subject was responsible for the observed relationship (see Appendix B, Figure 24). Similarly, results also indicated a nonsignificant, but large effect size negative relationship between maternal alcohol consumption and child whole blood S-HT (n = 9, r = -.50, p =,17) in LSC children. Evaluation of the scatterplot suggested that a single subject might be primarily responsible for the observed relationship (see Appendix B, Figure 25). To examine this possibility, the subject was excluded and the correlation was re-run. Results of this analysis indicated a less strong relationship than was originally detected, but the effect size was still of reasonable magnitude (n = 8, 1; = - .42, p = .30). No significant nor reasonable effect size relationships were observed in HSC children (see Appendix A, Table 29 for complete results). However, any interpretation of moderating effects of social competence here would be difficult given that estimates of effect size are unreliable in small samples. 111 -_ u .-~ - . ' ' invirn - th 2 le nd hild Bh irl 11d Aff ive Rania—tics To test the hypothesis that SE variables would predict child irritable impulsive aggressiveness and poor affective modulation, correlational and regression analyses were planned. First, correlations were conducted between SE variables and both child Attack and Anxious/Depressed scores. Results of the full sample of children indicated a pattern of relationships between maternal characteristics and poor child behavioral and affective modulation (see Appendix A, Table 22). Relationships were observed between the following SE variables and both child Attack and Anxious/Depressed scores, respectively: maternal violence (_n = 46, r = .40, p = < .01; n = 46, r = .32, p = .03), maternal functionng (11 = 62, r = -.33, p < .01; n = 62, r = -.55, p < .01), maternal neuroticism (n = 62, r = .32, p = .01; n = 62, r = .44, p < .01), maternal HRSD (n = 62, r = .26, p = .05; n = 62, r = .38, p < .01), and maternal alcohol consumption (11 = 62, _r_ = .58, p < .01; n = 62, r = .66, p < .01). Additionally, a nonsignificant, but medium effect size relationship was observed between maternal Buss-Durkee Assault/Irritability and child Anxious/Depressed (n = 51, r = .27, p = .06). In regard to paternal SE variables, significant relationships were observed between paternal functioning and both child Attack (n = 60 r= -.26, p = .05) and Anxious/Depressed (n = 60, r = -.34, p < . 01). Similarly, significant relationships were observed between paternal alcohol consumption and both child Attack (11 = 59, r = .45, p < .01) and Anxious/Depressed (n = 59, r = .54, p < .01; see Appendix A, Table 22 for complete results). 112 To examine the observed relationships further, scatterplots were created. Evaluation of the following scatterplots suggested that either a single subject or a subset of subjects might be primarily responsible for the following relationships: maternal violence with both Attack and Anxious/Depressed, paternal functioning with both Attack and Anxious/Depressed, maternal functioning with Attack, maternal neuroticism with attack, paternal alcohol consumption with Attack, and maternal alcohol consumption with Attack (see Appendix B, Figures 26-33, respectively). Next, for these relationships, the suspect outliers were deleted and the correlations were re-run. Results for these analyses were as follows: maternal violence with both Attack (n = 45, r = .29, p = .06) and Anxious/Depressed (n = 45, r = .18, p = .25), paternal functioning and both Attack (11 = 59, r = -.20, p = .13) and Anxious/Depressed (n = 58, r = -.15, p = .27), maternal functioning with Attack (n = 61, r = -.25, p = .05), maternal neuroticism and Attack (n = 61, r = .15, p = .26), paternal alcohol consumption and Attack (n = 58, r = .19, p = .16), and maternal alcohol consumption and Attack (3 = 61, r = .34, p < .01). Thus, after evaluating scatterplots and re-running correlations following the exclusion of suspect data points, the following relationships for the full sample of children remained: maternal functioning and both Attack and Anxious/Depressed, maternal Buss- Durkee Irritable/Assault and Anxious/Depressed, maternal neuroticism and Anxious/Depressed, maternal HRSD and both Attack and Anxious/Depressed, maternal alcohol consumption and both Attack and Anxious/Depressed, and paternal alcohol consumption and Anxious/Depressed. 113 Since the SE predictors which were found to be significantly related to child impulsive aggressiveness and/or poor affective modulation were themselves related to each other (see Appendix A, Table 22), additional evaluations using regression were employed to examine independent contributions to the dependent variables. For Attack, four SE variables were related to each other as well as to Attack at the zero order level: maternal violence, maternal functioning, maternal HRSD, and maternal alcohol consumption. Maternal functioning and HRSD were themselves highly related to each other (n = 62, r = -.68, p = < .001) raising the question of multicollinearity. To test for multicollinearity, both maternal functioning and HRSD were simultaneously entered in a regression predicting child Attack. The results indicate that in the presence of maternal functioning, maternal HRSD is unrelated to child Attack ([3 = .05, p = .75) while maternal functioning yielded a B = .29 (p = .08). Hence, in the final regression, maternal functioning was included along with maternal violence and maternal alcohol consumption. Regression results indicated that only maternal alcohol consumption remained a significant predictor (see Appendix A, Table 30). The overall R2=.39 [F(3,42)=10.77, p < .001]. For Anxious/Depressed, father’s alcohol consumption was related to Anxious/Depressed at the zero order level and highly related to maternal alcohol consumption (3 = 59, _r_ = .80, p < .001), raising the possibility of multicollinearity. However, entering both parents’ alcohol consumption in predicting child Anxious/Depressed yielded a significant [3 only for maternal alcohol consumption (maternal alcohol consumption [3 = .70, p < .001; paternal alcohol consumption [3 = -.02. 114 p = .89). Hence, paternal alcohol consumption was not entered in the following . regression. Similarly, maternal functioning and maternal HDRS were highly related to each other (n = 62, r = .68, p < .001) as well as to the dependent variable Anxious/Depressed. To examine the possibility of multicollinearity, both maternal variables were entered in a regression predicting child Anxious/Depressed. Results indicated that only maternal functioning remained significant (maternal functioning [3 = - .53, p < .001; maternal HDRS [3 = .02, p = .91 ). Hence, maternal HDRS was not entered in the full regression. The four SE variables which were related to each other as well as to Anxious/Depressed at the zero order level, but not too highly related to other predictors were entered in a regression analysis: maternal functioning, maternal Buss-Durkee Irritable Assault, maternal neuroticism, and maternal alcohol consumption. Results indicated that the only significant predictor was maternal alcohol consumption (see Appendix A, Table 31). The overall R2=.47 [F (4,46)=12.26, p < .001]. gm Next, the relationships between SE variables and child irritable impulsive aggressiveness and poor affective modulation were examined separately for boys and girls. In boys, a pattern of relationships between maternal characteristics and paternal alcohol consumption with child Attack and Anxious/Depressed scores was observed. In boys, results indicated significant relationships between the following SE variables and both child Attack and Anxious/Depressed, respectively: maternal violence (3 = 39, r = .40, p = .01; n = 39, r = .32, p = .04), maternal functionng (u = 45, r = -.32, p = .03; n = 45, r = -.56, p < .01), maternal neuroticism (n = 45, r = .40, p < .01; n = 45, r = 115 .54, p < .01), and maternal alcohol consumption (n = 45, r = .62, p < .01; n = 45, r = .71, p < .01). Additionally, significant relationships were observed between maternal Buss- Durkee Assault/Irritability and child Anxious/Depressed (n = 37, r = .34, p = .04) and between maternal HRSD and child Anxious/Depressed (n = 45, r = .45, p < .01). In regard to paternal SE variables, significant relationships were observed between paternal functioning and Attack (11 = 44, r = -.3 l, p = .04) and Anxious/Depressed (n = 44, r = - .39, p < .01). Additionally, significant relationships were observed between paternal alcohol consumption and both child Attack (_11 = 44, r = .48, p < .01) and Anxious/Depressed (_n = 44, r = 56, p < .01). See Appendix A, Table 23 for complete results. To further examine these relationships scatterplots were created. Evaluation of these scatterplots suggested that a subject or subset of subjects might be responsible for the following observed relationships: maternal violence and both Attack and Anxious/Depressed, paternal functioning and Attack, maternal functioning and Attack, and maternal neuroticism and Attack (see Appendix B, Figures 34-3 8, respectively). To evaluate this possibility, correlations were re-run after excluding the suspect data points. Results from these analyses produced the following results: maternal violence and both Attack (11 = 38, r = .28, p = .08) and Anxious/Depressed (n = 38, r = .17, p = .30) , paternal functioning and Attack (3 = 43, r = -.23, p = .13), maternal functioning and Attack (31 = 44, r = -.23, p = .13), maternal neuroticism and Attack (n = 44, r = .20, p = .19). 116 Thus, for boys, the following relationships remained following evaluation of scatterplots and re-analysis following suspect data deletion: paternal functioning and Anxious/Depressed, maternal functioning and Anxious/Depressed, maternal Buss-Durkee Irritable /Assault and Anxious/Depressed, maternal neuroticism and Anxious/Depressed, maternal HRSD and Anxious/Depressed, paternal alcohol consumption and both Attack and Anxious/Depressed, maternal alcohol consumption and both Attack and Anxious/Depressed. Since the SE predictors which were found to be significantly related to boy’s impulsive aggressiveness and/or poor affective modulation were themselves related to each other (see Appendix A, Table 22), additional evaluations using regression were employed to examine independent contributions to the dependent variables. For Attack, both maternal and paternal alcohol consumption were highly related to each other as well as to Attack at the zero order level. However. regression results indicated that only maternal alcohol consumption remained a significant predictor (see Appendix A. Table 32). The overall R2=.35[F(2,41)=12.79, p < .001]. For Anxious/Depressed, maternal functioning was related to boy’s Anxious/Depressed at the zero order level and highly related to maternal HRSD (n = 62, r = -.68, p < .001 ), raising the possibility of multicollinearity. However, entering maternal functioning and maternal HRSD in predicting child Anxious/Depressed yielded a significant [3 only for maternal functioning (maternal functioning [5 = -.49, p < .01; maternal HRSD B = .10, p = .59). Since one variable continued to predict when both were entered, this suggested that these variables were not