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  • Limbic Intrinsic Connectivity in Depressed and High-Risk Youth
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-08-16
    Manpreet K. Singh, Sara M. Leslie, Mary M. Packer, Elizabeth F. Weisman, Ian H. Gotlib

    ObjectiveDepression runs in families and has been associated with dysfunctional limbic connectivity. Whether aberrant limbic connectivity is a risk factor for or a consequence of depression is unclear. To examine this question, we compared resting state functional connectivity (RSFC) in youth with depressive disorders (DEP), healthy offspring of parents with depression (DEP-risk), and healthy comparison (HC) youth.MethodMagnetic resonance imaging at rest was acquired from 119 youth, ages 8-17 years (DEP, n=41, DEP-risk, n=39, and HC, n=39) and analyzed using seed-based RSFC in bilateral amygdala and nucleus accumbens (NAcc), covarying for age, IQ, and sex.ResultsWe found distinct risk- and disorder-specific patterns of RSFC across groups. DEP-risk and DEP youth shared reduced negative amygdala-right frontal cortex RSFC and reduced positive amygdala-lingual gyrus RSFC compared to HC youth (p<0.001). DEP-risk youth had weaker negative amygdala-precuneus RSFC compared to DEP and HC youth (p<0.001), suggesting a resilience marker for depression. In contrast, DEP youth had increased positive NAcc-left frontal cortex RSFC and reduced positive NAcc-insula RSFC compared to DEP-risk and HC youth (p<0.001), suggestive of disorder-specific features of depression. Greater depression severity was correlated with disorder-specific amygdala and NAcc RSFC (p<0.05).ConclusionRSFC in the amygdala and NAcc may represent selective disorder- and risk-specific markers in youth with, and at familial risk for, depression. Longitudinal studies are needed to determine whether these patterns predict long-term clinical outcomes.

  • Modifying the Impact of Eveningness Chronotype (‘Night-Owls’) in Youth: A Randomized Controlled Trial
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-08-15
    Allison G. Harvey, Kerrie Hein, Michael Dolsen, Lu Dong, Sophia Rabe-Hesketh, Nicole B. Gumport, Jennifer Kanady, James K. Wyatt, Stephen P. Hinshaw, Jennifer S. Silk, Rita L. Smith, Monique A. Thompson, Nancee Zannone, Daniel Jin Blum

    Objective To determine whether an intervention to reduce eveningness chronotype improves sleep, circadian, and health (emotional, cognitive, behavioral, social, physical) outcomes. Method Youth aged 10 to 18 with an evening chronotype and who were ‘at risk’ in one of five health domains were randomized to: (a) Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C; n=89) or (b) Psychoeducation (PE; n=87) at a university-based clinic. Treatments were 6 individual, weekly 50-minute sessions during the school year. TranS-C addresses sleep and circadian problems experienced by youth by integrating evidence-based treatments derived from basic research. PE provides education on the inter-relationship between sleep, stress, diet, and health. Results Relative to PE, TranS-C was not associated with greater pre-post change for total sleep time (TST) or bed time (BT) on weeknights but was associate with greater reduction in evening circadian preference (pre-post increase of 3.89 points, 95% CI: 2.94 to 4.85, for TranS-C and 2.01 points, 95% CI: 1.05 to 2.97 for PE, p = 0.006), earlier endogenous circadian phase, less weeknight-weekend discrepancy in TST and wakeup time, less daytime sleepiness, and better self-reported sleep via youth and parent report. In terms of functioning in the five health domains, relative to PE, TranS-C was not associated with greater pre-post change on the primary outcome. However, there were significant interactions favoring TranS-C on the Parent-Reported Composite Risk Scores for cognitive health. Conclusion For at-risk youth, the evidence supports the use of TranS-C over PE for improving sleep and circadian functioning, and improving health on selected outcomes Clinical Trial Registration. Teen Sleep Clinicaltrials entry: IDS: NCT01828320 and/or Unique Protocol ID: R01 HD071065-01A1. URL: https://clinicaltrials.gov/show/NCT01828320

  • Atypical Functional Connectivity of Amygdala Related to Reduced Symptom Severity in Children with Autism
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-08-07
    Inna Fishman, Annika C. Linke, Janice Hau, Ruth A. Carper, Ralph-Axel Müller

    ObjectiveConverging evidence indicates that brain abnormalities in autism spectrum disorders (ASDs) involve atypical network connectivity. Given the central role of social deficits in the ASD phenotype, this investigation examined functional connectivity of the amygdala – a brain structure critically involved in processing of social information – in children and adolescents with ASDs, as well as age-dependent changes and links with clinical symptoms.MethodResting-state functional magnetic resonance imaging (rs-fMRI) data from 55 participants with ASDs and 50 typically developing (TD) controls, ages 7-17 years, were included. Groups were matched for age, gender, IQ, and head motion. Functional connectivity MRI (fcMRI) analysis was applied to examine intrinsic functional connectivity (iFC) of the amygdala, including cross-sectional tests of age-related changes.ResultsDirect between-group comparisons revealed reduced functional connectivity between bilateral amygdalae and left inferior occipital cortex, accompanied by greater connectivity between right amygdala and right sensorimotor cortex in the ASD group. This atypical pattern of amygdala connectivity was associated with decreased symptom severity and better overall functioning, as specifically seen in an ASD subgroup with the most atypical amygdala iFC but least impaired social functioning. Age-related strengthening of amygdala-prefrontal connectivity, as observed in the TD group, was not detected in children with ASDs.ConclusionFindings support aberrant network sculpting in ASDs, specifically atypical integration between amygdala and primary sensorimotor circuits. Paradoxical links between atypical iFC and behavioral measures suggest that abnormal amygdala functional connections may be compensatory in some individuals with ASDs.

  • A Risk Calculator to Predict the Individual Risk of Conversion From Subthreshold Bipolar Symptoms to Bipolar Disorder I or II in Youth
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-08-07
    Boris Birmaher, John A. Merranko, Tina R. Goldstein, Mary Kay Gill, Benjamin I. Goldstein, Heather Hower, Shirley Yen, Danella Hafeman, Michael Strober, Rasim S. Diler, David Axelson, Neal D. Ryan, Martin B. Keller

    ObjectiveYouth with subthreshold mania are at elevated risk of conversion to bipolar disorder (BP) I/II. Predictors for conversion have been published for the group as a whole. However, risk factors are heterogeneous, indicating the need for personalized risk assessment.Method140 BP Not-Otherwise-Specified (BP-NOS) youths (6-17 years old) followed through the Course and Outcome of Bipolar Youth (COBY) study with at least one follow-up assessment prior to conversion to BP-I/II were included. Youths were assessed on average every 7 months for a median of 11.5 years using standard instruments. Risk predictors reported in the literature were utilized to build a 5-year risk calculator. Discrimination was measured using the time-dependent area under the curve (AUC) after 1000 bootstrap resamples. Calibration was evaluated comparing observed vs. predicted probability of conversion. External validation was performed using an independent sample of 58 BP-NOS youths recruited from the Pittsburgh Bipolar Offspring Study.ResultsSeventy-five (53.6%) COBY BP-NOS youths converted to BP-I/II, of which 57 (76.0%) converted within 5 years. Earlier-onset BP-NOS, familial hypomania/mania, and high mania, anxiety, and mood lability symptoms were important predictors of conversion. The calculator showed excellent consistency between the predicted/observed risks of conversion, good discrimination between converters/non-converters (AUC: 0.71, CI: 0.67-0.74), and a proportionally increasing rate of converters at each successive risk class. Discrimination in the external validation sample was good (AUC: 0.75).ConclusionIf replicated, the risk calculator provides a useful tool to predict personalized risk of conversion from subsyndromal mania to BP-I/II and inform individualized interventions and research.

  • Two-Year Follow-up of Internet and Telephone Assisted Parent Training for Disruptive Behavior at Age 4
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-08-03
    Andre Sourander, Patrick J. McGrath, Terja Ristkari, Charles Cunningham, Jukka Huttunen, Susanna Hinkka-Yli-Salomäki, Marjo Kurki, Patricia Lingley-Pottie

    Objective To determine whether an internet-based and telephone-assisted parent training intervention, which used whole population screening and which comprehensively targeted symptomatic 4-year-old children, was effective 24 months after the start of treatment. No long-term follow-up studies using a randomized controlled trial (RCT) existed on this subject. Method Of the 4,656 children 4 years old who were screened in Southwest Finland, 730 met the criteria for high-level disruptive behavioral problems, and 464 parents agreed to be randomized to the 11-week Strongest Families Smart Website (SFSW) intervention (n = 232) or an educational control (EC) (n = 232). After 24 months, 163 SFSW parents (70%) and 165 EC parents (71%) were still participating. Results When we compared the results at baseline and 24 months, the primary outcome of the Child Behavior Check List (CBCL) externalizing score showed significantly higher improvements in the SFSW group (effect size 0.22; p < 0.001). This group also showed greater improvements in the secondary outcomes: the CBCL total and internalizing scales, 5 of the 7 CBCL symptom domains, 3 of the 5 DSM subscores, and self-reported parenting skills. Fewer SFSW children (17.5%) than EC children (28.0%) had been referred to child mental health services between baseline and 24 months (odds ratio = 1.8; 95% confidence interval = 1.1−3.1). Conclusion The SFSW internet-based and telephone-assisted parental training program was effective 24 months after initiation, underlining the value of identifying children at risk in the community early and providing evidence-based parent training for a large number of families. Clinical trial registration information—Strongest Families Finland Canada Family-based Prevention and Treatment Program of Early Childhood Disruptive Behavior (Fin-Can). https://clinicaltrials.gov/ct2/show/NCT01750996; NCT01750996.

  • A Meta-Analysis of Maternal Prenatal Depression and Anxiety on Child Socio-Emotional Development
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-07-20
    Sheri Madigan, Hannah Oatley, Nicole Racine, R.M. Pasco Fearon, Lea Schumacher, Emis Akbari, Jessica Cooke, George M. Tarabulsy

    Objective Observed associations between maternal prenatal stress and children’s socio-emotional development have varied widely in the literature. The objective of the current study was to provide a synthesis of studies examining maternal prenatal anxiety and depression and the socio-emotional development of their children. Method Eligible studies through to February 2018 were identified utilizing a comprehensive search strategy. Included studies examined the association between maternal prenatal depression or anxiety and the future development of their children’s socio-emotional development (e.g., difficult temperament, behavioral dysregulation) up to 18 years later. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean effect sizes and test for potential moderators. Results 91 effect sizes from 71 studies met full inclusion criteria for data analysis. The weighted average effect size for the association between prenatal stress and child socio-emotional problems was OR = 1.66 (95% CI = 1.54-1.79). Effect sizes were stronger for depression (OR = 1.79; 95% CI = 1.61-1.99) compared to anxiety (OR = 1.50; 95% CI = 1.36-1.64). Moderator analyses indicated that effect sizes were stronger when depression was more severe and when socio-demographic risk was heightened. Conclusion Findings suggest that maternal prenatal stress is associated with offspring socio-emotional development, with the effect size for prenatal depression being more robust than anxiety. Mitigating stress and mental health difficulties in mothers during pregnancy may be an effective strategy for reducing offspring behavioural difficulties, especially in groups with social disadvantage and greater severity of mental health difficulties.

