Changes in autonomic regulation with age: implications for psychopharmacologic treatments in children and adolescents

Developmental changes in the cardiovascular system could have an impact on risks associated with psychopharmacological interventions. Children may be more vulnerable to adverse cardiac events due to immaturity in autonomic control of the heart. These changes are incompletely understood and are characterized in this study. A consecutive series of 70 boys, aged 6-14 years, was recruited. Developmental variation in the autonomic nervous system was evaluated by assessing heart period variability (HPV), pulse, and blood pressure in response to orthostasis. Increased age correlated significantly with greater heart rate and diastolic blood pressure response to orthostasis. HPV at rest and in response to tilt did not significantly correlate with age. Boys with family histories of hypertension had a significantly greater blood pressure response to orthostasis. These findings suggest that developmental age-related changes in the sympathetic nervous system, as reflected by changes of pulse and blood pressure response to tilt, occur across this age range. Parasympathetic changes, as reflected by HPV, do not. In light of these findings, more research is needed on children's and adolescents' relative cardiac risk with psychotropic medications as opposed to adults'.

Pathophysiology of childhood anxiety disorders

Prior reviews on the pathophysiology of anxiety consistently note the need for more research on biological aspects of childhood social phobia, separation anxiety disorder, and generalized anxiety disorder. The current review summarizes biological research that is relevant to these three disorders. In the first part of the review, barriers that have prevented progress in this area are delineated, and recent developments are discussed that set the stage for major advances in research on childhood anxiety disorders. In the second part of the review, studies are discussed that provide insights on the pathophysiology of childhood social phobia, separation anxiety disorder, and generalized anxiety disorder. Research on each specific disorder illustrates the manner in which recent developments in biological research facilitate novel research approaches uniquely suited for answering essential clinical questions in research on both childhood and adult anxiety disorders. For example, in research on social phobia, biological studies might enhance understandings of the longitudinal associations between individual childhood and adult disorders. In research on separation anxiety disorder, biological studies might enhance understanding on family-genetic associations between childhood and adult disorders. Finally, in research on generalized anxiety disorder, biological studies might enhance understandings of comorbidities among distinct childhood and adult disorders, particularly with respect to the relationship between anxiety and depressive disorders.

Dichotic listening deficits and the prediction of substance use in young boys

OBJECTIVE

Prior studies note relationships among verbal deficits, disruptive psychopathology, and substance use. The current study examines the relationship between verbal deficits, assessed through a dichotic listening test, and children's substance use.

METHOD

A series of 87 young boys was prospectively followed over a 1- to 2-year period. A prior study in these boys noted a cross-sectional relationship between disruptive psychopathology and deficits on a dichotic consonant-vowel listening test. The current study examines the predictive relationship between this language-related deficit at one study wave and substance use assessed during a follow-up study wave.

RESULTS

Reduced right ear accuracy, reflecting a deficit in left hemisphere processing ability, predicted substance use at follow-up. This association was independent of any other predictors, including cognitive or behavioral indices of substance use risk.

CONCLUSIONS

A lateralized deficit in verbal processing on a dichotic listening task predicts change in substance use by follow-up. Findings are consistent with other evidence linking early childhood lateralization abnormalities to development of disruptive psychopathology.

Memory and anxiety in prepubertal boys at risk for delinquency

OBJECTIVE

To examine the association between memory and anxiety symptoms in young urban-dwelling boys.

METHOD

A series of 111 boys, aged 7 to 11 years, at risk for disruptive psychopathology received standardized assessments of psychopathology and neuropsychological abilities, including verbal and design memory ability. While neuropsychological ability was rated at an initial study wave, psychopathology was rated at both an initial and a follow-up study wave, separated by approximately 18 months.

RESULTS

Anxiety symptoms were more strongly correlated with poor memory ability than with reduced intelligence. Disruptive symptoms, in contrast, were more strongly correlated with reduced intelligence than with poor memory ability. Finally, boys with an anxiety disorder exhibited reduced memory abilities relative to other boys in the sample. Relationships generally appeared strongest in longitudinal analyses, such that poorer memory ability at study intake predicted increased anxiety at follow-up.

CONCLUSIONS

Anxiety is associated with reduced memory ability in young urban boys at risk for disruptive psychopathology.