multicollinear. Nonetheless. ll7 since maternal functioning and not maternal HRSD was significant, HRSD was not entered in the final regression. Additionally, paternal alcohol consumption was related to Anxious/Depressed at the zero order level and highly related to maternal alcohol consumption (n = 59, r = .80, p < .001), again raising the possibility of multicollinearity. However, as was the case with all children described above, entering both parent’s alcohol consumption in predicting boy’s Anxious/Depressed yielded a significant B only for maternal alcohol consumption (maternal alcohol consumption B = .68, p < .001; paternal alcohol consumption B = .05, p = .78). Hence, paternal alcohol consumption was not entered into the final regression. The following variables which were related to each other as well as to Anxious/Depressed at the zero order level were entered in a regression analysis: maternal functioning, maternal Irritable Assault, maternal neuroticism, and maternal alcohol consumption. As found with the full sample of children, results of this analysis indicated that the only independent significant predictor was maternal alcohol consumption (see Appendix A, Table 33). The overall R2=.55 [F(4,32)=12.15, p < .001]. In girls, nonsignificant, but medium to large effect size relationships were observed between maternal functioning and child Anxious/Depressed (n = 17, r = -.46, p = .07), paternal alcohol consumption and both child Attack (3 = 15, r = .42, p = .12) and Anxious/Depressed (n = 15, r = .51. p = .06), between paternal violence and both Attack (n = 7, r = .60, p = .16) and Anxious/Depressed (n = 7, r = .71, p = .08), and maternal alcohol consumption and child Anxious/Depressed (n = 17, r = .42, p = .09). To further examine these relationships scatterplots were created. Evaluation of these scatterplots suggested that a subject or a subset of subjects might be responsible for the following 118 observed relationships: paternal violence and both Attack and Anxious/Depressed, paternal alcohol consumption and both Attack and Anxious/Depressed, and maternal alcohol consumption and both Attack and Anxious/Depressed (see Appendix B, Figures 39-44). Evaluation of these scatterplots alone confirmed that one subject was indeed responsible for the observed relationships between paternal violence and both child Attack and Anxious/Depressed (see Appendix B, Figures 39 and 40). For the remaining suspect relationships, analyses following deletion of suspect subjects produced the following results: paternal alcohol consumption and both Attack (11 = 14, r = .16, p = .58) and Anxious/Depressed (_n = 14, r = .06, p = .84). and maternal alcohol consumption and Anxious/Depressed (n = 16. r = .03, p = .92). Thus, for girls, the only relationship that remained following evaluation of scatterplots and re—analysis following suspect data deletion was the nonsignificant, but large effect size relationship between maternal functioning and child Anxious/Depressed. However, interpretation of this is difficult since estimates of effect size are unreliable in small samples. Overall, it appears that the relationships between SE variables and child irritable impulsive aggressiveness and poor affective regulation observed in the combined sample of boys and girls is largely accounted for by the presence of these relationships in the sample of boys. Additionally, results of regression analyses indicated that only maternal alcohol consumption was a significant predictor of both Attack and Anxious/Depressed in boys. am To examine the potential mediating and moderating effects of puberty on the relationships between SE variables and child irritable impulsive 119 aggressiveness and poor affective modulation, correlations were run between SE variables and pubertal status in the full sample of children (see Appendix A, Table 24). Results from analyses of the full sample of children as well as results of separate analyses of boys and girls alone failed to indicate any significant relationships between pubertal status and SE variables (see Appendix A, Table 24 and 25 for complete results). Next, to examine the potential moderating effects of pubertal status on the relationships between SE variables and child irritable impulsive aggressiveness and poor affective modulation, correlations were conducted between SE variables and both child Attack and Anxious/Depressed scores for pubescent and prepubescent children (see Appendix A, Table 26). Results of these analyses indicated a general pattern of significant relationships between maternal SE variables and paternal alcohol consumption and both child irritable impulsive aggressiveness and poor affective modulation in prepubescent children. In prepubescent children, significant or medium to large effect size relationships were observed between the following SE variables and both child Attack and Anxious/Depressed, respectively: maternal violence (3 = 35, r = .39, p = .03; n = 35, r = .32, p = .06), maternal functioning (n = 48, r = -.46, p = < .01; n = 48, r = -.60, p < .01), maternal neuroticism (n = 48, r = .44, p < .01; n = 48, r = .55, p < .01), maternal HRSD (n = 48, r = .35, p = .02; n = 48, r = .41, p < .01), and maternal alcohol consumption (3 = 48, r = .65, p < .01; n = 48, r = .70, p < .01). Additionally, a significant relationship was observed between maternal Buss-Durkee Irritable/Assault and child Anxious/Depressed (_n = 41, r = .32, p_ = .04) in prepubescent children. In regard to paternal SE variables, significant relationships in prepubescent children were observed 120 between paternal functioning and both child Attack (_n = 47, r = -.46, p = .03) and Anxious/Depressed (n = 47, r = -.45, p < .01) as well as between paternal alcohol consumption and both Attack (n == 46, r = .50, p < .01) and Anxious/Depressed (r1 = 46, r = .57, p < .01). To examine these relationships further, scatterplots were created. An evaluation of these scatterplots suggested that a single subject might be responsible for the following observed relationships in prepubescent children: maternal violence and both Attack and Anxious/Depressed, maternal functioning and Attack, paternal functioning and Attack, maternal neuroticism and Attack, paternal alcohol consumption and Attack, and maternal alcohol consumption and Attack (see Appendix B, Figures 45-51). To determine if these relationships were carried by single subjects, correlational analyses were run following deletion of suspect data points. These analyses revealed the following results: maternal violence and both Attack (3 = 34, r = .26, p = .14) and Anxious/Depressed (n = 34, r = .17, p = .33), paternal functioning and Attack (n = 46, r = -.25, p = .10), maternal functioning and Attack (11 = 47, r = -.43, p = .003), maternal neuroticism and Attack (3 = 47, r = .27, p = .07), paternal alcohol consumption and Attack (11 = 45, r = .23, p = .13), and maternal alcohol consumption and Attack (n = 47. _r_ = .41, p = .004). Thus, for prepubescent children, the following relationships remained following evaluation of scatterplots and/or re-analysis following suspect data deletion: maternal functioning and Anxious/Depressed, maternal neuroticism and Anxious/Depressed, maternal HRSD and both Attack and Anxious/Depressed, maternal alcohol consumption and both Attack and Anxious/ Depressed, maternal Buss-Durkee Irritable/Assault and 121 Anxious/Depressed, paternal functioning and Anxious/Depressed, and paternal alcohol consumption and Anxious/Depressed. Since the SE predictors which were found to be significantly related to child impulsive aggressiveness and/or poor affective modulation were themselves related to each other (see Appendix A, Table 22), additional evaluations using regression were employed to examine independent contributions to the dependent variables. For Attack in prepubescent children, maternal functioning was related to Attack and highly related to maternal HRSD (n_=48, r =-.70, p < .001), raising the possibility of multicollinearity. However, entering both maternal functioning and maternal HRSD in predicting prepubescent Attack yielded a significant B only for maternal functioning (maternal functioning, B = .-.42, p = .03; maternal HRSD, B = .05, p = .77). Thus, though there was no evidence of multicollinearity, maternal HRSD was not entered into the final regression. The following two maternal variables that were related to each other and to Attack at the zero order level were entered in a regression analyses: maternal functioning and maternal alcohol consumption. Similar to findings with boys, results for Attack in prepubescent children indicated that the only significant predictor was maternal alcohol consumption (see Appendix A, Table 34). The overall R2=.4l [F(2,45)=1 7.3 8, p < .001]. For Anxious/Depressed in prepubescent children, paternal alcohol consumption was related to Anxious/Depressed at the zero order level and highly related to maternal alcohol consumption (n = 46, r = .82, p < .01) raising the possibility of multicollinearity. However, entering paternal and maternal alcohol consumption in predicting prepubescent child Anxious/Depressed yielded a significant B only for maternal alcohol consumption 122 (maternal alcohol consumption B = .72. p < .001; paternal alcohol consumption B = -.008, p = .96). Hence, though there was no evidence of multicollinearity, paternal alcohol consumption was not entered into the final regression. Similarly, maternal functioning was related to Anxious/Depressed and highly related to maternal HRSD (n = 48, -.70, p < .001), raising the possibility of multicollinearity. However, entering both maternal functioning and maternal HRSD in predicting prepubescent Anxious/Depressed yielded a significant B only for maternal functioning (maternal functioning B = -.61, p < .01; maternal HRSD B = -.01, p = .94). Thus, while there was no evidence of multicollinearity, maternal HRSD was not entered in the final regression. The five SE variables which were related to each other as well as to Anxious/Depressed at the zero order level were entered in a regression analysis: maternal functioning, maternal neuroticism, maternal alcohol consumption, maternal irritable assault, and paternal functioning. Again, results indicated that the only independent significant predictor was maternal alcohol consumption (see Appendix A, Table 35). The overall R2=.60[F(5,34)=12.62, p < .001]. In pubescent children, a significant relationship was observed between paternal Buss-Durkee Assault/Irritability and child Attack (:1 = 10, r = .68, p = .03). Additionally, a nonsignificant, but large effect size relationship was observed between maternal violence and child Attack (n = 1 1. r = .58, p =.06) in pubescent children, though estimates of effect size are unreliable in small samples. Evaluation of the scatterplots for these relationships suggested that one subject might be primarily responsible for the observed relationship between paternal Buss-Durkee Irritable/Assault and Attack (see Appendix B, 123 Figure 52). To examine this possibility. the subject was removed and the correlation was re-run. Results of this analysis revealed that this subject may not be solely responsible for the observed relationship (n = 9, r = .50, p = .18), though