  • Evidence for Depressogenic Spontaneous Thoughts and Altered Resting-State Connectivity in Adolescents With a Maltreatment History
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-07-21
    Ferdinand Hoffmann, Essi Viding, Vanessa B. Puetz, Mattia I. Gerin, Arjun Sethi, Georgia Rankin, Eamon J. McCrory

    Objective Childhood maltreatment has been associated with major depressive disorder (MDD). Atypical self-generated thoughts (SGT), lacking in positive and privileging negative content - a feature of ruminative thinking - might represent one vulnerability factor for developing depression. Rumination in MDD has been linked to alterations in resting-state functional connectivity (RSFC) of the subgenual anterior cingulate cortex (sgACC) to the default mode network and the fronto-parietal network (FPN). This study aimed to investigate online SGT content and its variability, as well as sgACC RSFC, as potential risk markers for depression in adolescents who experienced maltreatment. Method 12-16 year-old adolescents (29 with maltreatment history [MT] and 39 with no maltreatment history [NMT]) performed an established mind-wandering task. Participants made non-demanding number discriminations during which intermittent questions probed their SGTs that were classified as: off-task, positive, negative, self-related, other-related, past-oriented, or future-oriented. Resting-state data were acquired separately for 22/29 MT and 27/39 NMT adolescents and seed-based functional connectivity analyses of the sgACC were performed. Results MT, relative to the NMT adolescents, generated significantly fewer positively-valenced thoughts, and exhibited more extreme ratings for positively-valenced thoughts. MT adolescents also showed significantly reduced RSFC between the sgACC and the FPN. Group differences in depressive symptoms between the MT and NMT adolescents were partly accounted by differences in sgACC-FPN RSFC. Conclusion Adolescents who experienced maltreatment show a reduction in positively-valenced spontaneous thoughts and reduced sgACC-FPN RSFC at the neural level. These may contribute to a ruminative thinking style, representing risk factors for developing depression later in life.

  • Reward-Related Attentional Bias at Age 16 Predicts Onset of Depression During Nine Years of Follow-Up
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-07-19
    Charlotte Vrijen, Catharina A. Hartman, Albertine J. Oldehinkel

    ObjectiveWe investigated whether low reward responsiveness marks a vulnerability for developing depression in a large cohort of never-depressed 16-year-old adolescents who completed a reward task and were subsequently followed for a period of nine years during which onset of depression was assessed.MethodData were collected as part of the Tracking Adolescents’ Individual Lives Survey (TRAILS), an ongoing prospective cohort study. Reward responsiveness was assessed by the Spatial Orienting Task at age 16 and depression was assessed at age 19 by the World Health Organization Composite International Diagnostic Interview (CIDI) and at age 25 by the Lifetime Depression Assessment Self-report (LIDAS). Participants who completed the reward task at age 16, had no previous onset of depression, and were assessed on onset of depression at age 19 and/or age 25 were included in the present study (n=531; 81 became depressed during follow-up).ResultsDifficulties in shifting attention from expected non-reward to expected reward and from expected punishment to expected non-punishment at age 16 predicted depression during follow-up. This was only found at an automatic level of information processing.ConclusionOur findings suggest that reduced reward responsiveness at age 16 marks a vulnerability for depression. Prevention programs may aim at enhancing at risk adolescents’ responsiveness to cues for potential rewards, particularly in situations in which they are focused on negative experiences.

  • Do Parental Psychiatric Symptoms Predict Outcome in Children With Psychiatric Disorders? A Naturalistic Clinical Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-07-17
    Laura W. Wesseldijk, Gwen C. Dieleman, Francisa J.A. van Steensel, Ellen J. Bleijenberg, Meike Bartels, Susan M. Bögels, Christel M. Middeldorp

    Objective Parental psychiatric symptoms may negatively affect the outcome of children’s psychopathology. Studies have so far mainly showed a negative effect of maternal depression. We studied the associations between a broad range of psychiatric symptoms in mothers as well as fathers with child’s outcome. Method Internalizing and externalizing psychiatric symptoms were assessed in 742 mothers, 440 fathers and their 811 children at the first evaluation in three child and adolescent psychiatric outpatient clinics, and at follow-up (on average 1.7 years later). We tested predictions of child’s symptoms scores at follow-up by parental symptoms scores at baseline, as well as by parental scores at follow-up and the child’s score at baseline. Results Children whose mother or father scored above the (sub)clinical threshold for psychiatric symptoms at baseline, had higher symptom scores at baseline and at follow-up. Offspring follow-up scores were most strongly predicted by offspring baseline scores, in addition to parental psychiatric symptoms at follow-up. Offspring symptom scores at follow-up were generally not predicted by parental scores at baseline. Mother and father associations were of similar magnitude. Conclusion The higher symptom scores at follow-up in children of parents with psychopathology were mainly explained by higher symptom scores at baseline. The continuing parent-offspring associations may be a result of reciprocal effects, i.e., parental symptoms influencing offspring symptoms as well as of offspring symptoms influencing parental symptoms. Still, the results show that these children are at risk for persisting symptoms, possibly indicating the need to treat mothers’ and fathers’ psychopathology.

  • Interaction Between Parenting Styles and Adrenarcheal Timing Associated With Affective Brain Function in Late Childhood
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-07-17
    Carolina Barbosa, Julian G. Simmons, Nandita Vijayakumar, Paul Dudgeon, George Patton, Lisa K. Mundy, Nicholas B. Allen, Sarah Whittle

    Objective Parenting and pubertal timing have consistently been associated with internalizing and externalizing symptoms in childhood and adolescence, and there is some evidence that the interaction between these factors may be important in conferring risk. However, few studies have investigated whether neurobiological factors mediate these relationships. The current study examined whether interactions between adrenarcheal timing and parenting styles were associated with affective brain function, and in turn mental health difficulties. Method Participants were 88 (46 females) healthy children (M age 9.42 years, SD=1.08), with 45 classified as relatively early and 43 as relatively late in adrenarcheal development based upon adrenal hormone levels. Participants completed an affective face functional magnetic resonance imaging (fMRI) task and parents reported on five parenting styles and on child internalizing and externalizing symptoms. Results Negative parenting styles (corporal punishment and poor monitoring) were associated with brain hemodynamic response while viewing affective faces in several subcortical and lateral prefrontal regions, and adrenarcheal timing and/or sex moderated most of these relationships. Sex differences in associations between ‘corporal punishment’ and brain activation to affective faces indicated that late females might show less adaptive affective neural function when more exposed to this parenting style. Conclusion Findings suggest that the interaction between parenting styles and adrenarcheal timing is associated with affective brain function in late childhood, with marked sex differences. Further longitudinal research with larger samples is needed to corroborate and expand upon these findings.

  • Sequential Screening to Improve Behavioral Health Needs Detection in Primary Care
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-06-22
    Nicholas D. Young, Christopher R. Takala

    Objective This study evaluates sequential screening to improve behavioral health needs detection, reduce unnecessary referrals, and discern adverse impacts (false negatives) for pediatric primary care populations. Method Monte Carlo simulation methodology was used to generate performance data for 6 sequential screening programs based on known technical properties of 3 broadband behavioral health measures and general psychopathology base rate estimates in pediatric primary care. Descriptive statistics, least squares power regression, and data visualization were used to compare performance across programs. Results Ratio of reduced referrals to false negatives was differentially impacted by measure choice, administration order, and technical properties. Certain screening programs performed best at lower base rates of psychopathology (approximately 12.8:1 ratio at 3% prevalence for SDQ-PSC [SDQ = Strengths and Difficulties Questionnaire, PSC = Pediatric Symptom Checklist] program), despite observed net sensitivity/specificity (.47/.97) that was comparable to other programs. Conclusion Sequential screening is a viable alternative to traditional single-measure behavioral health screening practices in primary care. However, stakeholders must be deliberate with instrument selection and implementation order to maximize anticipated benefits and minimize costs. Closer examination of practical issues is necessary to further discern advantages of a screening workflow in pediatric primary care.

  • Facial Emotion Recognition and Eye Gaze in ADHD With and Without Comorbid Conduct Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-06-19
    Jac N. Airdrie, Kate Langley, Anita Thapar, Stephanie H.M. van Goozen

    Objective Conduct disorder (CD) is associated with impairments in facial emotion recognition. However, CD commonly co-occurs with attention deficit hyperactivity disorder (ADHD); thus, it is unclear whether these impairments are explained by ADHD or by one of its core features - inattention. We explored whether emotion recognition impairments are specific to those with ADHD and comorbid CD while also examining the mechanisms that might explain such deficits. Method Sixty-three male and female adolescents with ADHD (mean age = 14.2 years, age range = 11–18 years) and with (ADHD+CD) or without comorbid CD (ADHD), and 41 typically developing controls (HC; mean age = 15.5, age range = 11–18 years) performed an emotion recognition task with concurrent eye-tracking. Results Participants with ADHD+CD were less accurate at recognising fear and neutral faces, and more likely to confuse fear with anger than ADHD alone and HC. Both ADHD subgroups fixated the eye region less than HC. Although there was a negative correlation between ADHD symptom severity and eye fixation duration, only CD severity was inversely related to emotion recognition accuracy. Conclusion Only ADHD participants with comorbid CD showed impairments in emotion recognition, suggesting that these deficits are specific to individuals with conduct problems. However, lack of attention to the eye region of faces appears to be a characteristic of ADHD. These findings suggest that emotion recognition impairments in those with ADHD+CD are related to misinterpretation rather than poor attention, offering interesting opportunities for intervention.

  • Article is discussed in an editorial. Biases in Interpretation as a Vulnerability Factor for Children of Parents With an Anxiety Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-05-30
    Rianne E. van Niekerk, Anke M. Klein, Esther Allart-van Dam, Mike Rinck, Pierre M. Souren, Giel J.M. Hutschemaekers, Eni S. Becker

    Objective Children of parents with an anxiety disorder have a higher risk of developing an anxiety disorder than children of parents without an anxiety disorder. Parental anxiety is not regarded as a causal risk factor itself, but is likely to be mediated via other mechanisms, for example via cognitive factors. We investigated whether children of parents with an anxiety disorder would show an interpretation bias corresponding to the diagnosis of their parent. We also explored whether children's interpretation biases were explained by parental anxiety and/or children’s levels of anxiety. Method In total, 44 children of parents with a panic disorder (PD), 27 children of parents with a social anxiety disorder (SAD), 7 children of parents with SAD/PD, and 84 children of parents without an anxiety disorder (controls) participated in this study. Parents and children filled out the Screen for Child Anxiety Related Disorders (SCARED) questionnaire, and children performed two ambiguous scenario tasks: one with and one without video priming. Results Children of parents with PD displayed significantly more negative interpretations of panic scenarios and social scenarios than controls. Negative interpretations of panic scenarios were explained by parental PD diagnosis and children’s anxiety levels. These effects were not found for children of parents with SAD. Priming did not affect interpretation. Conclusion Our results showed that children of parents with PD have a higher chance of interpreting ambiguous situations more negatively than children of parents without anxiety disorders. More research is needed to study whether this negative bias predicts later development of anxiety disorders in children.