Therapeutics of aggression in children

This paper examines the phenomenology, aetiology and therapeutics of childhood aggression that arises as part of a disruptive behaviour disorder. Phenomenology is discussed with an emphasis on treatment implications. Reviewed studies show that aggressive behaviour exhibits both episodicity and considerable individual stability. Aetiological theories are reviewed with emphasis on the interplay between biological and socio-environmental factors. Both factors are centrally involved in the development and treatment of aggression. A review of double-blind, placebo-controlled medication studies is presented. A computer-based, literature search using Medline and PsychInfo was conducted to locate all potentially relevant articles published in the past 20 years. It was found that there are various treatments available for reducing paediatric aggression including psychotherapeutic and psychopharmacological treatments. There are data to support the use of psychostimulants, lithium and antipsychotics, while data for other agents are only beginning to accumulate. Various pharmacological treatments can reduce aggression in children. However, given the role of both biological and social factors in the development of aggression, multimodal treatment may ultimately provide maximal benefits.

Childhood anxiety: integrating developmental psychopathology and affective neuroscience

This article reviews progress in research on childhood phobia, generalized anxiety, and separation anxiety disorders from the perspectives of developmental psychopathology and affective neuroscience. These perspectives represent two organizing theoretical schools in the realms of clinical and basic science research. Studies in developmental psychopathology suggest the need to identify specific subgroups of children with one of these anxiety disorders who are particularly at risk for anxiety disorders in adulthood. Studies in affective neuroscience suggest potential neurobiological avenues for identifying such children who face a particularly high risk for chronic anxiety disorders.

Panic induced by carbon dioxide inhalation and lack of hypothalamic-pituitary-adrenal axis activation

It has been hypothesized that spontaneous panic is distinct from anticipatory anxiety, which activates the hypothalamic-pituitary-adrenal (HPA) axis. Panic attacks characterized by prominent respiratory symptoms, such as those induced by sodium lactate, are not associated with increases in cortisol. We examined blood cortisol responses to CO2-induced panic. Cortisol levels did not increase and actually decreased significantly in 10 panicking subjects with panic disorder. No reductions were noted after 20 min of CO2 inhalation in either eight normal comparison subjects or six non-panicking panic disorder patients. These results lend support to the hypothesis that the pathophysiological mechanism underlying CO2-induced panic is different from that underlying general or anticipatory anxiety.

Adolescent depressive symptoms as predictors of adult depression: moodiness or mood disorder?

OBJECTIVE

The authors' goal was to examine the relationship between subclinical depressive symptoms in adolescence and major depressive episodes in adulthood.

METHOD

An epidemiologic sample of 776 young people received psychiatric assessments in 1983, 1985, and 1992. Among adolescents not meeting criteria for major depression, the authors estimated the magnitude of the association between subclinical adolescent depressive symptoms and adult major depression.

RESULTS

Symptoms of major depression in adolescence strongly predicted an adult episode of major depression: having depressive symptoms more than two-standard-deviations above the mean in number predicted a two-fold to three-fold greater risk for an adult major depressive episode.

CONCLUSIONS

Symptoms of depression in adolescence strongly predict an episode of major depression in adulthood, even among adolescents without major depression.

Heart period variability and psychopathology in urban boys at risk for delinquency

To examine associations between heart period variability (HPV) and psychopathology in young urban boys at risk for delinquency, a series of 697-11-year-old younger brothers of adjudicated delinquents received a standardized psychiatric evaluation and an assessment of heart period variability (HPV). Psychiatric symptoms were rated in two domains: externalizing and internalizing psychopathology. Continuous measures of both externalizing and internalizing psychopathology were associated with reductions in HPV components related to parasympathetic activity. These associations could not be explained by a number of potentially confounding variables, such as age, ethnicity, social class, body size, or family history of hypertension. Although familial hypertension predicted reduced HPV and externalizing psychopathology, associations between externalizing psychopathology and HPV were independent of familial hypertension. Psychiatric symptoms are associated with reduced HPV in young urban boys at risk for delinquency.

Ventilatory physiology of children and adolescents with anxiety disorders

BACKGROUND

Abnormalities in ventilatory physiology have been noted in adults with panic disorder. We tested the hypothesis that abnormalities in ventilatory physiology differentiate children and adolescents with anxiety disorders from psychiatrically healthy children.

METHODS

Ventilatory physiology was monitored with a canopy apparatus during room-air breathing and 15 minutes of carbon dioxide exposure in 33 children and adolescents comprising 18 probands with an anxiety disorder and 15 psychiatrically healthy children.