again, estimates of effect size in small samples are unreliable. Overall, the observed pattern in prepubescent and pubescent children that emerged is one where maternal alcohol consumption predicts both Attack and Anxious/Depressed in prepubescent children and no SE variables predict behavior in pubescent children. MW Next, to examine the potential mediating and moderating effects of social competence on the relationships between SE variables and child irritable impulsive aggressiveness and poor affective modulation, correlational analyses were conducted. First, to examine the potential mediating effects of social competence on the relationships between SE variables and child irritable impulsive aggressiveness, correlational analyses were conducted between social competence and Anxious/Depressed and Attack scores. Results failed to indicate any relationships (see Appendix A, Table 27 for complete results). Next, to examine the potential moderating effects of SC on the relationships between SE and child irritable impulsive aggressiveness and poor affective modulation, correlational analyses were conducted between SE variables and Attack and Anxious/Depressed within LSC and HSC children (see Appendix A, Table 29). Results of analyses in LSC children indicated significant relationships between the following maternal variables and child Anxious/Depressed: maternal violence (11 = 7, r = .78, p = 124 .04), maternal functioning (11 = 9, r = -.76, p = .02), and maternal alcohol consumption (:1 = 9, r = .82, p < .01). In relation to paternal SE variables. significant relationships were observed between paternal alcohol consumption and child Anxious/Depressed (n = 9, r = .91, p < .01), and paternal Buss-Durkee Irritable/Assault and Attack (_11 = 9, _r_ = .74, p = .04) in LSC children. Additionally, nonsignificant, but large effect size relationships were observed between paternal functioning and child Anxious/Depressed (n = 9, r = -.53, p = .14) and between paternal HRSD and child Attack (n = 9, r = .52, p = .15) in LSC children. However, because effect size estimates in small samples are unreliable, these findings are difficult to interpret. To examine these observed relationships in LSC children further, scatterplots were created. Evaluation of these scatterplots suggested that a single subject or a subset of subjects might be primarily responsible for the following relationships: paternal functioning and Anxious/Depressed, maternal functioning and Anxious/Depressed, maternal HRSD and Anxious/Depressed, paternal alcohol consumption and Anxious/Depressed, maternal alcohol consumption and Anxious/Depressed, and paternal Buss-Durkee Irritable/Assault and Attack (see Appendix B, Figures 53-58, respectively). To examine the possibility that these relationships were the result of single subjects or small subsets of subjects, correlations were re-run after the suspect subjects had been excluded. Results of these analyses are as follows: paternal functioning and Anxious/Depressed (n = 8, r = .38, p = .36), maternal functioning and Anxious/Depressed (n = 8, r = .17, p = .69), maternal HRSD and Anxious/Depressed (n = 8, r = -.03, p = .94), 125 paternal alcohol consumption and Anxious/Depressed (n = 8, r = .15, p = .72), maternal alcohol consumption and Anxious/Depressed (n = 8, r = .22, p = .60) and paternal Buss- Durkee and Attack (11 = 7, r =.39, p = .39). Thus, for LSC children, afier evaluation of scatterplots and re-running correlations for those that suggested the observed effect might have been produced by outliers, only the relationship between maternal violence and Anxious/Depressed remained. In HSC children, significant relationships were observed between the following maternal variables and both child Anxious/Depressed and Attack, respectively: maternal functioning (n = 53. r = -.49, p < .01; n = 53, r = -.37, p < .01), maternal neuroticism (n = 53, r = .48, p < .01; n = 53, r = .41, p < .01), and maternal alcohol consumption (3 = 53, r = .65, p < .01; n = 53, r = .62, p < .01). Significant relationships were also observed between maternal violence and child Attack (11 = 39, r = .40, p = .01) and maternal HRSD and child Anxious/Depressed (n = 53, r = .33, p = .02) in HSC children. In relation to paternal SE variables, significant relationships were observed between paternal functioning and both child Anxious/Depressed (n = 51, r = -.29, p = .04) and Attack (g = 51, r = -.29, p = .04). Additionally, significant relationships were observed between paternal alcohol consumption and both child Anxious/Depressed (n = 50, r = .47, p < .01) and Attack (:1 = 50, r = .48, p < .01; please see Appendix A, Table 29 for complete results) in HSC children. To examine these relationships further, scatterplots were created. Evaluation of these scattterplots suggested that a single subject might be primarily responsible for the following relationships: maternal violence and Attack, paternal functioning and Attack, 126 maternal functioning and Attack, maternal neuroticism and Attack, paternal alcohol consumption and Attack, and maternal alcohol consumption and Attack (see Appendix B, Figures 59-64). To examine this possibility, correlations were re-run following deletion of suspect subjects. Results from these analyses produced the following: maternal violence and Attack (11 = 38, r = .26, p = .12), paternal functioning and Attack (3 = 50, r = -.20, p = .16), maternal functioning and Attack (11 = 52, r = -.27, p = .05), maternal neuroticism and Attack ([1 = 52. r = .23, p = .10), paternal alcohol consumption and Attack (3 = 49, r = .15, p = .30), and maternal alcohol consumption and Attack (11 = 52, r = .34, p = .01). Thus, following evaluation of scatterplots and reanalysis of relationships following subject deletion, within HSC children the following relationships remained: paternal functioning and Anxious/Depressed, Maternal functioning and both Attack and Anxious/Depressed, maternal neuroticism and Anxious/Depressed, maternal HRSD and Anxious/Depressed, paternal alcohol consumption and Anxious/Depressed, and maternal alcohol consumption and both Attack and Anxious/Depressed. Since the SE predictors which were found to be significantly related to child impulsive aggressiveness and/or poor affective modulation were themselves related to each other in HSC children (see Appendix A, Table 29), additional evaluations using regression were employed to examine independent contributions to the dependent variables. For Attack in HSC children, a regression with maternal functioning and maternal alcohol consumption predicting child Attack indicated that only maternal alcohol consumption remained a significant predictor (see Appendix A, Table 36). The overall R2=.36[F(2,50)=15.76, p < .001). For Anxious/Depressed, paternal alcohol 127 consumption was related to Anxious/ Depressed at the zero order level and highly related to maternal alcohol consumption (n = 50, r = .82, p < .001), raising the possibility of multicollinearity. However, after entering both parent’s alcohol consumption in predicting HSC Anxious/Depressed yielded a significant B only for maternal alcohol consumption (maternal alcohol consumption B =.91, p < .001; paternal alcohol consumption B=-.27, p = .14). While there was no evidence of multicollinearity, paternal alcohol consumption was not entered in the final regression. Similarly, maternal functioning and maternal HRSD were highly correlated with each other (n = 53, r = -.66, p < .001), raising the possibility of multicollinearity. However, entering both maternal functioning and maternal HRSD in predicting HSC Anxious/Depressed yielded a significant B only for maternal functioning (maternal functioning B= -.49, p < .01; maternal HRSD B = .01, p = .95). Hence, maternal HRSD was not entered in the final regression. The four SE variables which were related to each other as well as to Anxious/Depressed at the zero order level were entered in a regression analysis: paternal functioning, maternal functioning, maternal neuroticism, and maternal alcohol consumption. Results indicated that maternal alcohol consumption and maternal neuroticism were the only independent significant predictors (see Appendix A, Table 37). The overall R2=.53[F(4,46)=15.03, p < .001]. 128 flypgthssis é-Sogioenvironmental Variables and Child Whole Blogd i-Hflf as Since there were no significant main effects for child whole blood 5-HT with the dependent variables of Attack or Anxious/Depressed, hypothesis 6 was not supported. Th r a ili f 1 Versus 2 E In the present study many tests were run which increases the likelihood of a Type 1 error. However, the issue of error is more complex given the possibility of Type 2 errors. In this study, for some questions there was relatively small sample size, which produced a restriction in statistical power. This problem of power was exacerbated when the sample was further broken down to examine interaction effects. Thus, the issue of Type 1 versus Type 2 error is a question of tradeoffs. Nonetheless, nonsignificant findings are not interpreted here. Additionally, any individual result reported here is in need of replication before any strong conclusions can be drawn. ngmag of Main Findings Given the caveats regarding the number of tests run in the present study, a summary of the formal hypotheses that were supported by statistically significant results is provided here. The results of the present study provided support for both Hypothesis 2 and Hypothesis 5. For Hypothesis 2, parental whole blood 5-HT was positively related to poor affective modulation as measured by parental depression. For Hypothesis 5, the socioenvironmental variables of both maternal violence and maternal alcohol consumption were positively related to child behavioral dysregulation and the 129 socioenvironmental variable of maternal alcohol consumption was positively related to child affective dysregulation. Those formal hypotheses not supported included: Hypothesis 1, parental whole blood 5-HT was not related to either parental ASPD or alcohol dependence diagnosis; Hypothesis 2, parental whole blood S-HT was not related to parental irritable impulsive aggressiveness or affective dysregulation as measured by the NEO-FFI Neuroticism factor; Hypothesis 3, child whole blood 5-HT was not related to either child behavioral or affective dysregulation in the full sample; Hypothesis 4, socioenvironmental variables were not related to child whole blood 5-HT; Hypothesis 6, socioenvironmental variables and child whole blood 5-HT were not independent predictors of child behavioral or affective dysregulation. Though few of the formal hypotheses were supported in the full data sets within adults and children, the basic relationships that were hypothesized emerged significant within subsets of the subjects. These are basically interaction effects. Among the exploratory analyses which were supported by significant results were Hypotheses 2, 3, and 5. For Hypothesis 2, ASPD was found to moderate the relationship between whole blood 5-HT and affective dysregulation such that there was a significant positive relationship between whole blood 5-HT and Neuroticism in LSES ASPD, but not LSES non-ASPD men. For Hypothesis 3, a) gender appeared to moderate the relationship between whole blood 5-HT and behavioral dysregulation in children such that there was a significant negative relationship between whole blood 5-HT and Attack in girls, but not in boys, b) puberty appeared to moderate the relationship between whole blood 5-HT and 130 both behavioral and affective dysregulation such that there were significant negative relationships between whole blood 5-HT and both Attack and Anxious/Depressed in pubescent, but not in prepubescent children, c) social competence appeared to moderate the relationship between whole blood 5-HT and irritable impulsive aggression such that a significant negative relationship was found between whole blood 5-HT and Attack in LSC, but not HSC boys. For Hypothesis 5, in addition to the main effects observed between SE variables and child behavior in the full sample, puberty appeared to moderate the relationships between SE variables and child behavioral and affective dysregulation such that maternal alcohol consumption predicted both child Attack and Anxious/Depressed in prepubescent, but not pubescent children. 