  • Strengthening College Students’ Mental Health Knowledge, Awareness, and Helping Behaviors: The Impact of Active Minds, a Peer Mental Health Organization
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-05-18
    Lisa Sontag-Padilla, Michael Dunbar, Feifei Ye, Courtney Kase, Rebecca Fein, Sara Abelson, Rachana Seelam, Bradley D. Stein

    Objective To examine the relation between college students’ familiarity with and involvement in Active Minds, a student peer organization focused on increasing mental health awareness, decreasing stigma, and affecting mental health knowledge, attitudes, and behaviors. Method Students (N = 1,129) across 12 California colleges completed three waves of a web-based survey during the 2016 and 2017 academic year to assess familiarity with and involvement in Active Minds and mental health attitudes, behaviors, and perceived knowledge. Fixed-effects models assessed relations between changes in organization familiarity and involvement and changes in mental health-related outcomes over time overall and stratified by students’ baseline engagement (i.e., familiarity/involvement) with Active Minds. Results Overall, increased familiarity with Active Minds was associated with increases in perceived knowledge (0.40; p < .001) and decreases in stigma over time (−0.33; p < .001). Increased involvement was associated with increases in perceived knowledge (0.40; p < .001) and a range of helping behaviors. Associations differed by students’ baseline engagement with Active Minds. For students with low engagement, increased familiarity with Active Minds was associated with decreased stigma and improved perceived knowledge. For students with moderate baseline engagement, increasing involvement with Active Minds was associated with increases in helping behaviors (e.g., providing emotional support, connecting others to services) over time. Conclusion Student peer organizations’ activities can improve college student mental health attitudes and perceived knowledge and significantly increase helping behaviors. Such organizations can complement more traditional programs and play an important role in improving the campus climate with respect to mental health.

  • Cognitive Behavioral Therapy for Children With Anxiety and Comorbid Attention-Deficit/Hyperactivity Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-05-17
    Karen L. Gould, Melanie Porter, Heidi J. Lyneham, Jennifer L. Hudson

    Objective 1. To determine whether comorbid ADHD diagnosis (including subtype) predicts response to cognitive behavior therapy (CBT) for anxiety in children. 2. To examine change in ADHD symptoms after treatment of primary anxiety. Method A sample of 842 children 5 to 18 years of age received CBT for a primary anxiety disorder. A subsample of 94 children met criteria for comorbid, mild-to-moderate ADHD, mostly comprising Predominantly Inattentive (n = 61) and Combined (n = 27) subtypes. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each timepoint (posttreatment, 3- and/or 6-month follow-up) and analyzed using linear and logistic mixed models. Results Neither ADHD diagnosis nor subtype predicted response or remission rates for children’s primary anxiety disorders. Children with ADHD also showed modest yet significant improvements in ADHD symptoms after CBT treatment for anxiety. Conclusion Our findings support the suitability of manualised group-based CBT for anxiety treatment in children with non-primary ADHD. Further research should examine whether the positive outcomes reported can be extended to children with primary or severe ADHD.

  • Results From the Child/Adolescent Anxiety Extended Long-Term Study (CAMELS): Primary Anxiety Outcomes
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-05-09
    Golda S. Ginsburg, Emily Becker-Haimes, Courtney Keeton, Philip C. Kendall, Satish Iyengar, Dara Sakolsky, Anne Marie Albano, Tara Peris, Scott Compton, John Piacentini

    Objective To report anxiety outcomes from the multisite Child/Adolescent Anxiety Multi-modal Extended Long-term Study (CAMELS). Rates of stable anxiety remission (defined rigorously as the absence of all DSM-IV TR anxiety disorders across all follow-up years) and predictors of anxiety remission across a 4-year period, beginning 4 to 12 years after randomization to 12 weeks of medication, cognitive behavioral therapy (CBT), their combination, or pill placebo were examined. Examined predictors of remission included acute treatment response, treatment assignment, baseline child and family variables, and interim negative life events. Method Data were from 319 youths (age range 10.9−25.2 years; mean age 17.12 years) originally diagnosed with separation, social, and/or generalized anxiety disorders and enrolled in the multi-site Child/Adolescent Anxiety Multimodal Study (CAMS). Participants were assessed annually by independent evaluators using the age-appropriate version of the Anxiety Disorders Interview Schedule and completed questionnaires (e.g., about family functioning, life events, and mental health service use). Results Almost 22% of youth were in stable remission, 30% were chronically ill, and 48% were relapsers. Acute treatment responders were less likely to be in the chronically ill group (odds ratio = 2.73; confidence interval = 1.14−6.54; p < .02); treatment type was not associated with remission status across the follow-up. Several variables (e.g., male sex) predicted stable remission from anxiety disorders. Conclusion Findings suggest that acute positive response to anxiety treatment may reduce risk for chronic anxiety disability; identified predictors can help tailor treatments to youth at greatest risk for chronic illness. Clinical Trial Registration Information: Child and Adolescent Anxiety Disorders (CAMS). http://clinicaltrials.gov/; NCT00052078.

  • Development of Posterior Medial Frontal Cortex Function in Pediatric Obsessive-Compulsive Disorde
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-21
    Kate Dimond Fitzgerald, Yanni Liu, Timothy Johnson, Jason Moser, Rachel Marsh, Gregory L. Hanna, Stephan F. Taylor

    Objective Abnormal engagement of the posterior medial frontal cortex (pMFC) occurs during performance monitoring in obsessive-compulsive disorder (OCD), including in pediatric patients. Yet, the development of pMFC function in OCD-affected youth remains poorly understood. Method Sixty-nine patients with pediatric OCD and 72 healthy controls (HC), 8 to 19 years, were scanned during the Multisource Interference Task (MSIT). The effects of group, age, performance and interactions on pMFC response to errors and interference were tested in region of interest ROI) and whole brain analyses. Secondary analyses considered bilateral anterior insula/frontal operculum (aI/fO), given the contribution of these regions with pMFC to a cingulo-opercular network (CON) for task control (e.g., error- and interference-processing). Results Error-related pMFC activity was greater for OCD than HC, increased with age in OCD, but decreased with age in HC. Greater pMFC activation associated with better performance in HC, but not OCD. In patients, greater pMFC activation to errors associated with lower OCD severity. Altered error-related activation and performance associations were also observed in right aI/fO in OCD, while left aI/fO response to interference associated with lower OCD severity. Conclusion Atypical increase of error-related pMFC activation with age in pediatric OCD suggests altered development of pMFC function during the early course of illness. Greater pMFC activation with better performance in HC, and with age and lower symptom severity in patients suggests an adaptive function of heightened pMFC response to errors that could be further enhanced (e.g., via cognitive training) to improve outcomes in OCD from the early course of illness.

  • Criterion Validity and Utility of the General Factor of Psychopathology in Childhood: Predictive Associations with Independently Measured Severe Adverse Mental Health Outcomes in Adolescence
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-19
    Erik Pettersson, Benjamin B. Lahey, Sebastian Lundström, Henrik Larsson, Paul Lichtenstein

    Objective We examined if a parent-rated general factor of psychopathology in childhood predicted independently measured severe adverse mental health outcomes in adolescence. Method We used the Child and Adolescent Twin Study in Sweden, which targets all twin children in Sweden. Parents rated their children (N = 16,806) on 43 symptoms of inattention, hyperactivity-impulsivity, conduct problems, and anxiety/emotionality when the twins turned 12 or 9 years old. Adverse mental health outcomes in adolescence were retrieved from national registers, and included a) psychiatric diagnoses; b) prescription of anxiolytic or antidepressant medication; c) court convictions of crimes; and d) failure to achieve eligibility for high school. Results Parent-rated inattention, hyperactivity-impulsivity, conduct problems, and anxiety/emotionality in childhood predicted all adverse mental health outcomes in adolescence (mean odds ratio = 1.76; range = 1.41 to 2.18; all ps < .05). However, several of these associations were non-significant in a multiple regression framework, suggesting the influence of common variance. A general factor of psychopathology uniquely predicted all outcomes (mean odds ratio = 1.58; range = 1.34 to 1.84; all ps < .05), whereas the specific factors only predicted a subset of the outcomes. Conclusion Mental health problems in childhood are associated with a host of adverse outcomes in adolescence and to a considerable extent these associations are driven by a general factor of psychopathology. The general factor may be important, therefore, to clinical prognosis, which informs clinical decision making for children.

  • Defining Treatment Response and Remission in Youth Anxiety: A Signal Detection Analysis with the Multidimensional Anxiety Scale for Children
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-17
    Sophie A. Palitz, Nicole E. Caporino, Joseph F. McGuire, John Piacentini, Anne Marie Albano, Boris Birmaher, John T. Walkup, Scott N. Compton, Golda S. Ginsburg, Philip C. Kendall

    Objective To determine the percent reduction cutoff on the Multidimensional Anxiety Scale for Children (MASC) that optimally predict treatment response and remission in youth with anxiety disorders. Method Youths and their parents completed the MASC-C/P pre- and post-treatment, and the Anxiety Disorders Interview Schedule for DSM-IV–Child and Parent Versions (ADIS-IV-C/P) and Clinical Global Impression – Improvement scale (CGI-I) were administered by independent evaluators. Treatment response and remission were defined by posttreatment ratings on the CGI-I and the ADIS-IV-C/P, respectively. Quality receiver operating characteristic methods determined the optimal cutoff on the MASC-P for predicting overall remission (loss of all study entry diagnoses), and optimal percent reductions on the MASC-P for predicting treatment response and remission of separation anxiety, social anxiety and generalized anxiety. Results A posttreatment raw score of 42 optimally predicted remission. A reduction of 35% on the total MASC-P predicted treatment response. A reduction of 30% on the Separation Anxiety/Panic subscale of the MASC-P predicted separation anxiety remission. A reduction of 35% on the Social Anxiety subscale of the MASC-P predicted social anxiety remission. The MASC did not evidence a cutoff for remission of Generalized Anxiety Disorder. Conclusion MASC cutoffs can facilitate comparison across studies and guide practice, aiding clinicians in assessing progress and informing treatment plans.

  • Preschool and School-Age Irritability Predict Reward-Related Brain Function
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-11
    Lea Dougherty, Karen T.G. Schwartz, Maria Kryza-Lacombe, Jill Weisberg, Philip A. Spechler, Jillian Lee Wiggins

    Objective Although chronic irritability in childhood is prevalent, impairing, and predictive of later maladjustment, its pathophysiology is largely unknown. Deficits in reward processing are hypothesized to play a role in irritability. The current study aimed to identify how the developmental timing of irritability during preschool and school-age relates to reward-related brain function during school-age. Method Children’s irritability was assessed during the preschool period (Wave 1; ages 3.0-5.9 years) and three years later (Wave 2; ages 5.9-9.6 years) using a clinical interview. At Wave 2, children (N=46; 28 females) performed a monetary incentive delay task in which they received rewards, if they successfully hit a target, or no reward regardless of performance, during fMRI acquisition. Results Children with more vs. less severe preschool irritability, controlling for concurrent irritability, exhibited altered reward-related connectivity: right amygdala with insula and inferior parietal lobe as well as left ventral striatum with lingual gyrus, post-central gyrus, superior parietal lobe and culmen. Children with more vs. less severe concurrent irritability, controlling for preschool irritability, exhibited a similar pattern of altered connectivity between left and right amygdalae and superior frontal gyrus and between left ventral striatum and precuneus and culmen. Neural differences associated with irritability were most evident between reward and no reward conditions when participants missed the target. Conclusion Preschool irritability and concurrent irritability were uniquely associated with aberrant patterns of reward-related connectivity, highlighting the importance of developmental timing of irritability for brain function.