RESULTS

During room-air breathing, probands had significantly larger minute ventilation, larger tidal volumes, and more variable breathing patterns than healthy comparisons, but the groups did not differ in end-tidal carbon dioxide or respiratory rate. During carbon dioxide challenge, probands exhibited larger minute ventilation and respiratory rate responses relative to comparisons.

CONCLUSION

These findings on the association between ventilatory physiology and anxiety disorders in children and adolescents are consistent with results from studies of adults with panic disorder.

Prospective associations between somatic illness and mental illness from childhood to adulthood

The association between somatic illness and psychiatric illness is well established in adults but is less clear in childhood and adolescence. A cohort of over 700 randomly selected children in Upstate New York were studied from ages 1-10 years in 1975 to young adulthood in 1992. Psychiatric and physical health were assessed by means of follow-up youth and parent interviews at 8-, 2 1/2-, and 6-year intervals (in 1983, 1985-1986, and 1991-1993). Cross-sectional and longitudinal analyses investigated: 1) the consistency of the relation between physical illness and mental illness in childhood; 2) the specificity of major depressive disorder (MDD) in accounting for the relation; 3) the specificity of immunologically mediated medical disorders in this relation; and 4) whether this relation was attributable to risks associated with low socioeconomic status. Cross-sectionally, ill health was associated with increased risk of psychiatric disorders at all ages, with significant odds ratios (ORs) ranging from 1.76 to 3.26. In prospective analyses, ill health increased the risk of new-onset MDD at all ages (ORs = 2.05-4.48). MDD also predicted subsequent ill health, independent of prior health problems (ORs = 3.81 and 4.04). Relations were not attributable to familial socioeconomic status. Associations were particularly strong between MDD and medical disorders associated with alterations in immunologic factors (ORs = 1.83-6.41). Theories of common immune-mediated vulnerabilities to medical illness and depression are consistent with these associations.

The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders

BACKGROUND

Various studies find relationships among anxiety and depressive disorders of adolescence and adulthood. This study prospectively examines the magnitude of longitudinal associations between adolescent and adult anxiety or depressive disorders.

METHODS

An epidemiologically selected sample of 776 young people living in upstate New York received DSM-based psychiatric assessments in 1983, 1985, and 1992 using structured interviews. The magnitude of the association between adolescent and adult anxiety or depressive disorders was quantified using odds ratios generated from logistic regression analyses and from a set of latent Markov analyses. We focus on longitudinal associations among narrowly defined DSM anxiety or depressive disorders.

RESULTS

In simple logistic models, adolescent anxiety or depressive disorders predicted an approximate 2- to 3-fold increased risk for adulthood anxiety or depressive disorders. There was evidence of specificity in the course of simple and social phobia but less specificity in the course of other disorders. Results from the analyses using latent variables suggested that while most adolescent disorders were no longer present in young adulthood, most adult disorders were preceded by adolescent disorders.

CONCLUSIONS

An anxiety or depressive disorder during adolescence confers a strong risk for recurrent anxiety or depressive disorders during early adulthood. Most anxiety and depressive disorders in young adults may be preceded by anxiety or depression in adolescence.

Neurological soft signs: one-year stability and relationship to psychiatric symptoms in boys

OBJECTIVE

This study had two main objectives: (1) to examine the 1-year stability of neurological soft signs and (2) to examine the longitudinal relationship between soft signs and psychiatric symptoms in young boys.

METHOD

A consecutive series of 56 boys from a high-risk sample received standardized psychiatric and soft sign assessments at study intake. Approximately 1 year later, 48 (86%) of these boys received a reassessment of their psychiatric and soft sign status.

RESULTS

Soft signs exhibited marked stability across the 1-year period (intraclass correlation = .70, p < .001). Symptoms of both internalizing and externalizing disorders correlated with poor performance on the soft sign examination. For both internalizing and externalizing symptoms, the association with soft signs occurred primarily among individuals with persistently high scores on symptom scales across the two assessments.

CONCLUSIONS

Performance on a standardized neurological soft sign examination is stable over a 1-year period. Soft signs measured with this examination relate to both internalizing and externalizing symptoms in young boys, particularly when symptoms are relatively stable over time. Further research should consider the clinical significance of childhood soft signs.

Verbal dichotic listening in boys at risk for behavior disorders

OBJECTIVE

The association between deficits in verbal processing skills and disruptive psychopathology remains one of the most frequently replicated findings in all of child psychiatry. This study uses a dichotic consonant-vowel listening test to examine the potential neural basis for this association.