131 DISCUSSION Discussion of the significant results include those for the formal hypotheses and the more exploratory analyses. This is then followed by a discussion of this study’s contributions to the present literature, and, lastly, an evaluation of the present results within the context of the literature that was described in the introduction. ,t' zr'H 3'9‘ 1- ' -- A ItthnlBlo 5- T d ht: At' t l:|," Han Disorder and Alcohglism No relationship was found between whole blood 5-HT and ASPD in men. Additionally, while it was hypothesized that there would be a relationship between whole blood 5-HT and alcohol dependence diagnosis which was accounted for by the relationship between whole blood 5-HT and ASPD, results indicated no evidence of a relationship between whole blood 5-HT and alcohol dependence diagnosis. {'zr'u‘r'ufi'ri",ar-th53Hr -»H3tu.‘.i'r"UH_1r'n and Irritable Impulsivs Aggrgssixengss Whole blood 5-HT was related to depression in the full sample of men and women. This relationship remained significant within both male and female samples. Though poor affective modulation as measured by depression was related to whole blood S-HT, poor affective modulation as measured by neuroticism was not related to whole blood S-HT. Additionally, the hypothesized relationship between whole blood 5-HT and irritable impulsive aggressiveness was not supported in the full sample. 132 U “‘1’. “ I' ' 'I h'I .3 Whol BlIId - _zrd .I'I e S'I As Dabbs and Morris (1990) found, SES was an important moderating variable. SES moderated the relationship between adult whole blood 5-HT and depression. This interaction was demonstrated by the significant relationship between whole blood 5-HT and HRSD in LSES, but not HSES subjects. However, this moderating effect of SES was not present for the relationships between whole blood 5-HT and either neuroticism or irritable impulsive aggressiveness. L 'I U1" I ~ 131133 9| i'n'fii II - 1 III -_.__ 3|! . i- I'v- WW An attempt at replicating the previous finding of a relationship between serotonergic function and impulsive aggression in personality disordered, but not healthy control subjects (Coccaro et al., 1997; Coccaro et al., 1996) led to an examination of the moderating effects of ASPD for men. Additionally, evaluating ASPD moderating effects in men was complicated by the relationship between ASPD and SES, with all but one ASPD man being in the LSES group. Hence, examination of differences in relationships between non-ASPD LSES and HSES men, and between non-ASPD and ASPD LSES men were conducted. Within LSES men, ASPD moderated the relationship between whole blood 5-HT and Neuroticism. Within ASPD LSES men there was a positive and significant relationship between whole blood 5-HT and Neuroticism, which was not found within non-ASPD LSES men. 133 'I4iI'I‘ ,‘tVV‘ien IiII WhIIBIOI -;'ITn _:I I. u :I ' .1! V ‘(o Aggressivsness and floor Affectivs Mgdulgtfign For the full sample of children, no significant relationships were found between whole blood 5-HT and either irritable impulsive aggressiveness or poor affective modulation. However, gender appears to moderate the relationship between whole blood 5-HT and irritable impulsive aggression. such that there was a significant negative relationship for girls, but not for boys. ’__I~u u II-__= ', l.‘ l: = iI , hiI i'WHIII WIII I III ,-_1._ :II Behaxinr Inconsistent findings regarding relationships between serotonergic function and behavior in children, particularly in whole blood 5-HT studies, suggest that age related developmental factors may need to be taken into account when evaluating these relationships in non-adult samples. In the present study, puberty was an important moderating variable. Though there were no main effect relationships in the full sample of boys and girls, significant relationships emerged between whole blood 5-HT and both irritable impulsive aggressiveness and poor affective modulation within pubescent, but not within prepubescent children. -I'r. lll"'|‘ II‘=.‘ "ellnshltw=II3‘“I I IIJJIII -: I B I . . B In boys, social competence appears to moderate the relationship between whole blood 5-HT and irritable impulsive aggressiveness. For LSC boys, there was a significant negative relationship between whole blood 5-HT and irritable impulsive aggressiveness 134 while there was no such relationship for HSC boys. This relationship within HSC girls was significant and negative, though the relationship could not be tested within LSC girls due to sampling characteristics. Though social competence appears to moderate the relationship between whole blood 5-HT and irritable impulsive aggression for boys, whether this is true for girls cannot be formally tested without more LSC girls. ' ir ment IV riables an hi1 Wh 1 No significant main effect relationships were found between socioenvironmental variables and whole blood 5-HT for the full sample, nor within boys and girls alone. {azr'II IIIs twen o ionvirI mntharil .II :I I III ' .II- Though there were a number of zero order relationships between SE variables and the dependent variables of child irritable impulsive aggressiveness and poor affective modulation, regression analyses indicated that maternal alcohol consumption and maternal violence were the only remaining significant predictors for Attack. For Anxious/Depressed, only maternal alcohol consumption emerged as a significant predictor. Since many of the effects occurred within interactions additional regression analyses were conducted within the levels of the interacting variables of gender, puberty, and social competence in order to evaluate the relative influence of the predictor variables. For the potential moderator gender, regression analyses indicated that maternal alcohol consumption was the only significant predictor for both Attack and Anxious/Depressed in boys, but not in girls. For the moderating variable puberty, regression analyses indicated that maternal alcohol consumption was the only significant 135 predictor for both Attack and Anxious/Depressed in prepubescent, but not pubescent children. For the moderating variable of Social Competence, maternal violence was the only significant predictor of Anxious/Depressed in LSC, but not HSC children. In HSC children, maternal alcohol consumption was the only predictor for Attack, and both maternal alcohol consumption and maternal neuroticism were significant predictors for Anxious/Depressed. I I-I _III ° IVriab'an hiIW I_' 3 III -I 2‘ .ll‘I'II‘I ..._ W ._ 1. r' ._ ,-_-v...._. i-' gum-”NH, Beam There was no evidence of a main effect, zero order relationship between child whole blood 5-HT and either child irritable impulsive aggressiveness or poor child affective regulation. t i 'on Li The present work extended previous findings that suggested the importance of age related developmental factors in understanding the relationships between serotonergic functioning and behavior in non-adult samples. Specifically, the current work indicated that puberty is an important moderator of the relationships between whole blood 5-HT and both irritable impulsive aggression and poor affective modulation. This finding may help explain some of the discrepancies in the child and adolescent literature. Previous whole blood 5-HT studies have found relationships between whole blood 5-HT and behavioral dysregulation in older, but not younger samples of children (Cook etal., 1995; Gabel et al., 1993; Hanna et al., 1995). Given the positive relationship between age and 136 pubertal status, it is possible that the lack of relationships observed in younger samples is related to prepubertal status within these samples. Similarly, the finding of a moderating role of social competence in the relationship between whole blood 5-HT and irritable impulsive aggression in boys extends findings from non-human primate research (Mehlman et al., 1995; Raleigh et al., 1983; Raleigh et al., 1985; Raleigh & McGuire, 1991) and suggests that an understanding of the relationships between social factors and serotonergic functioning may help provide a more complete understanding of the complex relationships between biology and behavior. The present study also provided an extension of previous work which found a relationship between decreased serotonergic functioning and impulsive aggression only in personality disordered individuals, but not in healthy controls (Coccaro etal., 1997; Coccaro et al., 1996). In the present work a similar relationship was found between whole blood 5-HT and affective dysregulation in LSES ASPD men, but not in LSES non- ASPD men. Together these findings stress the importance of studying subgroups of individuals when examining the relationships between serotonergic functioning and behavior. The present research also supported findings from other studies (Anthenelli et al., 1995; Schmidt et al., 1997) and indicated that cigarette smoking may be an important variable to take into consideration when studying relationships between whole blood 5- HT and behavior in adults. 