  • “P” and “DP”: Examining Symptom-Level Bifactor Models of Psychopathology and Dysregulation in Clinically Referred Children and Adolescents
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-10
    John D. Haltigan, Madison Aitken, Tracey Skilling, Joanna Henderson, Lisa Hawke, Marco Battaglia, John Strauss, Peter Szatmari, Brendan F. Andrade

    Objective This study examined cross-informant evidence for a general factor of psychopathology (“P”), and a narrower, clinically-oriented dysregulation general factor based on the Dysregulation Profile (“DP”) in a large clinical sample of children and adolescents. We also compared the magnitude of P and DP general factor associations with self-harm and suicidal ideation as an indicator of criterion validity. Method Item-wise data from the Child Behavior Checklist (N = 2,934; ages 4-18) were analyzed using confirmatory bifactor modeling and replicated in a supplementary analysis using Youth Self Report data (N = 2,395). Results General P and DP bifactor models fit the data better than single-factor and correlated factor models. Cross-informant criterion analyses on a subset of youth (n = 1,552) suggested that whether modeled as latent P or DP, associations with a brief composite index of self-harm and suicidal ideation are essentially of the same magnitude. Conclusion Our findings provide novel, large-sample support for the existence of general factors of psychopathology and dysregulation in clinically referred children and adolescents using a standardized rating system of psychopathology symptoms. Moreover, our results provide preliminary evidence that general psychopathology and dysregulation factors are clinically meaningful constructs. In addition, our findings raise the possibility that the DP general factor may serve as an efficient proxy for the general psychopathology factor in future clinical applications. Further efforts are necessary to understand the core empirical meaning of the P factor and to determine how it can be applied to clinical assessment and intervention.

  • Attention-Deficit/Hyperactivity Disorder in Preschoolers – the Accuracy of a Short Screener
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-04-07
    Kristin Romvig Overgaard, Beate Oerbeck, Svein Friis, Are Hugo Pripp, Guido Biele, Heidi Aase, Pål Zeiner

    Objective While early and accurate screening is required for the remediation of Attention-Deficit/Hyperactivity Disorder (ADHD), possible gender differences have not been extensively studied. We examined the classification accuracy of the parent and preschool teacher version of the Strengths and Difficulties Questionnaire (SDQ) hyperactivity-inattention (HI) subscale in girls and boys. Method The study was part of the Norwegian Mother and Child Cohort Study (MoBa). Parents and preschool teachers rated a total of 238 girls and 276 boys (mean age 3 ½ years) with the SDQ HI subscale. Blinded to the parent and teacher ratings, interviewers classified the children by ADHD diagnoses with the Preschool Age Psychiatric Assessment Interview. Results Areas under the curves for the parent HI subscale scores were good for both girls and boys (.87 and .80, respectively). Preschool teacher classifications were fair (.76) for girls and poor (.62) for boys, a significant difference (p = .017). The subscale accurately identified children without ADHD at low parent scores (≤4), and fairly accurately identified ADHD at high scores (≥9) with maximum probabilities of finding true cases were .75 in girls and .55 in boys. Intermediate scores gave the best balance between sensitivity and specificity with low probabilities of correctly identifying children with ADHD. Conclusion The parental SDQ HI subscale was useful for screening for ADHD in preschool girls and boys. For preschool teachers, the subscale was useful for screening girls.

  • Has the Prevalence of Child and Adolescent Mental Disorders in Australia Changed Between 1998 and 2013-14?
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-16
    Michael G. Sawyer, Christy E. Reece, Alyssa C.P. Sawyer, Sarah Johnson, David Lawrence

    Objective This study examined whether the 12-month prevalence of major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), and conduct disorder (CD) among 6-17 year-olds in Australia changed between 1998 and 2013-14. It also investigated whether changes in the prevalence of disorders over this time varied for children living in families containing two parents versus single parents, and families with high versus low income. Method The study used data from national surveys conducted in Australia in 1998 (N=3,597) and 2013-14 (N=5,359). In both surveys the participating children were randomly selected from all 6-17 year olds in Australia, and mental disorders were assessed using the Diagnostic Interview Schedule for Children Version IV (DISC-IV) completed by parents. Results There was little change in the overall prevalence of mental disorders between 1998 (12.5%, 95% CI=11.4-13.7) and 2013-14 (11.1%, 95% CI=10.1-12.2). Although there were some differences in the changes for children with different disorders, most were small in magnitude. Specifically, MDD prevalence increased from 2.1% (95% CI=1.7-2.7) to 3.2% (95% CI=2.7-3.8), ADHD prevalence declined from 9.9% (95% CI=8.9-10.9) to 7.8% (95% CI=6.9-8.7), and CD prevalence declined from 2.7% (95% CI=2.2-3.3) to 2.1% (95% CI=1.7-2.7). There was a persisting pattern of higher prevalence among children living in single-parent and low-income households. Conclusion Lack of change at a population level in the prevalence of child mental disorders suggests that new innovations in research, policy and practice are needed to successfully address the major public health problem posed by child and adolescent mental disorders in the community.

  • Irritability Trajectories, Cortical Thickness, and Clinical Outcomes in a Sample Enriched for Preschool Depression
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-16
    David Pagliaccio, Daniel S. Pine, Deanna M. Barch, Joan L. Luby, Ellen Leibenluft

    Objective Cross-sectional, longitudinal, and genetic associations exist between irritability and depression. Prior studies have examined developmental trajectories of irritability, clinical outcomes, and associations with child and familial depression. However, studies have not integrated neurobiological measures. The current study examined developmental trajectories of irritability, clinical outcomes, and cortical structure among preschoolers oversampled for depressive symptoms. Method Beginning at 3-5 years old, a sample of 271 children enriched for early depressive symptoms were assessed longitudinally by clinical interview. Latent class mixture models identified trajectories of irritability severity. Risk factors, clinical outcomes, and cortical thickness were compared across trajectory classes. Cortical thickness measures were extracted from three waves of magnetic resonance imaging at 7-12 years of age. Results Three trajectory classes were identified among these youth: 53.50% of children exhibited elevated irritability during preschool that declined longitudinally, 30.26% exhibited consistently low irritability, and 16.24% exhibited consistently elevated irritability. Compared to other classes, the elevated irritability class exhibited higher rates of maternal depression, early life adversity, later psychiatric diagnoses and functional impairment. Further, elevated baseline irritability predicted later depression beyond adversity and personal and maternal depression history. The elevated irritability class exhibited thicker cortex in the left superior frontal and temporal gyri and the right inferior parietal lobule. Conclusion Irritability manifested with specific developmental trajectories in this sample enriched for early depression. Persistently elevated irritability predicted poor psychiatric outcomes, higher risk for later depression, and reduced overall function later in development. Greater frontal, temporal, and parietal cortical thickness was also found, providing neural correlates of this risk trajectory.

  • The Epigenetic Clock at Birth: Associations With Maternal Antenatal Depression and Child Psychiatric Problems
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-15
    Anna Suarez, Jari Lahti, Darina Czamara, Marius Lahti-Pulkkinen, Anna K. Knight, Polina Girchenko, Esa Hämäläinen, Eero Kajantie, Jari Lipsanen, Hannele Laivuori, Pia M. Villa, Rebecca M. Reynolds, Alicia K. Smith, Elisabeth B. Binder, Katri Räikkönen

    Objective Maternal antenatal depression may compromise the fetal developmental milieu and contribute to individual differences in aging and disease trajectories in later life. We evaluated the association between maternal antenatal depression and a novel biomarker of aging at birth, namely epigenetic gestational age (GA) based on fetal cord blood methylation data. We also examined if this biomarker prospectively predicts and mediates maternal effects on early childhood psychiatric problems. Method 694 mothers from the PREDO Study provided information on history of depression diagnosed before pregnancy, 581 completed the Center for Epidemiological Studies Depression Scale throughout pregnancy, and 407 completed the Child Behavior Checklist at child’s age 3.7 (standard deviation(SD)=0.75) years. DNA methylation (DNAm) GA of fetal cord blood DNA was based on the methylation profile of 148 selected CpGs. Epigenetic GA was calculated as the arithmetic difference between DNAm GA and chronological GA and adjusted for chronological GA. Results Maternal history of depression diagnosed before pregnancy [Mean difference=-0.25 SD units, 95% Confidence Interval (95%CI) -0.46;-0.03)] and greater antenatal depressive symptoms (-0.08 SD unit per SD unit increase, 95%CI -0.16;-0.004) were associated with child’s lower epigenetic GA. Child’s lower epigenetic GA, in turn, prospectively predicted total and internalizing problems and partially mediated the effects of maternal antenatal depression on internalizing problems in boys. Conclusion Maternal antenatal depression is associated with lower epigenetic GA in offspring. This lower epigenetic GA seems to be associated with a developmental disadvantage for boys, who in early childhood show greater psychiatric problems.

  • Course of Disinhibited Social Engagement Disorder From Early Childhood to Early Adolescence
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-15
    Katherine L. Guyon-Harris, Kathryn L. Humphreys, Nathan A. Fox, Charles A. Nelson, Charles H. Zeanah

    Objective Disinhibited social engagement disorder (DSED) is poorly understood beyond early childhood. In a sample of children who experienced severe, early deprivation, we examined the course of DSED signs from early childhood to early adolescence using variable-centered (linear mixed modeling) and person-centered (growth mixture modeling) approaches. Method 124 children with a history of institutional care from a randomized controlled trial of foster care as an alternative to institutional care, as well as 69 community comparison children matched on age and sex were included in the study. DSED signs were assessed at baseline (mean age of 22 months), age 30, 42, and 54 months, and age 8 and 12 years using a validated caregiver report of disturbed attachment behavior. Results Variable-centered analyses based on intent-to-treat groups indicated that signs of DSED decreased sharply for children randomized to foster care and decreased slightly but remained elevated for children randomized to care as usual. Person-centered analyses revealed four profiles (i.e., elevated, persistent modest, early decreasing, and minimal). Elevated and persistent modest courses were associated with greater placement disruptions (F[3,99]=4.29, p=.007 partial η2=.12), later age of placement into foster care (F[3,56]=3.41, p<.05, partial η2=.16), and more time in institutional care (F[3,115]=11.91, p<.001, partial η2=.24) compared to decreasing and minimal courses. Conclusion Early and sustained placement into families following deprivation is associated with minimal or decreasing signs of DSED across development. Reducing the amount of time children spend in institutions and preserving placements may help reduce signs of DSED into early adolescence among previously institutionalized children.