METHOD

A series of 87 young boys recruited from a sample at risk for disruptive disorders received standardized psychiatric, neuropsychological, and language skills assessments. Approximately 1 year later, these boys received a reassessment of their psychiatric status and a test that assesses the neural basis of language-processing ability, a dichotic consonant-vowel listening test.

RESULTS

Disruptive psychopathology predicted reduced right ear accuracy for dichotic syllables, indicative of a deficit in left hemisphere processing ability. Deficits in reading and language ability also correlated with right ear accuracy for dichotic syllables.

CONCLUSIONS

Boys with disruptive behavior disorders, relative to at-risk but nondisruptive boys, exhibit a deficit in verbal processing abilities on dichotic listening tasks. This deficit in verbal processing ability is also manifested as low scores on standardized tests of reading achievement and language comprehension.

Neuroendocrine response to fenfluramine challenge in boys. Associations with aggressive behavior and adverse rearing

BACKGROUND

There is evidence of relationships among serotonin, aggressive behavior, and a childhood history of socially adverse-rearing conditions. This study examines the prolactin response to fenfluramine hydrochloride challenge in young boys who show clinically significant aggressive behavior or who are raised in a social environment that is conducive to the development of chronic aggression.

METHODS

A series of 34 younger brothers of convicted delinquents underwent standardized psychiatric and observation-based assessments of their social-rearing environments that were conducted during home visits. Approximately 2 years later, these boys underwent a reassessment of psychiatric status and an assessment of central serotonergic activity using the fenfluramine challenge procedure.

RESULTS

Increasing degrees of aggressive behavior at either assessment were positively correlated with the prolactin response to fenfluramine challenge. Furthermore, adverse-rearing circumstances that were conducive to the development of aggressive behavior also exhibited positive correlations with the prolactin response. This association between adverse rearing and the prolactin response was statistically independent of that between aggression and the prolactin response.

CONCLUSION

In young boys, aggressive behavior and social circumstances that are conducive to the development of aggressive behavior are positively correlated with a marker of central serotonergic activity.

Psychiatric symptoms in adolescence as predictors of obesity in early adulthood: a longitudinal study

OBJECTIVES

This study examined the longitudinal relationship between psychopathology and obesity in young adulthood.

METHODS

More than 700 youth in a population-based sample were psychiatrically assessed in 1983 (mean age = 14 years) and 1992 (mean age = 22 years). Self-reported body mass index (BMI) in 1992 was regressed on measures of depression and conduct disorder as well as a set of covariates including indices of physical health, social class, intelligence, and cigarette and alcohol use. Associations were examined with BMI treated as a continuous variable and with a binary index of obesity derived from the BMI distribution in each gender.

RESULTS

BMI in young adults was positively related to a number of covariates. With all covariates controlled, BMI was inversely related to adult depressive symptoms in males but not females. BMI was positively related to adolescent symptoms of conduct disorder in both sexes. Similar associations were found between psychiatric symptoms and obesity.

CONCLUSIONS

Conduct disorder symptoms in adolescence predicted BMI and obesity in early adulthood. These associations remained after controlling for factors that can affect the association between psychopathology and obesity.

Childhood anxiety disorders

Although anxiety is among the most common psychiatric problems faced by children and adolescents, anxiety disorders have been a relatively neglected research topic in comparison to childhood disruptive behavior and depressive disorders. Recent epidemiologic data have brought increasing attention to these impairing disorders. A review of these data is provided, and results from recent studies on the genetics, biology, and treatment of childhood anxiety disorders are integrated with a discussion of directions for future research. The data reviewed here point both to our growing understanding of childhood anxiety and to the need for continued research to address significant shortcomings in our knowledge base.

Minor physical anomalies: modifiers of environmental risks for psychiatric impairment?

OBJECTIVE

To test the hypothesis that minor physical anomalies (MPAs) modify an adolescent's vulnerability to environmental risk factors for psychopathology.

METHOD

One hundred eighteen unreferred male adolescents who had been evaluated as 7-year-olds received a comprehensive neuropsychiatric evaluation. The evaluation included standardized assessments of environmental risk factors for psychiatric impairment, neurological signs, IQ, MPAs, and psychiatric impairment. The relationship between psychiatric status and environmental risk was examined as a function of the MPA profile.