137 The present findings also corroborated the well documented relationship between serotonergic dysfunction and depression in adults and indicate that this relationship is similar for men and women. The present work also indicates that SES moderates this relationship as demonstrated by the significant relationship between whole blood 5-HT and HRSD in LSES, but not HSES subjects. Additionally, results from the present study highlight maternal characteristics as important predictors of child behavior, particularly in prepubescent children. Interestingly, results indicated that in pubescent children, the biological variable of whole blood 5-HT emerged as an important predictor of child behavior. Thus, in pubescent children the influence of environmental and biological variables can be seen. mmmmflmmm Particularly important to note was the importance of moderating variables in examining the relationships between whole blood 5-HT and irritable impulsive aggressiveness and poor affective modulation in both adults and children/adolescents as well as for the relationships between socioenvironmental variables and both child behavior and whole blood 5-HT. For adults, SES and ASPD were important variables, and in children, gender, puberty, and social competence proved to be important in understanding the relationships of interest. vi it The most widely accepted finding in the literature describes an inverse relationship between serotonin and irritable impulsive aggression in adult males. However, in the present study there was no such main effect relationship in the adult male 138 sample. This relationship however, was found within LSES ASPD, but not LSES non- ASPD men. Again, this emphasizes the importance of evaluating interaction effects. Perhaps other studies which find the relationship between serotonergic functioning and irritable impulsive aggression are also examining LSES ASPD men. In fact, the data reviewed indicate that the majority of the reviewed studies of the relationship between serotonergic functioning and irritable impulsive aggression examined subjects who were clinically sampled for violent behavior (murderers under forensic evaluation) unlike the present sample who meet diagnosis for ASPD and/or alcohol dependence, but were not identified on the basis of the presence of violent behavior. Thus, on a continuum of non- violent to violent, the samples from the majority of studies that have found a main effect relationship between 5-HT dysfunction and irritable impulsive aggression would place at the far end of the violent pole, while the present sample would be located somewhere between non-violent and violent, with the LSES ASPD portion of the men placing closer to the violent clinical samples than the remainder of the present sample. If this is the case, it would be possible that a main effect relationship between 5-HT dysfunction and irritable impulsive aggression would only be found in that subset of the present sample that most closely resembles the more violent and disordered clinical samples used in the majority of existing studies in regard to the construct of irritable impulsive aggression. One interpretation provided from the data reviewed is that affective dysregulation appears to play a key role in the expression of violence. Given the relationships between serotonergic dysfunction and both irritable impulsive aggression and depression in adults and the co-morbidity of early depression and conduct disorder in children and 139 adolescents, the present finding of relationships between whole blood 5-HT and both irritable impulsive aggression and affective dysregulation in pubescent children may provide support for the hypothesis that affective dysregulation is a central component to the expression of violence. Perhaps a central serotonergic deficit is related to both of these disinhibitory behaviors which in combination increases the likelihood of violent response to affectively charged situations. Further examination of the relationships among serotonergic dysfunction, violent behavior, and affective dyscontrol may help provide a more comprehensive understanding of 5-HT’s role in behavior. Furthermore, the earlier described developmental model and data from the MSU/U of M Family Study that inform the present study predicts that early problems of impulsivity would lead to earlier and more severe forms of alcoholism and antisociality. While this model was not formally tested, the present finding of a relationship between decreased whole blood 5-HT and behavioral dysregulation in a subsample of the children, those who are pubescent, would fit into this model provided these children continue a lifetime trajectory of increased behavioral difficulties. Maybe it is the case that children with serotonergic dysfunction are more likely to exhibit a developmental lifetime trajectory of earlier and increased behavioral problems, antisociality, alcohol use, alcohol related problems, and are more likely to develop antisocial alcoholism. Furthermore, like the findings from non-human primate data, perhaps social competence may act as a buffer for these children, such that high social competence might protect those children with low whole blood 5-HT from exhibiting maladaptive impulsive aggression. Continued study of the current sample would be necessary to formally test this model. 140 The present study does not provide support for the serotonin hypothesis of alcoholism (Ballenger and LeMarquand) which was described in the introduction. While the present study did not test whether alcohol consumption produces a pattern of an initial increase in 5-HT followed by a later decrease in 5-HT, or whether this cycle leads to repetitive attempts to pharmacologically correct a preexisting deficit in 5-HT functioning with alcohol use, there was no data to support a relationship between serotonergic dysfunction and either alcohol dependence or alcohol consumption. Thus, the present findings contrast with those studies in the literature that have found relationships between decreased 5-HT and both alcoholism diagnosis (violent or nonviolent) and alcohol consumption. As described earlier in the introduction, it is possible that the primary relationship underlying the reported relationships between 5-HT dysfunction and a variety of behavioral disorders (alcoholism, depression, suicide) is between 5-HT and impulsive aggression. If this is the case, it would be possible that those studies that have found relationships between 5-HT dysfunction and alcoholism are complicated by the presence of impulsive aggression and as such constitute a subgroup of alcoholic with particular aggressive characteristics. As reported earlier, in reviewing the studies of 5-HT dysfunction in alcoholics it appears that many of these studies have samples that are likely to be ASPD alcoholics which may have complicated the results presented. Thus, the results from the present study which provide a lack of evidence for a main effect relationship between 5-HT dysfunction and alcohol dependence provides corroborating support for the hypothesis that there is no primary relationship between S-HT dysfunction 141 and alcoholism outside of the subgroup of ASPD alcoholism or early onset violent alcoholism which is characterized by impulsive aggression. Methgdglogical Limitatigns The present study formally hypothesized that there would be main effect relationships between whole blood 5-HT and both irritable impulsive aggression and poor affective modulation in both adults and children. Additionally, it was informally hypothesized that social and developmental factors would interact with the relationships between both child whole blood 5-HT and socioenvironmental variables and irritable impulsive aggressiveness in children. However, to test these informal hypotheses, a series of exploratory analyses were conducted which increased the total number of tests conducted on this data set. While the present author believes these analyses were both necessary and beneficial to understanding the complexity of the relationships under examination, it must be noted that the likelihood of a Type 1 error increased as a result of the large number of tests performed. Therefore, it is necessary to replicate the present findings. Perhaps small sample size was the greatest limitation of the present study. Though, nonsignificant findings were only reported, and not interpreted, the fact that several of these relationships were “nonsignificant, but of large effect size” may indicate that increased power may be necessary to detect relationships that are present, but nonsignificant. Additionally, given the importance of interactions when studying the relationships among whole blood S-HT, behavior, and socioenvironmental variables, the current study was hampered by the small sample size of both adult and child samples 142 since moderating variables further split subjects into small groupings and left some cells unfilled. For example, the lack of socially competent children, particularly LSC girls, made it impossible to evaluate the moderating effects of social competence on the relationships between whole blood 5-HT and irritable impulsive aggression and poor affective modulation in girls. Similarly, because of power limitations related to sample size, when testing for moderating effects there was insufficient power to reasonably test correlations for statistical differences between groups, thus formal testing of correlations between groups defined by moderating variables was not carried out. The concern here is that such formal testing of differences between groups with these sample sizes would yield a high rate of Type 2 errors. The important result is that there appears to be evidence for consistent moderating effects and that such moderation needs to be tested with still larger sample sizes. Also, at the main effect level, for children, the small girl/boy ratio made it difficult to fully examine the relationships of interest in girls. In relation to this point, it would also be beneficial to have a sample large enough to allow an examination of potential age effects within prepubescent and pubescent children. Additionally, while it was beneficial to examine the relationships of interest in a non-clinical sample, data from the adults suggest that it may be necessary to evaluate subgroups of clinical samples to fully understand the relationships between whole blood 5-HT and behavior. For that purpose, large samples of previously identified subgroups are necessary. 143 li in n u r Dircti Researchers in this area have just recently begun to examine relationships among biological variables and behavior within developmentally differentiated subsets of children and adolescents. Given the inconsistencies in the child/adolescent literature, the developmental theories of early childhood problems leading to later life difficulties, and the hormonal influence that defines puberty, it would seem reasonable to expect moderating developmental effects when examining relationships between biology and behavior such as those between whole blood 5-HT and both behavioral and affective dysregulation. In the present study pubertal status appeared to function as a moderating variable. These results indicate that there is a negative relationship between whole blood 5-HT and both irritable impulsive aggression and poor affective modulation in pubescent, but not prepubescent children who are at risk for later behavioral problems such as alcoholism and aggressiveness. These results are consistent with the interpretation that the lack of similar findings, at least for studies of whole blood 5-HT and irritable impulsive aggression, in younger samples may be due to the potential prepubescent status of these samples. However, this interpretation is merely speculative and future investigations are needed to replicate the present finding. Pubertal status would appear to be an important variable to evaluate as a moderator in relation to the developmental context of the role S-HT dysfunction may play in various models of behavior over the life course. For example, the present findings can be interpreted to imply that in prepubescent children the socioenvironmental variables of 144 maternal characteristics are important determinants of child behavior while as noted above, biology as represented here by whole blood 5-HT is an important determinant of child behavior in pubescent