  • Autistic Traits and Suicidal Thoughts, Plans and Self-Harm in Late Adolescence: Population-Based Cohort Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-15
    Iryna Culpin, Becky Mars, Rebecca M. Pearson, Jean Golding, Jon Heron, Isidora Bubak, Peter Carpenter, Cecilia Magnusson, David Gunnell, Dheeraj Rai

    Objective To examine the hypothesis that ASD diagnosis and traits in childhood are associated with suicidal thoughts, plans and self-harm at 16 years, and that any observed associations are explained by depression at 12 years. Method We examined associations between ASD diagnosis and four dichotomised ASD traits (social communication, pragmatic language, repetitive behaviour, sociability) with suicidal and non-suicidal self-harm, suicidal thoughts and plans at age 16 years in 5,031 members of the UK-based birth cohort study-the Avon Longitudinal Study of Parents and Children. We assessed whether any associations were explained by depressive symptoms in early adolescence measured by the Short Moods and Feelings Questionnaire at 12 years. Results Children with impaired social communication had a higher risk of self-harm with suicidal intent (RR 2.14, 95% CI 1.28–3.58), suicidal thoughts (1.42, 1.06–1.91) and suicidal plans (1.95, 1.09–3.47) by age 16 years as compared to those without. There was no evidence for an association between ASD diagnosis and the outcomes although these analyses were imprecise due to small numbers. There was also no evidence of an association between other autism traits and the outcomes. Approximately 32% of the total estimated association between social communication impairment and self-harm was explained by depressive symptoms at 12 years. Conclusion Social communication impairments are an important autistic trait in relation to suicidality. Early identification and management of depression may be a preventative mechanism and future research identifying other potentially modifiable mechanisms may lead to interventions against suicidal behaviour in this high-risk group.

  • Psychosis in Children and Adolescents
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-03-13
    Jon McClellan

    Psychosis is characterized by overt disruptions in thought, perceptions, and behavior. Complex syndromes presenting with psychosis, including schizophrenia spectrum disorders, mood disorders and medical illnesses, are differentiated by characteristic patterns of symptom presentation and course of illness. Accurate diagnosis is important to guide treatment and to avoid inaccurate labeling, since most youth reporting psychotic-like experiences do not have a true psychotic disorder.

  • Prevalence of Mental Disorder and Service Use by Immigrant Generation and Race/Ethnicity Among U.S. Adolescents
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-15
    Katholiki Georgiades, Diana Paksarian, Kara E. Rudolph, Kathleen R. Merikangas

    Objective To examine differences in lifetime prevalence of mental disorder and service utilization among U.S. adolescents by both immigrant generation and race/ethnicity. Method 6,250 adolescents aged 13 to 18 years in the National Comorbidity Survey Replication Adolescent Supplement were assessed for lifetime prevalence of mood and/or anxiety disorders, behavior disorders, and mental health service utilization. Twelve groups defined by self-identified race-ethnicity (non-Hispanic white, Hispanic, non-Hispanic black, Asian) and immigrant generation (1st, 2nd, 3rd or greater) were compared. Results Differences in prevalence of lifetime mental disorder were most apparent when immigrant generation and race/ethnicity were considered jointly. Compared to 3rd+ generation non-Hispanic white adolescents, the odds of mood/anxiety disorder were increased among 2nd generation Asian (adjusted odds ratio [AOR]=2.51; 95%CI=1.22-5.17) and 3rd+ generation Hispanic (AOR=1.28; 95%CI=1.00-1.63) but reduced among 1st generation Asian (AOR=0.27; 95%CI=0.10-0.71) and 2nd generation non-Hispanic white adolescents (AOR=0.50; 95%CI=0.30-0.81). The odds of behavior disorder were lower among 1st generation Asian (AOR=0.26; 95%CI=0.09-0.71) and all generations of non-Hispanic black adolescents (AORs range 0.43-0.55). Adjusting for lifetime disorder, 1st generation Hispanic and non-Hispanic white adolescents and all generations of non-Hispanic black adolescents were less likely to receive mental health services (AORs range 0.24-0.55). Conclusions Variation in risk of disorder by immigrant generation and race/ethnicity underscores the importance of considering social, economic, and cultural influences in etiologic and treatment studies of adolescent psychopathology. Lower rates of service use, particularly among 1st generation immigrant adolescents, highlight the need to identify and address barriers to recognition and treatment of mental disorders among adolescents from immigrant and racial-ethnic minority backgrounds.

  • Suicidal Thoughts and Behaviors Among First-Year College Students: Results From the WMH-ICS Project
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-13
    Philippe Mortier, Randy P. Auerbach, Jordi Alonso, Jason Bantjes, Corina Benjet, Pim Cuijpers, David D. Ebert, Jennifer Greif Green, Penelope Hasking, Matthew K. Nock, Siobhan O’Neill, Stephanie Pinder-Amaker, Nancy A. Sampson, Gemma Vilagut, Alan M. Zaslavsky, Ronny Bruffaerts, Ronald C. Kessler

    Objective College entrance may be a strategically well-placed “point of capture” for detecting late adolescents with suicidal thoughts and behaviors (STB). However, a clear epidemiological picture of STB among incoming college students is lacking. We present the first cross-national data on prevalence as well as socio-demographic and college-related correlates for STB among first-year college students. Method Web-based self-report surveys were obtained from 13,984 first-year students (response rate 45.5%) across 19 colleges in eight countries (Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Spain, United States). Results Lifetime prevalence of suicidal ideation, plans, and attempts was 32.7%, 17.5%, and 4.3%, respectively. Twelve-month prevalence was 17.2%, 8.8%, and 1.0%, respectively. About 75% of STB cases had onset before the age of 16 years (Q3 = 15.8), with persistence figures in the range 41-53%. About half (53.4%) of lifetime ideators transitioned to a suicide plan; 22.1% of lifetime planners transitioned to an attempt. Attempts among lifetime ideators without plan were less frequent (3.1%). Significant correlates of lifetime STB were cross-nationally consistent and generally modest in effect size (median adjusted OR [aOR] = 1.7). Non-heterosexual orientation (aOR range 3.3-7.9) and heterosexual orientation with some same-sex attraction (aOR range 1.9-2.3) were the strongest correlates of STB, and of transitioning from ideation to plans and/or attempts (aOR range 1.6-6.1). Conclusion The distribution of STB in first-year students is widespread, and relatively independent of socio-demographic risk profile. Multivariate risk algorithms based on a high number of risk factors are indicated to efficiently link high-risk status with effective preventive interventions.

  • Sustained Effects of Collaborative School-Home Intervention for Attention-Deficit/Hyperactivity Disorder Symptoms and Impairment
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-08
    Linda J. Pfiffner, Mary E. Rooney, Yuanyuan Jiang, Lauren M. Haack, Allyson Beaulieu, Keith McBurnett

    Objectives The Collaborative Life Skills (CLS) program is a school-home intervention for students with Attention Deficit Hyperactivity Disorder (ADHD) symptoms and impairment. CLS integrates school, parent, and student treatments followed by booster sessions during a maintenance period into the subsequent school year. The program is delivered by school-based mental health providers. Beneficial post-treatment effects have been documented. This study evaluates effects of CLS after the maintenance period in the subsequent school year. Method Using a cluster randomized design, schools within a large urban public-school district were randomly assigned to CLS (12 schools) or usual services (11 schools). Approximately six students participated at each school (N=135, grade range=2-5). Measures were completed at baseline, post-treatment, and follow-up during the next school year. Results Students from schools assigned to CLS, relative to those assigned to usual services, showed significantly greater improvement at follow-up on parent, but not teacher, ratings of ADHD and oppositional defiant disorder (ODD) symptom severity, organizational skills, and global impairment. Within-group analyses indicated that parent and teacher-reported post-treatment gains for CLS in ADHD and ODD symptoms, organizational skills and academic competence maintained into the next school year. Conclusions These results extend support for CLS to the following school year by demonstrating sustained benefits on parent-reported ADHD and ODD symptoms and functional impairment. The lack of significant teacher-reported differences between CLS and usual services highlights the need for further study of booster treatments for improving outcomes with new teachers across school years.

  • Data-Driven Subtyping of Executive-Function-Related Behavioral Problems in Children
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-08
    Joe Bathelt, Joni Holmes, Duncan E. Astle

    Objective Executive functions (EF) are cognitive skills important for regulating behavior and achieving goals. Executive function deficits are common in children who struggle in school and are associated with multiple neurodevelopmental disorders. However, there is also considerable heterogeneity across children, even within diagnostic categories. This study took a data-driven approach to identify distinct clusters of children with common profiles of EF-related difficulties, and then identified patterns of brain organization that distinguish these data-driven groups. Method The sample consisted of 442 children identified by health and educational professionals as having difficulties in attention, learning and/or memory. We applied community clustering, a data-driven clustering algorithm, to group children by similarities on a commonly used rating scale of EF-associated behavioral difficulties, the Conners-3 questionnaire. Furthermore, we then investigated whether the groups identified by the algorithm could be distinguished on white matter connectivity using a structural connectomics approach combined with partial least squares analysis. Results The data-driven clustering yielded three distinct groups of children with symptoms of either: (1) elevated inattention and hyperactivity/impulsivity, and poor executive function, (2) learning problems, and (3) aggressive behavior and problems with peer relationships. These groups were associated with significant inter-individual variation in white matter connectivity of the prefrontal and anterior cingulate cortices. Conclusion In sum, data-driven classification of EF-related behavioral difficulties identified stable groups of children, provided a good account of inter-individual differences, and aligned closely with underlying neurobiological substrates.

  • The Impact of Antidepressant Dose and Class on Treatment Response in Pediatric Anxiety Disorders: A Meta-Analysis
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-08
    Jeffrey R. Strawn, Jeffrey A. Mills, BeauA. Sauley, Jeffrey A. Welge

    Objective To determine the trajectory and magnitude of antidepressant response as well as the effect of antidepressant class and dose on symptomatic improvement in pediatric anxiety disorders. Method Weekly symptom severity data were extracted from randomized, parallel group, placebo-controlled trials of selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) in pediatric anxiety disorders. Treatment response was modeled for the standardized change in continuous measures of anxiety using Bayesian updating. Posterior distributions for each study served as informative conjugate priors to update subsequent study posteriors. Change in symptom severity was evaluated as a function of time, class and, for SSRIs, standardized dose. Results Data from 9 trials (SSRIs: n=5; SSNRIs, n=4) evaluating 7 medications in 1,673 youth were included. In the logarithmic model of treatment response, statistically—but not clinically—significant treatment effects emerged within 2 weeks of beginning treatment (standardized medication-placebo difference = -0.054, CI: -0.076 to -0.032, p=0.005, approximate Cohen’s d ≤ 0.2) and by week 6, clinically significant differences emerged (standardized medication-placebo difference = -0.120, CI: -0.142, -0.097, p=0.001, approximate Cohen’s d = 0.44). Compared to SSNRIs, SSRIs resulted in significantly greater improvement by the second week of treatment (p=0.0268) and this advantage remained statistically significant through week 12 (all ps<0.03). Improvement occurred earlier with high dose SSRI treatment (week 2, p=0.002) compared to low-dose treatment (week 10, p=0.025), but SSRI dose did not impact overall response trajectory (p>0.18 for weeks 1-12). Conclusions In pediatric patients with generalized, separation and/or social anxiety disorders, antidepressant-related improvement occurs early in the course of treatment and SSRIs are associated with more rapid and greater improvement compared to SSNRIs.