RESULTS

There was a significant interaction between MPAs and environmental risk in predicting psychiatric status. Environmental risk was more predictive of psychiatric impairment at age 17 in subjects with high scores on the MPA scale than in subjects with low scores on the scale. This relationship was particularly apparent in subjects with conduct disorder. MPAs also exhibited relationships with two childhood factors, neurological soft signs and Verbal IQ, that had been shown to predict adolescent psychopathology in prior reports on this cohort.

CONCLUSIONS

MPAs may contribute to psychiatric impairment by influencing an individual's vulnerability to environmental risk factors for psychopathology. These suggestive findings are consistent with an emerging body of literature examining the role of biopsychosocial interactions in psychiatric disorders.

The association between major depression and headache: results of a longitudinal epidemiologic study in youth

Retrospective epidemiologic research in adults suggests that a long-term association between major depression and headache arises during childhood or adolescence. This study uses data from a prospective epidemiologic study to examine the association between major depression and headache from late childhood into early adulthood. An epidemiologically selected sample of 776 youth, aged 9-18, was assessed psychiatrically in 1983 using DISC interviews with both youth and parent informants. Reassessments were conducted in 1985-1986 and 1992. Current and past histories of functionally impairing migraine or chronic headache were elicited in both 1985-1986 and 1992. Regression analyses examined the relationships between major depression and headache status. The prevalence of current functionally impairing headache was approximately 10% in both 1985-1986 and 1992. There were lifetime and cross-sectional associations between headache and major depression. Headache was approximately twice as common in depressed adolescents compared with nondepressed adolescents. Major depression in adolescents, without current or past headache, prospectively predicted the new onset of headaches in young adulthood. Among adolescents who had no history of chronic impairing headache in 1985-1986, those with current major depression faced a nearly tenfold increased risk of developing such headaches at some time during the next 7 years. Consistent with findings of retrospective studies among adults, a longitudinal/ developmental relationship between major depression and functionally impairing headache was found in this prospective epidemiologic study of youth. These findings suggest that (1) neurochemical and pharmacologic commonalities between depression and headache should receive further investigation and that (2) it may be clinically useful to inquire about family history of headache syndromes in adolescents with major depression because such questioning may provide insight about the risk of subsequent functionally impairing headache in a depressed adolescent.

Discriminating depression and anxiety in youth: a role for diagnostic criteria

OBJECTIVE

To test the hypothesis that anxiety and depression in youth, as in adults, become increasingly discriminable when youth meet criteria for an emotional disorder.

METHOD

The study uses cross-sectional data at two points in time from a large (n = 776) community sample of youths, aged eight to twenty. Associations between major depression and five anxiety disorders (overanxious, obsessive compulsive and separation anxiety disorders, and social and simple phobias) are examined by symptom scale and diagnosis.

RESULTS

Anxiety and depression are moderately correlated, and substantially comorbid by diagnostic category. Symptoms are more discriminable among youths with diagnoses of at least one emotional disorder than among those without. A single factor accounts for symptoms among the non-diagnosed but multiple factors are required for the diagnosed group.

CONCLUSIONS

Anxiety and depression are discriminable among youth who meet criteria for a specific emotional disorder but more highly associated among youths without such a diagnosis. This suggests that in youth, as has been shown in adults, depression and anxiety become increasingly discriminable as emotional psychopathology becomes more severe.

Cardiac profile and disruptive behavior in boys at risk for delinquency

The objective of this study was to examine associations in youth between antisocial behavior and cardiovascular profile. Younger brothers of adjudicated delinquents (N = 120) received a standardized psychiatric assessment and an assessment of three factors often studied in behavioral cardiology research: family history of hypertension, resting blood pressure, and obesity. As a group, relative to population norms, these youth exhibited signs of obesity and elevated blood pressure, with 30% of the sample appearing clinically obese and 24% having a blood pressure above the 90th percentile for national norms in their age cohort. Within the sample, score on the Child Behavior Checklist (CBCL) Delinquency scale correlated with blood pressure (r = .29-.34) and an index of obesity, weight/height3 (r = .20). Further, scores on the CBCL Delinquency, Aggression, and Externalizing scales were elevated in boys with a positive family history of hypertension. Among boys at risk for delinquency, disruptive psychopathology relates to factors often studied in behavioral cardiology research. Relationships between risk factors for ischemic cardiovascular disease and hostile behavior may be manifested with measures of disruptive psychopathology.