children. The present data can best be understood within a developmental model. For example, as a child, it is possible that maternal characteristics might play a central role in determining behavior, while in this culture, when children reach puberty there appears to be a diminishment of parental influence. Conversely, in puberty, which is socially defined as a period of individuation and biologically defined as a period of hormonal activation, it would be reasonable to expect that biology might become more central to determining behavior than parental characteristics. Furthermore, the present findings suggest several clinical implications. First, early identification of maternal characterisitcs which may place children at risk for problems in behavioral and affective dysregulation may be necessary. Second, the finding that maternal characterisitcs appear to be important predictors of early problems in child behavioral and affective dysregulation suggests that it would be useful to clinically intervene with mothers of problem children early on. Third, given that social competence may buffer children with serotonergic dysfunction fi'om expressing problems in behavioral control, particular attention to increasing social skills in children may be a useful preventative strategy. Fourth, given that the relationships between serotonergic dysfunction and both behavioral and affective dysregulation appear to emerge in pubescent children, further evaluation of clinical interventions targeting the relationship between biology and behavior in adolescents and their effects on the behavioral and affective modulation systems may be warranted. Lastly, while the present findings did 145 not support the hypothesized relationship between the proposed environmental variables and whole blood 5-HT, continued examination of environmental variables that may have direct positive effects on serotonergic functioning as well as on behavior might be beneficial. In future investigations, other potentially moderating variables should also be evaluated because it may be the case that some effects of whole blood S-HT occur within interactions. Additionally, the effects of potentially moderating variables combined with the composition of research samples may produce inconsistent results. Therefore, more complex interactions should also be evaluated. It may be the case that both gender and social competence interact with 5-HT. It could also be the case that still more complex moderating effects are operating. For example, it may be that pubertal status, social competence, gender, and 5-HT all interact in producing effects on dependent variables such as irritable impulsive aggression and affective dysregulation. Thus, such complex interactions may be an important area of examination for future research. In adults, the present results suggest that one relationship to carefully evaluate as it may contribute to other relationships is the relationship between whole blood 5-HT and cigarette smoking. Future studies of the relationship between serotonergic function and behavior may want to examine cigarette smoking as a potential confound. As noted above, while the most widely supported finding in the literature between 5-HT dysfunction and irritable impulsive aggression was not found in this study, there was a similar observed relationship between whole blood 5-HT and affective dysregulation, but only within an interaction in that it appeared within LSES ASPD men. Further 146 evaluation of this relationship and its possible association to the expression of violence would be beneficial. The literature generally supports relationships between 5-HT dysfunction and aggression, 5-HT dysfunction and impulsive violence, and between S-HT dysfunction and impulsivity. It may be that the relationship between 5-HT dysfunction and aggression is primarily a function of impulsivity. To this author’s knowledge, there has been no direct evaluation of whether impulsivity mediates the relationship between 5-HT dysfunction and aggression. It would be important to evaluate such a potential mediational model. Also, this would apply to children where it was found that whole blood 5-HT was related to irritable impulsive aggression in pubescent children. In summary, the present research demonstrates the importance of examining interactions with gender, puberty, social competence, SES, and ASPD when examining the relationships between serotonergic function and behavioral and affective regulation as well as the relationships between socioenvironmental variables and both serotonergic function and behavior. Therefore, it is important for future examinations of serotonergic function and behavior to design studies such that these interactions may be fully evaluated. To do this, subject selection should be conducted in a manner that provides the statistical power necessary to fully examine moderating effects of variables such as gender, pubertal status, SES, and social competence. 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N 62 62 62 62 62 62 **. Correlation is Significant at the 0.01 level (2-tailed). 157 Table 5- Correlations Among Child Whole Blood 5-HT, Potential Covariates, and Dependent Variables for Boys (11 = 45) and Girls (11 = 17) IGDR S-HTL AGE SEASON BMI ANX/O” EP ETTAH‘ ale S-HT Pear 1.000 W .059 .189 -.194 -.20 Sig (24) . .083 .702 .213 .201 .170 N 45 45 45 45 45 45 AGE Pear -.26l 1.000 -.392 .356 -.062 .015 Sig (24) .083 . .008 .016 .688 .923 N 45 45 45 45 45 45 SEASON Pear .059 -.392 1.000 -.217 .012 .095 Sig (2-1) .702 .008 . .152 .939 .534 N 45 45 45 45 45 45 BM] Pear -.189 .356 -.217 1.000 -.133 .086 Sig (24) .213 .016 .152 . .384 .575 N 45 45 45 45 45 45 ANX/DEP Pear -.194 -.O62 .012 -.133 1.000 .744 Sig (24) .201 .688 .939 .384 . .000 N 45 45 45 45 45 45 CBCL Attack Pear -.208 .015 .095 .086 .744 1.000 Sig (2-1) .170 .923 .534 .575 .000 . N 45 45 45 45 45 45 Fem S-HT Pear 1.000 .046 .388 -.232 -.385 -.484 Sig (2-1) . .862 .124 .369 .127 .049 N 17 17 17 17 17 17 AGE Pear .046 1.000 .122 .379 .144 .157 Sig (24) .862 . .641 .133 .582 .547 N 17 17 17 17 17 17 SEASON Pear .388 .122 1.000 -.232 -.523 -.280 Sig (2-1) . 124 .641 . .370 .031 .276 N 17 17 17 17 17 17 BMI Pear -.232 .379 -.232 1.000 -.146 -.270 Sig (24) .369 . 133 .370 . .577 .294 N 17 17 17 17 17 17 ANX/DEP Pear -.385 .144 -.523 -.l46 1.000 .786 Sig (24) .127 .582 .031 .577 . .000 N 17 17 17 17 17 17 CBCL Attack Pear -.484 .157 -.280 -.270 .786 1.000 Sig (2-1) .049 .547 .276 .294 .000 . N 17 17 17 17 17 17 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). 158 ee. H ..w wow H oow ww. H oww 88.580 .o. H ow. wo.. H oo. oo. H ww. 8.on ow.w H we.w. ww.w H www. ow.w H wow. 828...... .o w... wow.eww H oww.wew 282.. w.8... ow.w H we.o. ww.. 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[km-0 164 Table 12. Correlations Between Parental Whole Blood S-HT, Irritable Assault, Neuroticism, and HDRS in Low SES (n = 41) and High SES (n = 15) Subjects ES S-HT IRR+ASS NEURTC HAMWC ixed S-HT Pear 1.000 .082 710 .331 Sig. (2-t) . .677 .249 .064 N 32 28 32 32 IRR+ASS Pear .082 1.000 .382 .086 Sig. (2-t) .677 . .045 .665 N 28 28 28 28 NEURTC Pear .210 .382 1.000 .429 Sig. (2-t) .249 .045 . .014 N 32 28 32 32 HAMWC Pear .331 .086 .429 1.000 Sig. (2-t) .064 .665 .014 . N 32 28 32 32 LOW S-HT Pear 1.000 -.274 .145 .368 Sig. (2-t) . .130 .367 .018 N 41 32 41 41 1RR+ASS Pear -.274 1.000 .063 -.013 Sig. (2-t) .130 . .734 .943 N 32 32 32 32 NEURTC Pear .145 .063 1.000 .328 Sig. (2—t) .367 .734 . .037 N 41 32 41 41 HAMWC Pear .368 -.013 .328 1.000 Sig. (2-t) .018 .943 .037 . N 41 32 41 41 HIGH S-HT Pear 1.000 -.178 -.259 .249 Sig. (2-t) . .525 .351 .371 N 15 15 15 15 1RR+ASS Pear -.178 1.000 .423 -.125 Sig. (2-t) .525 . .116 .658 N 15 15 15 15 NEURTC Pear -.259 .423 1.000 .204 Sig. (2-t) .351 .1 l6 . .465 N 15 15 15 15 HAMWC Pear .249 -.125 .204 1.000 Sig. (2-t) .371 .658 .465 . N 15 15 15 15 *. Correlation is significant at the 0.05 level (2-tailed). 165 Table 13. Correlations Between Paternal Whole Blood 5-HT, Irritable Assault, Neuroticism, and HDRS in Low SES (n = 23) and High SES (n = 8) Men SES 5-111?— IRR+ASS NEURTC HAMWC ixed 5-HT Pearson 1.000 .276 3512 .366 Sig. (2-tailed) . .361 .277 .198 N 14 13 14 14 IRR+ASS Pearson .276 1.000 .202 .011 Sig. (2-tailed) .361 . .508 .972 N 13 13 13 13 NEURTC Pearson -.312 .202 1.000 .263 Sig. (2-tailed) .277 .508 . .363 N 14 13 14 14 HAMWC Pearson .366 .011 .263 1.000 Sig. (2-tailed) .198 .972 .363 . N 14 13 14 14 Low S-HT Pearson 1 .000 -.376 .452 .225 Sig. (2-tailed) . .1 13 .030 .301 N 23 19 23 23 IRR+ASS Pearson -.376 1.000 -.244 -.076 Sig. (2-tailed) .l 13 . .314 .757 N 19 19 19 19 NEURTC Pearson .452 -.244 1.000 .545 Sig. (2-tailed) .030 .314 . .007 N 23 19 23 23 HAMWC Pearson .225 -.076 .545 1.000 Sig. (2-tailed) .301 .757 .007 . N 23 19 23 23 High S-HT Pearson 1.000 -. 175 -.258 .636 Sig. (2-tailed) . .678 .537 .090 N 8 8 8 8 IRR+ASS Pearson -.175 1.000 .112 -.089 Sig. (2-tailed) .678 . .791 .835 N 8 8 8 8 NEURTC Pearson -.258 .112 1.000 .312 Sig. (2-tailed) .537 .791 . .453 N 8 8 8 8 HAMWC Pearson .636 -.089 .312 1.000 Sig. (2-tailed) .090 .835 .453 . N 8 8 8 8 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tai1ed). 166 Table 14. Correlations Between Maternal Whole Blood 5-HT, Irritable Assault, Neuroticism, and HDRS in Low SES (n = 18) and High SES (n = 7) Women SES FIVEHT IRR+ASS NEURTC HAMWC ixed FIVEHT Pearson 1.000 .061 .450 .33 Sig. (2-tailed) . .830 .061 .176 N 18 15 18 18 IRR+ASS Pearson .061 1.000 .543 .164 Sig. (2-tailed) .830 . .037 .559 N 15 15 15 15 NEURTC Pearson .450 .543 1.000 .571 Sig. (2-tailed) .061 .037 . .013 N 18 15 18 18 HAMWC Pearson .334 .164 .571 1.000 Sig. (2-tailed) .176 .559 .013 . N 18 15 18 18 Low FIVEHT Pearson 1.000 -.067 -.011 .460 Sig. (2-tai1ed) . .829 .966 .055 N 18 13 18 18 IRR+ASS Pearson -.067 1.000 .273 .039 Sig. (2-tailed) .829 . .367 .900 N 13 13 13 13 NEURTC Pearson -.011 .273 1.000 .215 Sig. (2-tailed) .966 .367 . .392 N l8 13 18 18 HAMWC Pearson .460 .039 .215 1.000 Sig. (2-tailed) .055 .900 .392 . N 18 13 18 18 High FIVEHT Pearson 1.000 -.295 -.278 .007 Sig. (2-tailed) . .521 .546 .988 N 7 7 7 7 IRR+ASS Pearson -.295 1.000 .897 -.125 Sig. (2-tailed) .521 . .006 .789 N 7 7 7 7 NEURTC Pearson -.278 .897 1.000 .219 Sig. (2-tailed) .546 .006 . .637 N 7 7 7 7 HAMWC Pearson .007 -.125 .219 1.000 Sig. (2-tailed) .988 .789 .637 . N 7 7 7 7 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). 