  • Gun and Non-Gun Related Violence Exposure and Risk for Subsequent Gun Carrying Among Male Juvenile Offenders
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-02-06
    Jordan Beardslee, Edward Mulvey, Carol Schubert, Paul Allison, Arynn Infante, Dustin Pardini

    Objective Although studies have found that youth exposed to violence are more likely to carry guns than non-exposed youth, this association could be due to common causal factors or other pre-existing differences between individuals. In this study, within-individual change models were used to determine whether juvenile offenders exhibit an increased propensity to carry a firearm after being exposed to gun violence and/or non-gun violence. The advantage of this approach is all time-invariant factors are eliminated as potential confounders. Method 1170 racially/ethnically diverse male juvenile offenders were recruited in Arizona and Pennsylvania (ages 14-19 at recruitment). Participants were interviewed every six months for three years followed by four annual assessments. The outcome was gun carrying and the primary predictors were exposure to gun violence and non-gun violence. Time-varying covariates included exposure to peers who carried guns, exposure to peers who engaged in other (non-gun) criminal acts, developmental changes in gun carrying, and changes in gun carrying due to incarceration/institutionalization. Results Adolescent offenders were significantly more likely to carry a gun in recall periods following exposure to gun violence, but not after exposure to non-gun violence. Effect of gun violence on carrying was significant throughout adolescence and young adulthood, and could not be accounted for by time-varying and time-invariant confounders. Conclusions Interventions to reduce illegal gun carrying should target young men in medical and mental health settings who experience or witness gun violence, as well as those living in communities with high rates of gun violence.

  • Working Memory and Vigilance as Multivariate Endophenotypes Related to Common Genetic Risk for Attention-Deficit/Hyperactivity Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2018-01-09
    Joel T. Nigg, Hanna C. Gustafsson, Sarah L. Karalunas, Peter Ryabinin, Shannon McWeeney, Stephen V. Faraone, Michael Mooney, Damien A. Fair, Beth Wilmot

    Objective Understanding the role of endophenotypes is essential for process models of psychopathology. This study examined which candidate cognitive endophenotypes statistically mediate common variant genetic risk for attention-deficit/hyperactivity disorder (ADHD). Method A case-control design using community-recruited volunteer children 7-11 years old (n=656, n=435 ADHD) of whom 514 were homogenous European ancestry for the primary models (n=337 ADHD, 177 non-ADHD). Children were assessed with a multi-informant, best-estimate diagnostic procedure and laboratory measures of working memory, response inhibition, executive functioning, arousal/attention, temporal information processing, and processing speed. Latent variables were created for the candidate cognitive measures and for parent- and teacher-rated ADHD dimensions. Polygenic risk scores (PGS) were computed, using a discovery sample of 20,183 individuals with ADHD and 35,191 controls from the Psychiatric Genetics Consortium. Cognitive measures that survived multiple testing correction for association with the PGS were evaluated for mediation with ADHD using structural equation models. Results Results were essentially identical in the homogeneous European ancestry subgroup (n=514) and in the full sample (n=656). For the European population, the PGS was associated with ADHD diagnosis (Nagelkerke R2= .045; beta=.233, SE=.053, p=.000011) and multi-indicator dimensional ADHD latent variables by parent report (beta=.185, SE=.043) and teacher report (beta=.165, SE=.042). The PGS effect was statistically mediated by working memory (indirect effect, beta=.101, SE=.029, 95% CI=.05, .16, p=.00049, 43% of genetic effect accounted for) and arousal/alertness (indirect effect beta=.115, 95% CI=.04, .20, SE=.041, p=.005, 49% of genetic effect accounted for). Conclusion This is the first clear demonstration from molecular genetic data that working memory and arousal regulation are promising cognitive endophenotypes for ADHD with regard to mediating genetic risk from common genetic variants.

  • Reduced Functional Brain Activation and Connectivity During a Working Memory Task in Childhood-Onset Schizophrenia
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-28
    Frances F. Loeb, Xueping Zhou, Kirsten E.S. Craddock, Lorie Shora, Diane D. Broadnax, Peter Gochman, Liv S. Clasen, Francois M. Lalonde, Rebecca A. Berman, Karen F. Berman, Judith L. Rapoport, Siyuan Liu

    Objective Working memory (WM) deficits are consistently reported in schizophrenia and are related to poor functional outcomes. Functional magnetic resonance imaging (fMRI) studies of adult-onset schizophrenia (AOS) show reduced functional activations and connectivity in the WM network, but no prior fMRI study has examined WM in childhood-onset schizophrenia (COS). The aim of this study was to examine the neural correlates of WM in COS. Method Adult patients with COS (n=32, 21.3±1.1years), nonpsychotic siblings of COS (n=30, 19.4±0.8), and healthy controls (n=39, 20.0±0.7) completed 1- and 2-back working memory tasks during 3T fMRI scanning. Both functional activation and connectivity analyses were conducted. A separate group of 23 younger patients with COS (17.9±7.4) could not perform the tasks after twice completing a standard training and were not studied here. Results Patients with COS who were included scored significantly lower than controls on all tasks (p<.001). Patients with COS showed significantly lower activations in the dorsolateral prefrontal cortices, posterior parietal cortices, cerebellum and caudate, as well as reduced fronto-parietal and cortico-striatal functional connectivity compared to controls (p<.05, corrected). Siblings had functional activations and connectivity intermediate between patients and controls in a similar set of regions (p<.05, corrected). In patients, functional connectivity strength in the left fronto-parietal network correlated positively with accuracy scores during the 1-back task (p=.0023, corrected). Conclusion Reduced functional activation and connectivity in the WM network in COS supports pathophysiologic continuity with AOS. The low participation rate and accuracy of the patients highlights the disease severity of COS. Hypo-activations and hypo-connectivity were shared by siblings of patients with COS, suggesting COS as a potential endophenotype. Clinical trial registration information Evaluating Genetic Risk Factors for Childhood-Onset Schizophrenia; http://ClinicalTrials.gov/; NCT00001198;

  • Identifying Clinically Significant Irritability in Early Childhood
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-28
    Jillian Lee Wiggins, Margaret J. Briggs-Gowan, Ryne Estabrook, Melissa A. Brotman, Daniel S. Pine, Ellen Leibenluft, Lauren S. Wakschlag

    Objective Advances in developmentally sensitive measurement now enable differentiation of normative vs. clinically salient irritability in early childhood. Yet, clinical application of these measures is still nascent. Here, we first developed an optimized model of clinically salient irritable behaviors at preschool age. Based on this model, we next derived an empirically-based cutoff in relation to concurrent DSM-5 irritability-related disorders (i.e., oppositional defiant disorder [ODD], disruptive mood dysregulation disorder [DMDD], other depressive disorders) and used longitudinal models to test the predictive validity of the cutoff for impairment and irritability trajectories and later DSM disorders. Method Preschool children oversampled for irritability were followed over three time points into early school age (N=425; mean age at baseline=4.7 years, mean follow-up=2.9 years). Mothers reported on children’s irritability via the developmentally-validated Multidimensional Assessment of Profile of Disruptive Behavior (MAP-DB) Temper Loss scale, impairment via the Family Life Impairment Scale, and DSM categories via the Preschool Age Psychiatric Assessment and Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. Results Of 22 MAP-DB Temper Loss behaviors, two behaviors—one normative (easily frustrated), one rare, dysregulated (destructive tantrums)—uniquely related to cross-domain impairment. At baseline, these two irritability items identified diagnostic status (ODD, DMDD, other depressive disorders) with good sensitivity (70-73%) and specificity (74-83%). Also, children above the irritability cutoff at baseline exhibited more persistent irritability and impairment and greater likelihood of DSM disorders in early school-age. Conclusion Clinical identification of early-onset irritability can be enhanced via brief, developmentally optimized indicators. Further research to apply these findings to tiered early intervention is important.

  • Early Childhood Adverse Experiences, Inferior Frontal Gyrus Connectivity, and the Trajectory of Externalizing Psychopathology
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-28
    Deanna M. Barch, Andy C. Belden, Rebecca Tillman, Diana Whalen, Joan L. Luby

    Objective Early adverse childhood experiences (ACEs) have been linked to the development of both internalizing and externalizing psychopathology. In our prior work, we found that ACEs predicted reductions in the volume of the inferior frontal gyrus (IFG), a brain region important for impulse control and emotion regulation. Here we tested the hypothesis that ACEs might influence child behavioral outcomes through an impact on IFG functional connectivity, which may influence impulsive or risk-taking behavior. Method We examined the effects of prospectively assessed ACEs on IFG connectivity in childhood, and their relationship to the trajectory of subsequent psychopathology from late school age and early adolescence, utilizing data from an 11-year longitudinal study of children starting in preschool that included three waves of resting state functional connectivity across childhood and early adolescence. Results ACEs predicted functional connectivity of both left and right IFG. Multi-level modeling of symptoms across 3 waves of assessments indicated that more ACEs predicted both internalizing and externalizing symptoms. However, altered IFG connectivity specifically predicted greater externalizing symptoms over time in middle childhood and early adolescence, as compared to internalizing symptoms. Longitudinal modeling indicating that the relationships between externalizing and functional connectivity maintained across three waves of functional connectivity assessment. Conclusion These findings underscore the relationship of ACEs to later psychopathology and suggest that connectivity of the IFG, a region known to play an important role in impulse control and emotion regulation, may play a key role in the risk trajectory of ACEs to externalizing problems. However, further work is needed to understand whether these relationships reflect a direct effect of ACEs or whether ACEs are a marker for other environmental or genetic factors that may also influence brain development and behavior.

  • Effect of Time-Dependent Selective Serotonin Reuptake Inhibitor Antidepressants During Pregnancy on Behavioral, Emotional, and Social Development in Preschool-Age Children
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-28
    Angela Lupattelli, Mollie Wood, Eivind Ystrom, Svetlana Skurtveit, Marte Handal, Hedvig Nordeng

    Objective To evaluate the effect of prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) on children’s behavioral, emotional, and social development by age 5 years, and over time since age 1.5. Method The prospective Norwegian Mother and Child Cohort Study was linked to the Medical Birth Registry of Norway. We included women who reported depressive/anxiety disorders before and/or during pregnancy. Children born to women who used SSRIs in early (weeks 0-16), mid (weeks 17-28), or late (> week 29) pregnancy were compared to unexposed. Children’s internalizing and externalizing behaviors (Child Behavior Checklist) and temperament traits (Emotionality, Activity and Shyness Temperament Questionnaire) were measured at 1.5, 3, and 5 years. Mean scores were calculated and standardized. We fit general linear marginal structural models to account for time-varying exposure and confounders, and censoring; three-level growth-curve models. Results We included 8,359 mother–child dyads, and 4,128 children had complete outcome data at age 5. Children exposed to SSRIs in late pregnancy had an increased risk for anxious/depressed behaviors by age 5 compared with unexposed (adjusted β: 0.50, 95% CI: 0.04, 0.96). Such risk was not evident for earlier timings of exposure. There was no evidence for a substantial prenatal SSRI effect on externalizing, social, and emotional problems. Conclusion These findings suggest no substantial increased risk for externalizing, emotional, and social problems in preschool-age children following prenatal SSRI exposure. While the role of chance and potential unmeasured confounding cannot be ruled out, late-pregnancy SSRI exposure was associated with greater anxious/depressed behaviors in the offspring.