167 Table 15. Correlations Between Paternal Whole Blood 5-HT, Irritable Assault, Neuroticism, and HDRS By ASPD Diagnosis and SES ASPD SES s-HT IRR+ASS NEURTC ”11' DR' s' *"—"0 Mixed S-HT Pear 1.000 -.091 047*??? Sig. (2-0 . .791 .082 .333 N 11 11 11 11 IRR+ASS Pear -.091 1.000 .062 -.363 Sig. (24) .791 . .857 .272 N 11 11 11 11 NEURTC Pear -.547 .062 1.000 .225 Sig. (24) .082 .857 . .506 N 11 11 11 11 HDRS Pear .323 -.363 .225 1.000 Sig. (2-0 .333 .272 .506 . N 11 11 11 11 Low S-HT Pear 1.000 .219 .233 .519 Sig. (20) . .543 .490 .102 N 11 10 11 11 IRR+ASS Pear .219 1.000 -.754 -.532 Sig. (2-1) .543 . .012 .113 N 10 10 10 1o NEURTC Pear .233 -.754 1.000 .528 Sig. (24) .490 .012 . .095 N 11 10 11 11 HDRS Pear .519 -.532 .528 1.000 Sig. (2-0 .102 .1 13 .095 . N 11 10 11 11 High 5-141 Pear 1.000 -.160 -.323 .644 Sig. (24) . .732 .480 .118 N 7 7 7 7 IRR+ASS Pear -.160 1.000 .330 .024 Sig. (2-0 .732 . .470 .959 N 7 7 7 7 NEURTC Pear -.323 .330 1.000 .214 Sig. (2-1) .480 .470 . .645 N 7 7 7 7 HDRS Pear .644 .024 .214 1.000 Sig. (24) .118 .959 .645 . N 7 7 7 7 1 Mixed 5-HT Pear 1.000 1.000 .995 .444 Sig. (2-1) . . .063 .707 N 3 2 3 3 IRR+ASS Pear 1.000 1.000 1.000 1.000 Sig. (2-t) . . . . N 2 2 2 2 I68 Table 15. Correlations Between Paternal Whole Blood S-HT, Irritable Assault, Neuroticism, and HDRS By ASPD Diagnosis and SES con't. ASPD SES S-HT IRR+ASS NEURTC HDRS 1 Mixed NEURTC Pear .995 1.000 1.000 .525-T Sig. (2-1) .063 . . .643 N 3 2 3 3 HDRS Pear .444 1.000 .531 1.000 Sig. (24) .707 . .643 . N 3 2 3 3 Low S-HT Pear 1.000 -.803 .727 .221 Sig. (2-1) . .009 .007 .490 N 12 9 12 12 IRR+ASS Pear -.803 1.000 .018 .224 Sig. (20) .009 . .963 .563 N 9 9 9 9 NEURTC Pear .727 .018 1.000 .564 Sig. (2-1) .007 .963 . .056 N 12 9 12 12 HDRS Pear .221 .224 .564 1.000 Sig. (2-1) .490 .563 .056 . N 12 9 12 12 High 5-HT Pear .51 i Sig. (2-t) . . . . N 1 1 1 1 IRR+ASS Pear f if .5 Sig. (2-t) . . . N 1 1 1 1 NEURTC Pear 791 .4 .51 Sig. (2-t) . . . . N 1 1 1 1 HDRS Pear .a' Sig. (2-t) . . . . N 1 1 1 1 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is Significant at the 0.01 level (2-tailed). a. Cannot be computed because at least one of the variables is constant. 169 Table 16. Correlations Between Child Whole Blood S-HT, Attack, and Anxious/Depressed Scores in Full Sample of Boys and Girls Combined (N=62) 5-HT ATTACK ANX/DEP -HT Pearson Correlation 1.000 -.202 -.21 Sig. (2-tailed) . .1 15 .096 N 62 62 62 ATTACK Pearson Correlation -.202 1.000 .739 Sig. (2-tailed) .1 IS . .000 N 62 62 62 ANX/DEP Pearson Correlation -.213 .739 1.000 Sig. (2-tailed) .096 .000 . N 62 62 62 **. Correlation is significant at the 0.01 level (2-tailed). Table 17. Correlations Between Child Whole Blood S-HT, Attack, and Anxious/Depressed By Gender IGDR S-HT ATTACK ANX/DEF emale S-HT Pearson l .000 -.484 -.3 Sig. (2-tailed) . .049 .127 N 17 l7 l7 ATTACK Pearson -.484 1.000 .786 Sig. (2-tailed) .049 . .000 N 17 17 17 ANX/DEP Pearson -.385 .786 1.000 Sig. (2-tailed) .127 .000 . N 17 17 17 Male S-HT Pearson 1 .000 -.208 -. 194 Sig. (2-tailed) . .170 .201 N 45 45 45 ATTACK Pearson -.208 1.000 .744 Sig. (2-tailed) .170 . .000 N 45 45 45 ANX/DEP Pearson -.194 .744 1.000 Sig. (2-tailed) .201 .000 . N 45 45 45 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is Significant at the 0.01 level (2-tailed). 170 Table 18. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in Prepubescent (n=48) and Pubescent (n=1 4) Children S-HT AWK ANX/D‘fi‘ repubescent S-HT Pear 1.000 -.059 -.151 Sig. (2-t) . .689 .307 N 48 48 48 ATTACK Pear -.059 1.000 .764 Sig. (2-t) .689 . .000 N 48 48 48 ANX/DEP Pear -.151 .764 1.000 Sig. (2-t) .307 .000 . N 48 48 48 Pubescent S-HT Pear 1 .000 -.631 -.565 Sig. (2-t) . .015 .035 N 14 14 14 ATTACK Pear -.631 1.000 .627 Sig. (2-t) .015 . .016 N 14 14 14 ANX/DEP Pear -.565 .627 1.000 Sig. (2-t) .035 .016 . N 14 14 14 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is Significant at the 0.05 level (2-tailed). 171 Table 19. Correlations Between Child Whole Blood S-HT, Attack, and Anxious/Depressed in Prepubescent and Pubescent Boys and Girls PUB GDR S-I-IT_ ATTACK ANX/DEP Prepubescent Female S-HT ITearson 1.000 3260 -.156 Sig. (2-tailed) . .414 .628 N 12 12 12 ATTACK Pearson -.260 1.000 .739 Sig. (2-tai1ed) .414 . .006 N 12 12 12 ANX/DEP Pearson -.156 .739 1.000 Sig. (2-tailed) .628 .006 . N 12 12 12 Male S-HT Pearson 1.000 -.082 -. 161 Sig. (2-tai1ed) . .634 .349 N 36 36 36 ATTACK Pearson -.082 1.000 .777 Sig. (2-tailed) .634 . .000 N 36 36 36 ANX/DEP Pearson -.l61 .777 1.000 Sig. (2-tailed) .349 .000 . N 36 36 36 Pubescent Female 5-HT Pearson 1.000 -.878 -.795 Sig. (2-tailed) . .050 .108 N 5 5 5 ATTACK Pearson -.878 1.000 .893 Sig. (2-tailed) .050 . .041 N 5 S 5 ANX/DEP Pearson -.795 .893 1.000 Sig. (2-tailed) .108 .041 . N 5 5 5 Male S-HT Pearson 1 .000 -.607 -.542 Sig. (2-tailed) . .083 .131 N 9 9 9 ATTACK Pearson -.607 1.000 .533 Sig. (2-tailed) .083 . .140 N 9 9 9 ANX/DEP Pearson -.542 .533 1.000 Sig. (2-tailed) .131 .140 . N 9 9 9 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed). 172 Table 20. Correlations Between Child Whole Blood S-HT, Attack, and Anxious/Depressed in LSC (n=9) and HSC (n=53) Children oc Cmp S-HT AfiACK ANX/DEP ow S-HT Pearson I .000 -.526 -.476 Sig. (2-tailed) . .146 .196 N 9 9 9 ATTACK Pearson -.526 1.000 .488 Sig. (2-tailed) .146 . .182 N 9 9 9 ANX/DEP Pearson -.476 .488 1.000 Sig. (2-tai1ed) .196 .182 . N 9 9 9 High 5-HT Pearson 1.000 -.128 -. 140 Sig. (2-tailed) . .360 .318 N 53 53 53 ATTACK Pearson -.l28 1.000 .790 Sig. (2-tailed) .360 . .000 N 53 53 53 ANX/DEP Pearson -.l40 .790 1.000 Sig. (2-tailed) .318 .000 . N 53 53 53 **. Correlation is significant at the 0.01 level (2-tailed). 173 Table 2]. Correlations Between Child Whole Blood 5-HT, Attack, and Anxious/Depressed in LSC and HSC Boys and Girls Soc Cmp GDR S-HT_ ATTACK ANX/DEP ow Fem S-HT War 1 .000 -1 .000 -1 .00 Sig. (2-t) . . . N 2 2 2 ATTACK Pear -1.000 1.000 1.000 Sig. (2-t) . . . N 2 2 2 ANX/DEP Pear -1.000 1.000 1.000 Sig. (2-t) . . . N 2 2 2 Male 5-HT Pear 1.000 -.774 -.580 Sig. (2-t) . .041 .172 N 7 7 7 ATTACK Pear -.774 1.000 .432 Sig. (2-t) .041 . .333 N 7 7 7 ANX/DEP Pear -.580 .432 1.000 Sig. (2-t) .172 .333 . N 7 7 7 High F em S-HT Pear 1.000 -.517 -.368 Sig. (2-t) . .049 .177 N 15 15 15 ATTACK Pear -.517 1.000 .776 Sig. (2-t) .049 . .001 N 15 15 15 ANX/DEP Pear -.368 .776 1.000 Sig. (2-t) .177 .001 . N 15 15 15 Male 5-HT Pear 1.000 -.092 -.094 Sig. (2-t) . .581 .574 N 38 38 38 ATTACK Pear -.092 1.000 .807 Sig. (2-t) .581 . .000 N 38 38 38 ANX/DEP Pear -.094 .807 1.000 Sig. (2-t) .574 .000 . N 38 38 38 **. Correlation is significant at the 0.01 level (2—tailed). *. 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D8< www. ooo. 8 o o 8om. 8oo. 8X08). mom. 0 8 w. a a mem- 8oo. 8X00 mNN. Sc. 0 o voN. am 8. 38884882 88mm. 88mm. Dm 8.8.88. n88< Um 8.88 88".; 828.20 08.. 8888818 088 8. 88882889882858 888 8.8888. 8.8.0 .888. 888 8.8.8 88.8. 8.9.3 8.8.8 .88.88..8> 8.8 888.588. 8888.850 .88 8.888 214 mm mm . ooo. .8.-8.< ooo.8 oo8. mm mm ooo. . D8< oo8. ooo.8 mm mm ooo. ooo. 8X02 oNo. omo. om om ooo. 8oo. 8X00 @88. wow. mm mm 8m 8. m 5. 8>88 o8N. Nmm. mm mm 88w. 8Nm. _>88 8888. 8 mN. ov 088 wwo. 8 88. 84 0 04 o o o o o E < " . . . . 0 100 200 300 400 FIVEHT Figure 8. Whole Blood 5-HT and Attack in Pubescent Children (n=14) 222 10 8 o 6 o O O O 4 a. o O 2 . O O 0 ES 0 o 0 <2: -2 . . , 0 100 200 300 400 FIVEHT Figure 9. Whole Blood 5-HT and Anxious/Depressed in Pubescent Children (n=14) 6- 54 o 4. 3 o 2 o o o 1 o 0 :£ U 04 o o E- < " . . . . 0 100 200 300 400 FIVEHT Figure 10. Whole Blood 5-HT and Attack in Pubescent Boys (n=9) 223 ANX/DEP O o 0 1710 200 300 400 FIVEHT Figure 11. Whole Blood 5-HT and Anxious/Depressed in Pubescent Boys (n=9) 3 . 2 -| o 2 . 1 . 1 . :4 U 0 o o o E < -1 140 160 ISO 200 220 240 260 280 300 FIVEHT Figure 12. Whole Blood 5-HT and Attack in Pubescent Girls (n=5) 224 10 4-1 . 01 O ANX/DEP -2 140 160 180 200 220 240 260 280 300 F IVEHT Figure 13-Whole Blood 5-HT and Anxious/Depressed in Pubescent Girls (n=5) 67 ATTACK -1 100 200 300 400 FIVEHT Figure 14. Whole Blood 5-HT and Attack in LSC Children (n=9) 225 0« o o -2 100 200 300 400 ANX/DEP F IVEHT Figure 15. Whole Blood 5-HT and Anxious/Depressed in LSC Children (n=9) 6- 5 o 4. 34 o o 2 o l 0 >4 0 0 o o E < '1 , fi 100 200 300 400 F IVEHT Figure 16. Whole Blood 5-HT and Attack in LSC Boys (n=7) 226 I‘P“ - 16 I44 0« o o ANX/DEP -2 .. 100 200 300 400 y F IVEHT Figure 15. Whole Blood 5-HT and Anxious/Depressed in LSC Children (n=9) 6. ATTACK -1 100 200 300 Km F lVEHT Figure 16. Whole Blood 5-HT and Attack in LSC Boys (n=7) 226 I6 144 l2- lO~ ()4 g .2 100 200 300 400 ANX/DEP FIVEHT Figure 17. Whole Blood 5-HT and Anxious/Depressed in LSC Boys (n=7) 31 2% oo. o 2. l4 0 o 14 >4 0 U o o. o o o o o E‘: < -l 140 I60 180 200 220 240 260 280 300 FIVEHT Figure 18. Whole Blood 5-HT and Attack in HSC Girls (n=15) 227 107 4i .0 ANX/DEP -2 140 160 180 200 220 240 260 280 300 FIVEHT Figure 19. Whole Blood 5-HT and Anxious/Depressed in HSC Girls (n=15) 300. 280 ~- 260 240. 2204 2001' 180. 160 I40 FIVEHT 120 . 30 40 50 oo 70 80 90 100 MVIOL Figure 20. Maternal Violence and Whole Blood 5-HT in Girls (n = 7) 228 400 o ' . o o 3004 o o o o o o o 0 o o 2 o 200i 0 : ' 8 3 o o o E g1 2 a 100 . . f 1 20 40 60 80 100 DVIOL Figure 21. Paternal Violence and Whole Blood S-HT in Prepub Children (n=36) 400. C 3001 O C C 200. 3 C C O 100. ' C p. I LL] E: u“ 0 r r r v 1 20 40 60 80 100 120 DVIOL Figure 22. Paternal Violence & S-HT in Pubescent Children (n = 11) 229 400 3004 200 i o FIVEHT 100 30 40 50 60 70 80 90 100 MVIOL Figure 23. Maternal Violence and Child Whole Blood S-HT in LSC Children (11 = 7) 400- O O 300 . 200. 3 O O E— E Z 0 m 100 I I V *1 20 40 60 80 100 DVIOL Figure 24. Paternal Violence and 5-HT in LSC Children (n=7) 230 400 . o O 300. 200 . ' . O O p. :1: O L; o a 100 f . -2 1 0 1 2 3 4 MQXF Figure 25 . Maternal Alcohol Consumption & 5-HT in LSC Children (n=9) l04 o 3t 64 o 44 Q Q 2 o o o o o 5 0 o o o o E < -2 30 4O 50 60 70 80 90 100 llO MVIOL Figure 26. Maternal Violence and Attack in Full Sample of Children (N=46) 231 20 o o 104 o o o o o o o o o o o 0 o o o m g E -10 30 4O 50 60 70 80 90 100 110 MVIOL Figure 27. Maternal Violence and Anx/Dep in Full Sample of Children (n=46) m. & A O O o o o 24 no a. 0 an on on o oo. 00 o 5 0 no o «a» 00 up an E < 4 30 40 50 60 70 80 90 DGAF Figure 28. Paternal Functioning and Attack in Full Sample of Children (N = 60) 232 20 o o o 10~ on o o o o .oo. 000 no... 0 o. .oo. o .00 co co 0-« o o u no a. ml 3 an , 30 40 50 60 70 80 90 DGAF Figure 29. Paternal Functioning and Anx/Dep in Full Sample of Children (N = 60) 10. o 3. 64 o 4 o oo o o o 2 one... o o .oo.. .00 50 o ”announce < 5.2 , , C, , 1 30 40 50 60 70 80 90 MGAF Figure 30. Maternal Functioning and Attack in Full Sample of Children (N = 62) 233 10« o 8. 6. o 4 oo o o o o 2« o. 000 o oo.. o o o «no 0 o oo. 0 i4) 0« o .oo.... oo o oo o o o .< 10 20 30 40 50 60 MNEUROT Figure 31. Maternal Neuroticism and Attack in Full Sample of Children (n=62) 10. o 3. 64 o 44 ID 0 oo o 24 oo.- o .o. L: 0 .oo. E -2 . - . - 4 0 l 2 3 4 5 6 DQXF Figure 32. Paternal Alcohol Consumption and Attack in Full Sample (N = 59) 234 “I 10 O 8. 6. 0 4~ 0 o o O O O 2 « .0 O O O O C 0 E4) 0 a. o 0 <1: E -2 . -2 0 2 4 6 8 MQXF Figure 33. Maternal Alcohol Consumption & Attack in Full Sample of Children (N = 62) 10. O 8. 6. O 4- o o 2 o o o O 6 0 o o o o < 30 4'0 5'0 60 70 80 90 100 1 io MVIOL Figure 34. Maternal Violence and Attack in Boys (n=39) 235 20 O O 10. O O O O O O O O 0 o : . o O. ”E 3‘: 40 . . , 30 40 50 oo 70 8'0 90 100 710 MVIOL Graph 35. Maternal Violence and Anx/Dep in Boys (n=39) 10. O 8. 6. O 4 o o O O O 2 co on o no 00 O O O O O. 0 E4) 0 o. 00 o o o. 000 E <1 '2 . . . . 30 40 50 60 70 8'0 90 DGAF Figure 36. Paternal Functioning and Attack in Boys (n=44) 236 lO o 8. 6. o 4 o o o o o o 2 o .0 o o a». o o o o o. Efi 0 o 0 110010 to 0.01! .< E. . , - .-. 30 40 50 60 70 80 90 thU\F Figure 37. Maternal Functioning and Attack in Boys (n=45) 10. 