  • The Effectiveness of School-Based Mental Health Services for Elementary-Aged Children: A Meta-Analysis
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-24
    Amanda L. Sanchez, Danielle Cornacchio, Bridget Poznanski, Alejandra Golik, Tommy Chou, Jonathan S. Comer

    Objective Given problems and disparities in the utilization of community-based mental health services for youth, school personnel have assumed frontline mental health service roles. To date, the majority of research on school-based services has evaluated analogue educational contexts with services implemented by highly trained study staff, and little is known about the effectiveness of school-based mental health services when implemented by school professionals. Method: We used random-effects meta-analytic procedures to synthesize effects of school-based mental health services for elementary-aged children based exclusively on studies without direct implementation by researchers, and potential moderators of treatment response. Forty-three controlled trials evaluating 49,941 elementary school-aged children met selection criteria (mean grade=2.86, 60.3% male). Results Overall school-based services demonstrated a small-to-medium effect (Hedges’ g=0.39) in reducing mental health problems, with the largest effects found for targeted intervention (Hedges’ g=0.76), followed by selective prevention (Hedges’ g=0.67), relative to universal prevention (Hedges’ g=0.29). Mental health services integrated into students’ academic instruction (Hedges’ g=0.59), those targeting externalizing problems (Hedges’ g=0.50), those incorporating contingency management (Hedges’ g=0.57), and those implemented multiple times per week (Hedges’ g=0. 0.50) showed particularly strong effects. Conclusion Considering serious barriers precluding youth from accessing necessary mental health care, the present meta-analysis suggests child psychiatrists and other mental health professionals are wise to recognize the important role that school personnel, who are naturally in children’s lives, can play in reducing child mental health problems.

  • Examining the Association Between Autistic Traits and Atypical Sensory Reactivity: A Twin Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-06
    Mark J. Taylor, Peik Gustafsson, Henrik Larsson, Christopher Gillberg, Sebastian Lundström, Paul Lichstenstein

    Objective Atypical responses to sensory stimuli are common features of autism spectrum disorders (ASD). Consequently, atypical sensory reactivity (SR) is now a diagnostic feature of ASD. Quantitative genetic research on ASD has overlooked these symptoms, however. We therefore investigated the association between autistic traits and SR using twin methods. Method Autistic traits and SR were assessed by two separate scales in 12,419 Swedish twin pairs (n=3,586 monozygotic [MZ], n=8,833 dizygotic [DZ]) when the twins were aged 9 or 12. The classic twin design estimated the degree to which etiological factors associated with autistic traits were also associated with SR, and the degree to which such shared factors explained the covariance between these phenotypes. DeFries-Fulker analysis estimated the genetic correlation between screening diagnoses of ASD, defined broadly and strictly, and SR. Results Autistic traits and SR were both highly heritable (62-75% and 66-71%, respectively). There was a moderate phenotypic correlation between autistic traits and SR (r=.47). Genetic influences on these phenotypes correlated moderately (genetic correlation=.60). These overlapping genetic factors explained most of the correlation between autistic traits and SR. Genetic correlations with SR increased for broad ASD (genetic correlation =.72) and strict ASD (genetic correlation=.80). Conclusion The genetic overlap observed between autistic traits and SR lends quantitative genetic support to the notion that ASD and SR are strongly linked. Such symptoms may thus comprise part of the ASD genotype, as well as phenotype. Associations persisted across all definitions of ASD, indicating a genetic link between the broader ASD phenotype and SR.

  • Effects of State Autism Mandate Age Caps on Health Service Use and Spending Among Adolescents
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-12-05
    Alene Kennedy-Hendricks, Andrew J. Epstein, David S. Mandell, Molly K. Candon, Steven C. Marcus, Ming Xie, Colleen L. Barry

    Objective Many states with mandates requiring commercial insurers to cover autism spectrum disorder (ASD) health services specify upper age limits above which coverage is no longer mandated. It is unknown what effects these age caps have on health service use and spending among adolescents who have exceeded the age cap. Method Using administrative claims data from three national commercial insurers, a difference-in-differences approach was used to estimate effects of age caps on health service use and spending among adolescents with ASD. Statistical models compared changes in use and spending between those above versus below the age cap among those eligible versus ineligible for mandated coverage. The analytic sample included data from 2008 through 2012 on 7,845 individuals (151,976 person-months) ages 10-21 years in 11 states imposing mandate age caps going into effect during adolescence. Results Age caps were associated with 4.2 percentage point (95% CI: -7.0, -1.5) lower probability of any ASD-specific service use in a month and $69 less (95% CI: -112, -$26) in average monthly spending on ASD-specific services than would have been expected given concomitant pre-post age cap differences among individuals in the same states who were never eligible for mandate-covered services. In addition, age caps were associated with $99 (95% CI: -$168, -$30) lower average monthly spending on all health care services. Conclusion Insurance mandates that include age caps going into effect during adolescence reduce health service use and spending among individuals with ASD during a critical phase of the life course.

  • Biobehavioral Markers of Attention Bias Modification in Temperamental Risk for Anxiety: A Randomized Control Trial
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-28
    Pan Liu, Bradley C. Taber-Thomas, Xiaoxue Fu, Koraly E. Pérez-Edgar

    Objective Children with behavioral inhibition (BI), a temperament characterized by biologically-based hypervigilance to novelty and social withdrawal, are at high risk for developing anxiety. We examined the effect of a novel attention training protocol, attention bias modification (ABM), on symptomatic-behavioral-neural risk markers in children with BI. Method Nine- to twelve-year-old typically-developing children identified as BI (n=84) were assigned to a four-session active ABM training (n=43) or placebo protocol (n=41) using a double-blind, randomized control trial approach. Anxiety symptoms (Diagnostic Interview Schedule for Children–Fourth Edition), attention bias (measured by a dot-probe task, attention bias [AB]=incongruent reaction time [RT]-congruent RT) and AB-related neural activation (measured by functional magnetic resonance imaging activation for the incongruent>congruent contrast in the dot-probe task) were assessed both before and after the training sessions. Results Our results showed that (1) active ABM (n=40) significantly alleviated participants’ symptoms of separation anxiety, but not social anxiety, compared with the placebo task (n=40); (2) ABM did not modify behavioral AB scores in the dot-probe task; and (3) at the neural level, active ABM (n=15) significantly reduced amygdala and insula activation and enhanced activation in ventrolateral prefrontal cortex relative to placebo (n=19). Conclusion Our findings provide important evidence for ABM as a potentially effective protective tool for temperamentally at-risk children, in a developmental window prior to the emergence of clinical disorder and open to prevention and intervention.

  • Longitudinal Diffusion Tensor Imaging Study of Adolescents and Young Adults With Bipolar Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-26
    Judah Weathers, Elizabeth T.C. Lippard, Linda Spencer, Brian Pittman, Fei Wang, Hilary P. Blumberg

    Objective Longitudinal neuroimaging during adolescence/young adulthood, when bipolar disorder (BD) commonly emerges, can help elucidate the neurodevelopmental pathophysiology of BD. Adults with BD have shown reduced structural integrity in the uncinate fasciculus (UF), a white matter (WM) tract providing major connections between the amygdala and ventral prefrontal cortex (vPFC) important in emotion regulation. In this longitudinal diffusion tensor imaging (DTI) study of adolescents/young adults, we hypothesized differences in age and time-related changes in UF integrity in BD compared to healthy control (HC). Method Two DTI scans were obtained in 27 adolescents/young adults with BD and 37 HC adolescents/young adults, on average approximately 2.5 years apart. Interactions between diagnosis with age and with time for UF fractional anisotropy (FA) were assessed. Exploratory analyses were performed including euthymic-only participants with BD, and for potential influences of demographic and clinical factors. Whole-brain analyses were performed to explore for interactions in other regions. Results There were significant interactions between diagnosis with age and with time for UF FA (p<.05). Healthy control adolescents/young adults showed significant UF FA increases with age and over time (p<.05), while no significant changes with age or over time were observed in the adolescents/young adults with BD. Significant interactions with age and time were also observed in analyses including euthymic-only participants with BD (p<.05). Conclusion These findings provide neuroimaging evidence supporting differences in UF WM structural development during adolescence/young adulthood, suggesting differences in the development of an amygdala-vPFC system subserving emotion regulation may be a trait feature of BD neurodevelopment.

  • Novel Loci Associated With Attention-Deficit/Hyperactivity Disorder Are Revealed by Leveraging Polygenic Overlap With Educational Attainment
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-26
    Alexey A. Shadrin, Olav B. Smeland, Tetyana Zayats, Andrew J. Schork, Oleksandr Frei, Francesco Bettella, Aree Witoelar, Wen Li, Jon A. Eriksen, Florian Krull, Srdjan Djurovic, Stephen V. Faraone, Ted Reichborn-Kjennerud, Wesley K. Thompson, Stefan Johansson, Jan Haavik, Anders M. Dale, Yunpeng Wang, Ole A. Andreassen

    Objective Attention-deficit/hyperactivity disorder (ADHD) is a common and highly heritable psychiatric condition. By exploiting the reported relationship between ADHD and educational attainment (EA), we here aimed to improve discovery of ADHD-associated genetic variants and investigate genetic overlap between these phenotypes. Method A conditional/conjunctional false discovery rate (condFDR/conjFDR) method was applied to genome-wide association study (GWAS) data on ADHD (2,064 trios, 896 cases, and 2,455 controls) and EA (n=328,917 n = 328,917 ) to identify ADHD-associated loci and loci overlapping between ADHD and EA. Identified single nucleotide polymorphisms (SNPs) were tested for association in an independent population-based study of ADHD symptoms (n=17,666 n = 17,666 ). Genetic correlation between ADHD and EA was estimated using LD score regression and Pearson correlation. Results At levels of condFDR<0.01 condFDR < 0.01 and conjFDR<0.05, conjFDR < 0.05 , we identified five ADHD-associated loci, three of these being shared between ADHD and EA. None of these loci had been identified in the primary ADHD GWAS, demonstrating the increased power provided by the condFDR/conjFDR analysis. Leading SNPs for 4 of 5 identified regions are in introns of protein coding genes: KDM4A, MEF2C, PINK1, RUNX1T1, while the remaining one is an intergenic SNP on chromosome 2 at 2p24. Consistent direction of effects in the independent study of ADHD symptoms was shown for 4 of 5 identified loci. A polygenic overlap between ADHD and EA was supported by significant genetic correlation (rg=−0.403 r g = − 0.403 , p=7.90×10−8 p = 7.90 × 10 − 8 ) and >10-fold mutual enrichment of SNPs associated with both traits. Conclusion We identified five novel loci associated with ADHD and provided evidence for a shared genetic basis between ADHD and EA. These findings could aid understanding of the genetic risk architecture of ADHD and its relation to EA.