8i 0 o o 2. o. oo o oo.. o o o o o o co 0~ o o .oo.. oo o oo o o AJWVMCK. -2 10 2'0 30 40 50 60 MNEUROT Figure 38. Maternal Neuroticism and Attack in Boys (n=45) 237 3 2 o o 2. l o l. =4 0. U 0 E < " . 20 30 40 50 60 70 8O 90 100 DVIOL Figure 39. Paternal Violence and Attack in Girls (n=7) 8 _ o 6 . o 4 o 2 . o a. 0 . o g E -2 20 30 40 50 60 70 80 90 100 DVIOL Figure 40. Paternal Violence and Anxious/Depressed in Girls (n=7) 238 2. o o o 2 l 4 Q Q 1 . 5 04 O O 00 E < " . . . . -1 0 1 2 3 4 3 DQXF Figure 41. Paternal Alcohol Consumption and Attack in Girls (n=15) 10. 8 o O 6- o O O 4 o o 2 o O. O 0 g 04 o o 32 -2 , -1 0 1 2 3 4 5 DQXF Figure 42. Paternal Alcohol Consumption and Anxious/Depressed in Girls (n=15) 239 to 1 ATTACK MQXF Figure 43. Maternal Alcohol Consumption and Attack in Girls (n = 17) 10. 8 o o o 6- o o o 4 o o 2 o o o o g 0 o o o .2: -2 2 -l 0 l 2 3 4 5 MQXF Figure 44. Maternal Alcohol Consumption and Anxious/Depressed in Girls (n=17) 240 O 8. 6 . 4. Q Q 2 o o O O :4 U 0 o o o o E < -2 , , . . . - . . . 30 40 50 60 70 80 90 100 1 10 MVIOL Figure 45. Maternal Violence and Attack in Prepubescent Children (n=3 5) 20- O O 10. O O O O O O O O O 0 o o D- m D 2 .2: -10 . . . . 1 . , 30 40 50 60 70 80 90 100 1 10 MVIOL Figure 46. Maternal Violence and Anxious/Depressed in Prepubescent Children (n=3 5) 241 o 8. 6. 4 o oo o o 2 0 00000 0 o oo.. oo. 50 o noooouoooo E <-2 30 40 50 60 70 80 90 MGAF Figure 47. Maternal Functioning and Attack in Prepubescent Children (n=47) 10. o 8. 6. 4 oo o o 24 one“... .00 oo.. o 50 “one... 000 E a: -2 30 40 50 6O 70 80 90 DGAF Figure 48. Paternal Functioning and Attack in Prepubescent Children (n = 46) 242 O 3. 6. 4~ o o o O O 2. o. oo. o oo o o O O O O O O. 0 E4) 0. o. oo.... .oo. o < E -2 , . 10 2’0 30 40 5'0 710 MNEUROT Figure 49. Maternal Neuroticism and Attack in Prepubescent Children (n=48) 10- O 3. 6. 44 o o O O 2. O O O - O O. 0 (>5 0. .Q a < E -2 . -1 0 1 2 3 4 E 6 DQXF Figure 50. Paternal Alcohol Consumption and Attack in Prepubescent Children (n=46) 243 o 8. 6. 44 o o o o o 2. oo. o o o o o :4 . U 0 -0 o E < '2 . . . . -2 0 2 4 6 8 MQXF Figure 51. Maternal Alcohol Consumption and Attack in Prepubescent Children (n=48) 67 5 o 4. 3i O 2 o o o o 1. :4 U 0 o o o E < '1 . 4 6 8 IO 12 l4 16 18 DAl Figure 52. Paternal Irritable Assault and Attack in Pubescent Children (n=10) 244 2-1 . 04 Q ANX/DEP -2 30 411 5'0 610 7'0 80 DGAF Figure 53. Paternal Functioning and Anx/Dep in LSC Children (n=9) 16. O 14. 12. 1 | 10. 01 O O ANX/DEP -2 30 40 5‘0 6'0 70 8‘0 9'0 MGAF Figure 54. Maternal Functioning and Anx/Dep in LSC Children (n=9) 245 10. 6. ANX/DEP E’ o MHRSD Figure 55. Maternal HRSD and Anx/Dep in LSC Children (n=9) 16. o 14. 12. 10. 8. 6- o 4 o o 2 o :3. LL] E . . E -2 -l 0 I 2 3 4 DQXF Figure 56. Paternal Alcohol Consumption and Anx/Dep in LSC Children (n=9) 246 l6 o 14. 12. 10. 81 64 0 4~ 0 o o 2- o n. LL] g 0] o o E -2 -2 -l 0 1 2 3 4 MQXF Figure 57. Maternal Alcohol Consumption and Anx/Dep in LSC Children (n=9) 6. 51 o 4. 3 o o 2 0 14 Q Q >4 0 0 o o E < 'l , 0 2 4 6 8 10 12 14 16 18 DAI Figure 58. Paternal Irritable Assault and Attack (11 = 8) 247 10- o 8. 6‘1 4. Q Q 2 o o o >4 0 L) o o o o E .< -2 30 40 50 60 70 80 90 ICC 110 MVIOL Figure 59. Maternal Violence and Attack in HSC Children (n=39) 10. o 8. 6. 4« o o o 24 o. oo o oo. no 00 o o o oo o 5 04 oo o oo o o 00 000 E .< -2 40 50 60 70 80 90 DGAF Figure 60. Paternal Functioning and Attack in HSC Children (n=51) 248 54 Q 4. 3. o o 2 o 1 o 0 >4 U 0 o. o E < -1 30 4O 50 60 70 80 90 MGAF Figure 61. Maternal Functioning and Attack in HSC Children (n=53) 101 o 8. 6. 4 oo o o 24 00 00000000 0 o o o o o o o 1&4) 0. oo oo.... oo.. o < E -2 . , , , - IO 20 30 40 50 60 MNEUROT Figure 62. Maternal Neuroticism and Attack in HSC Children (n=53) 249 10 o 8. 6. 4 o o o 2« oo. o. o no 0 >4 . U 0 ... E < -2 -l 0 I 2 3 4 5 6 DQXF Figure 63. Paternal Alcohol Consumption and Attack in HSC Children (n=50) 10- o 3. 6. 4 o o o o 2 no 0 o o 0 >4 . U 0 c.- o E < '2 . . . . . -2 0 2 4 6 8 MQXF Figure 64. Maternal Alcohol Consumption and Attack in HSC Children (11 = 53) 250 APPENDIX C 251 Q1. Q2. Q3. Q4. Q5. Q6. PARENT HEALTH HISTORY FORM BBS (8/95) Within the past 3 years, have you had a regular physician or a clinic you usually attend? I ............. YES 2 ............. NO [GO TO Q2] Do you remember the date of your last physical examination within the past 3 years? 1 ............. YES 2 ............. NO [GO TO Q3] / / (Month, day, year of last physical) What is your current height? ft. ins. What is your current weight? lbs. Have you been on a medication program for hyperactivity for a period of time, such as ritalin or other medication in the past year? 1 ............. YES 2 ............. NO [GO TO Q6] AGE STARTED: AGE ENDED: Have you been on a medication program for any other long term or chronic condition in the past year (such as asthma, cystic fibrosis, etc.)? 1 ............. YES 2 ............. NO [GO TO Q7] MEDICATION AGE STARTED TO AGE ENDED REASON (CONDITION) 252 The next set of questions deal with other medications you have taken in the past month. If you have taken the medication, write in the brand of medication taken, TOTAL number of days you have taken the medication in the past month (estimate, if necessary), and the reason(s) for taking them. Q7. Have you taken any pain or fever relievers (aspirin, Tylenol, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q8] MEDICATION DAYS REASON (ILLNESS/CONDITION) Q8. Have you taken any cough medicine (Robitussin, Pediacare, T riaminic, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q9] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q9. Have you taken any decongestants/nasal spray (Sudafed, Dimetapp, Acttfed, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q10] MEDICATION DAYS REASON (IlLNESS/CONDIT ION) 253 Q10. Have you taken any Antihistamines (Chlortrimaton, Actifed, Benadryl, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q11] MEDICATION DA YS REASON (ILLNESS/CONDIT ION) Q11. Have you taken any multisympton cold remedies (Nyquil, Corididin, Cotylenol, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q12] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q12. Have you taken any antibiotics (Penicillin, Amoxicillin, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q13] MEDICATION DAYS REASON (ILLNESS/CONDITION) Q13. Have you taken any asthma medication in the past month? 1 ............. YES 2 ............. NO [GO TO Q14] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) 254 Q14. Have you taken any allergy medication in the past month? 1 ............. YES 2 ............. NO [GO TO Q15] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q15. Have you taken any vitamins/dietary supplements in the past month? 1 ............. YES 2 ............. NO [GO TO Q16] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q16. Have you taken any neuroleptic medications (Thorazine, Mellaril, Stelazine, Prolixin, Haldol, Clozaril, Risperidol, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q17] MEDICATION DAYS REASON (ILLNESS/CONDITION) Q17. Have you taken any tricyclic antidepressants (Prozac, Zoloft, Desyrel, Efiexor, etc) in the past month? 1 ............. YES 2 ............. NO [GO TO Q18] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) 255 Q18. Have you taken any monoamine oxidase inhibitors (Nardil, Parnate, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q19] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q19. Have you taken lithium in the past month? 1 ............. YES 2 ............. NO [GO TO Q20] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q20. Have you taken any anticonvulsant medication (Depacote, Tegretol, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q21] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) Q21. Have you taken any anti-anxiety medication (Buspar, Valium, Librium, Dalmane, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q22] MEDICATION DAYS REASON (ILLNESS/CONDITION) 256 Q22. Have you taken any stimulant medication (Ritalin, Cylert, Dexedrine, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q23] MEDICATION DAYS REASON (IlLNESS/CONDIT ION) Q23. Have you taken any anti-hypertensive medication (Inderal, Catapres, Tenex, etc.) in the past month? 1 ............. YES 2 ............. NO [GO TO Q24] MEDICATION DAYS REASON (ILLNESS/CONDITION) Q24. Have you taken any other medications in the past month? 1 ............. YES 2 ............. NO [GO TO 25] MEDICATION DAYS REASON (ILLNESS/CONDIT ION) 257 Q25. Have you been hospitalized W? 1 ............. YES 2 ............. NO [GO TO 26] AGE 1N.. REASON: OPERATION OR ILLNESS # OF DAYS a. b. Q26. Have you been in an accident resulting in injury serious enough to require immediate medical treatment (e. g., broken bones, concussion, stitches, bums, poisonings/accidental ingestion, etc.) in the past 3 years? 1 ............. YES 2 ............. No [GO TO Q27] AGE 1N.. REASON: INJURY OR ACCIDENT # OF DAYS a. b. Cigarette Use Q27. Have you ever smoked cigarettes? _ Never _ Once or twice _ Occasionally, but not regularly _ Regularly in the past _ Regularly now 258 Q28. Q29. Q30. Over the past 4 weeks, on average how many days did you smoke cigarettes? _ days Over the past 4 weeks, on days you did smoke, how many cigarettes did you usually smoke? _ cigarettes When was the last time you smoked any cigarettes? date of last cigarette or number of days since last cigarette YOUR RECENT ALCOHOL USE 31. 32. 33. 34. 35. 36. Over the past 4 weeks, on the average, how many days a week did you have a drink? _ days a week Over the past 4 weeks, on a day when you did drink, how many drinks did you usually have in 24 hours? (One drink is a 12 oz. can of beer, a 4 oz. glass of wine, or a single shot of 80 proof) _ drinks per 24 hours Over the past 4 weeks what is the most number of days per week you had a drink? days Over the past 4 weeks, what is the most number of drinks you've had in 24 hours? _ drinks Over the past 4 weeks, how long was the longest period you were abstinent (went without drinking)? _ days When was that? (date) to (date) Were your drinking patterns over the last 4 weeks fairly typical for you? _No, it was less than usual _Yes, it was fairly typical _No, it was more than usual 259 YOUR m5 RECENT ALCOHOL USE 37. 38. 39. 40. 41. 42. Over the past 4 weeks, on the average, how many days a week did your spouse have a drink? _ days a week Over the past 4 weeks, on a day when you spouse drank, how many drinks did he/she usually have in 24 hours? (One drink is a 12 oz. can of beer, a 4 oz. glass of wine, or a single shot of 80 proof) _ drinks per 24 hours Over the past 4 weeks what is the most number of days per week your spouse had a drink? _ drinks Over the past 4 weeks, what is the most number of drinks your spouse had in 24 hours? _ drinks Over the past 4 weeks, how long was the longest period your spouse was abstinent (went without drinking)? _ days When was that? (date) to (date) Were your spouse's drinking patterns over the last 4 weeks fairly typical for him/her? _No, it was less than usual _Yes, it was fairly typical _No, it was more than usual 260 LIST OF REFERENCES 261 LIST OF REFERENCES Abramson, R. K., Wright, H. H., Carpenter, R., Brennan, W., Lumpuy, 0., Cole, E., & Young, S. R. (1989). 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