  • Sexual Risk Behavior Among Youth With Bipolar Disorder: Identifying Demographic and Clinical Risk Factors
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-26
    Megan Krantz, Tina Goldstein, Brian Rooks, John Merranko, Fangzi Liao, Mary Kay Gill, Rasim Diler, Danella Hafeman, Neal Ryan, Benjamin Goldstein, Shirley Yen, Heather Hower, Jeffrey Hunt, Martin Keller, Michael Strober, David Axelson, Boris Birmaher

    Objective This study aims to document rates of sexual activity among youth with bipolar spectrum disorder (BD), and to examine demographic and clinical factors associated with first sexual activity and sexual risk behavior over follow-up. Method The sample was drawn from the Course and Outcome of Bipolar Youth (COBY) study of 413 youth ages 7-17 at baseline who met criteria for BD via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS). Psychiatric symptoms over follow-up were assessed using the Adolescent Longitudinal Interview Follow-Up Evaluation (ALIFE). Sexual behavior and level of sexual risk (e.g., unprotected sex, multiple partners, and/or partners with known sexually transmitted infections [STIs]) were assessed by trained evaluators using the ALIFE Psychosocial Functioning Scale (PSF). Analyses were conducted in relation to first sexual behavior over follow-up, and then to subsequent sexual behaviors, for a mean 9.7 (SD=3.2) years. Results Sexually active COBY youth (n=292/413; 71%) were more likely female, using substances, and not living with both parents. Consistent with findings among healthy youth, earlier first sexual activity in the sample was significantly associated with low socioeconomic status (SES), female sex, comorbid disruptive behavior disorder, and substance use. As with healthy youth, sexual risk behavior over follow-up was significantly associated with Non-Caucasian race, low SES, substance use, and history of sexual abuse. Among those COBY youth who were sexually active, 11% reported sexual assault or abuse, 36% reported becoming pregnant (or significant other becoming pregnant), and 15% reported having at least one abortion (or significant other having an abortion) over follow-up. Hypomanic symptoms over follow-up were temporally associated with greatest risk for sexual risk behavior. Conclusion Demographic and clinical factors may help identify youth with BD at significantly greatest risk for sexual activity and sexual risk behavior. Attending to sexual risk behaviors in this population is warranted.

  • Sexually Transmitted Infection Among Adolescents and Young Adults With Attention-Deficit Hyperactivity Disorder: A Nationwide Longitudinal Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-10
    Mu-Hong Chen, Ju-Wei Hsu, Kai-Lin Huang, Ya-Mei Bai, Nai-Ying Ko, Tung-Ping Su, Cheng-Ta Li, Wei-Chen Lin, Shih-Jen Tsai, Tai-Long Pan, Wen-Han Chang, Tzeng-Ji Chen

    Objective Previous studies suggest that ADHD is related to risky sexual behaviors, which have been regarded as a major risk factor of sexually transmitted infection (STI). However, the association between ADHD and subsequent STIs remains unknown. Method Using the Taiwan National Health Insurance Research Database, 17,898 adolescents and young adults who were diagnosed with ADHD by psychiatrists and 71,592 age-/sex-matched comparisons without ADHD were enrolled between 2001 and 2009 and followed up to the end of 2011 in our study. Participants who developed any STI during the follow-up period were identified. Cox regression analysis was performed to examine the risk of STIs between patients with ADHD and those without ADHD. Results Patients with ADHD were prone to developing any STI (hazard ratio [HR]: 3.36, 95% CI: 2.69∼4.21) after adjusting for demographic data, psychiatric comorbidities, and ADHD medications compared with the comparison group. Substance use disorders (HR: 1.94, 95% CI: 1.27∼2.98) were also associated with the STI risk. Both short-term use (0.70, 95% CI: 0.53∼0.94) of and long-term use (HR: 0.59, 95% CI: 0.37∼0.93) of ADHD medications were related to a reduced risk of subsequent STIs. However, an association between substance use disorders and STIs was observed only in women. By contrast, the effect of ADHD medications on the reduction of STI risk was observed only in men. Conclusion Adolescents and young adults with ADHD had an elevated risk of developing any STI later in life compared with the non-ADHD comparisons. Patients with ADHD who also had substance use disorders were at the highest risk of subsequent STIs. Treatment with ADHD medications was associated with a reduced risk of subsequent STIs.

  • Brain Structural Correlates of Subclinical Obsessive-Compulsive Symptoms in Healthy Children
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-10
    Maria Suñol, Oren Contreras-Rodríguez, Dídac Macià, Gerard Martínez-Vilavella, Ignacio Martínez-Zalacaín, Marta Subirà, Jesús Pujol, Jordi Sunyer, Carles Soriano-Mas

    Objective Subclinical obsessive-compulsive (OC) symptoms are frequently observed in children and have been reported to predict a subsequent diagnosis of OC disorder (OCD). Therefore, identifying the putative neurobiological signatures of such risk is crucial, because it would allow for the characterization of the underpinnings of OCD without the interfering effects of chronicity, medication, or comorbidities, especially when interpreted within the context of OCD clinical heterogeneity and taking into account normal neurodevelopmental changes. The present study aimed to identify the brain volumetric features associated with subclinical OC symptoms and the potential modulatory effects of sex and age in a large sample of healthy children. Method Two hundred fifty-five healthy children were assessed using the Obsessive-Compulsive Inventory–Child Version and underwent a brain structural magnetic resonance examination. The relation between total and symptom-specific scores and regional gray and white matter (GM and WM) volumes was evaluated. Participants were grouped according to sex and age (younger versus older) to assess the effect of these factors on symptom–brain morphometry associations. Results Ordering symptoms were negatively related to GM volumes in the ventral caudate. Hoarding symptoms were positively associated with GM and WM volumes in the left inferior frontal gyrus, and obsessing symptoms correlated negatively with GM and WM volumes in the right temporal pole. Doubt-checking symptoms correlated positively with WM volumes in the right inferior fronto-occipital fasciculus and the corpus callosum. Sex and age modulated some of these associations. Conclusion Subclinical OC symptoms are associated with specific brain volumetric features, which could be considered potential neural signatures of increased risk for OCD.

  • From Childhood Conduct Problems to Poor Functioning at Age 18: Examining Explanations in a Longitudinal Cohort Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-06
    Jasmin Wertz, Jessica Agnew-Blais, Avshalom Caspi, Andrea Danese, Helen L. Fisher, Sidra Goldman-Mellor, Terrie E. Moffitt, Louise Arseneault

    Objective Childhood conduct problems are associated with poor functioning in early adulthood. We tested a series of hypotheses to understand the mechanisms underlying this association. Method We used data from the Environmental Risk (E-Risk) Longitudinal Twin Study, a 1994–1995 birth cohort of 2,232 twins born in England and Wales, followed to age 18 with 93% retention. Severe conduct problems in childhood were assessed at ages 5, 7, and 10 years using parent and teacher reports. Poor functioning at age 18 years, including cautions and convictions, daily cigarette smoking, heavy drinking, and psychosocial difficulties, was measured through interviews with participants and official crime record searches. Results 18-year-olds with versus without a childhood history of severe conduct problems had greater rates of each poor functional outcome, and they were more likely to experience multiple poor outcomes. This association was partly accounted for by concurrent psychopathology in early adulthood, as well as by early familial risk factors, both genetic and environmental. Childhood conduct problems, however, continued to predict poor outcomes at age 18 years after accounting for these explanations. Conclusion Children with severe conduct problems display poor functioning at age 18 years because of concurrent problems in early adulthood and familial risk factors originating in childhood. However, conduct problems also exert a lasting effect on young people’s lives independent of these factors, pointing to early conduct problems as a target for early interventions aimed at preventing poor functional outcomes.

  • National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-06
    Beth Han, Wilson M. Compton, Carlos Blanco, Lisa Colpe, Larke Huang, Richard McKeon

    Objective This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. Method We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied. Results Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county’s population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults. Conclusion During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.

  • Impaired Value Learning for Faces in Preschoolers With Autism Spectrum Disorder
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-11-06
    Quan Wang, Lauren DiNicola, Perrine Heymann, Michelle Hampson, Katarzyna Chawarska

    Objective One of the common findings in autism spectrum disorder (ASD) is limited selective attention toward social objects such as faces. Evidence from both human and nonhuman primate studies suggests that selection of objects for processing is guided by the appraisal of object values. We hypothesized that impairments in selective attention in ASD may reflect a disruption of a system supporting learning about object values in social domain. Method We examined value learning in social (faces) and nonsocial (fractals) domains in preschoolers with ASD (n = 25) and typically developing (TD) controls (n = 28) using a novel value learning task implemented on a gaze-contingent eye-tracking platform consisting of value learning and selective attention choice test. Results Children with ASD performed more poorly than TD controls in the social value learning task, but both groups performed similarly on the nonsocial task. Within-group comparisons indicated that value learning in TD children was enhanced on the social compared to nonsocial task, but no such enhancement was seen in children with ASD. Performance in the social and nonsocial conditions was correlated in the ASD but not in the TD group. Conclusion The study provides support for a domain-specific impairment in value learning for faces in ASD and suggest that in ASD value learning in social and nonsocial domains may rely on a shared mechanism. These findings have implications for both models of selective social attention deficits in autism and identification of novel treatment targets.

  • Parental Rheumatoid Arthritis and Autism Spectrum Disorders in Offspring: A Danish Nationwide Cohort Study
    J. Am. Acad. Child Adolesc. Psychiatry (IF 6.25) Pub Date : 2017-10-09
    Ane Lilleøre Rom, Chun Sen Wu, Jørn Olsen, Damini Jawaheer, Merete Lund Hetland, Lina Steinrud Mørch

    Objective Maternal rheumatoid arthritis (RA) has been associated with an increased risk of autism spectrum disorder (ASD) in the offspring. We assessed the potential influence of both maternal and paternal RA on the risk of ASD in offspring to disentangle the influence of genetic inheritance from other conditions potentially leading to fetal programming. Method The nationwide cohort study included all children born alive from 1977 to 2008 in Denmark (N = 1,917,723). Cox regression models were used to calculate hazard rate ratios (HR) of ASD in offspring exposed to maternal or paternal RA, compared to unexposed children. Results Maternal RA was associated with an approximately 30% increased risk of ASD in the offspring (HR = 1.31 and 95% CI = 1.06−1.63). Also, paternal RA seemed to increase the risk of ASD by approximately 30% (HR = 1.33, 95% CI = 0.97−1.82). Conclusion Our findings suggest maternal as well as paternal RA to be associated with an increased risk of ASD in the offspring, indicating that genetic factors associated with RA may also play a role in the etiology of ASD in children of parents with RA.

Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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