Latent class analysis shows strong heritability of the child behavior checklist-juvenile bipolar phenotype

Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions

OBJECTIVE

Pediatric bipolar disorder (PBD) is associated with poor outcomes, including suicidal ideation (SI) and suicide attempt (SA). However, frequencies and risk factors of SI/SA and targeted intervention trials for SI/SA in PBD have not been reviewed systematically.

METHODS

We conducted a systematic PubMed review, searching for articles reporting on prevalences/incidences, correlates and intervention studies targeting SI/SA in PBD. Weighted means were calculated, followed by an exploratory meta-regression of SI and SA correlates.

RESULTS

Fourteen studies (n = 1595), in which 52.1% of patients were male and the mean age was 14.4 years, reported data on SI/SA prevalence (N = 13, n = 1508) and/or correlates (N = 10, n = 1348) in PBD. Weighted mean prevalences were: past SI = 57.4%, past SA = 21.3%, current SI = 50.4%, and current SA = 25.5%; incidences (mean 42 months of follow-up) were: SI = 14.6% and SA = 14.7%. Regarding significant correlates, SI (N = 3) was associated with a higher percentage of Caucasian race, narrow (as opposed to broad) PBD phenotype, younger age, and higher quality of life than SA. Significant correlates of SA (N = 10) included female sex, older age, earlier illness onset, more severe/episodic PBD, mixed episodes, comorbid disorders, past self-injurious behavior/SI/SA, physical/sexual abuse, parental depression, family history of suicidality, and poor family functioning. Race, socioeconomic status, living situation, and life events were not clearly associated with SA. In a meta-regression analysis, bipolar I disorder and comorbid attention-deficit hyperactivity disorder were significantly associated with SA. Only one open label study targeting the reduction of SI/SA in PBD was identified.

CONCLUSIONS

SI and SA are very common but under-investigated in PBD. Exploration of predictors and protective factors is imperative for the establishment of effective preventive and intervention strategies, which are urgently needed.

The dysregulation profile in young children: empirically defined classes in the Generation R study

OBJECTIVE

Children with co-occurring internalizing and externalizing problems have higher levels of impairment and worse outcomes later in life, but it is unclear whether these children can be distinguished validly from children who have problems in a single domain. We used a person-centered statistical approach to examine whether a group of children with co-occurring internalizing and externalizing problems can be identified in a general-population sample of young children.

METHOD

This study included a population-based sample of 6,131 children, aged 5 through 7 years. Mothers (92.6%) reported emotional and behavioral problems using the Child Behavior Checklist/1.5-5 (CBCL). A latent profile analysis was performed on the CBCL syndrome scales. Identified classes were compared on early socioeconomic and parental risk factors using multinomial logistic regression.

RESULTS

We identified 4 classes, as follows: a class scoring high on all internalizing and externalizing scales (1.8%); a class with internalizing problems (5.3%); a class with externalizing problems and emotional reactivity (7.3%); and a class without problems (85.6%). The first class, with co-occurring problems, was associated with higher levels of maternal and paternal affective symptoms and hostility than the other 3 classes.

CONCLUSIONS

The class with co-occurring internalizing and externalizing problems appears to be highly similar to the CBCL Dysregulation Profile described in older children. This empirically based dysregulation profile offers a promise to the study of the development of poor self-regulation.

The child behavior checklist dysregulation profile predicts adolescent DSM-5 pathological personality traits 4 years later

Emotional dysregulation in childhood has been associated with various forms of later psychopathology, although no studies have investigated the personality related adolescent outcomes associated with early emotional dysregulation. The present study uses a typological approach to examine how the child behavior checklist-dysregulation profile (CBCL-DP) predicts DSM-5 pathological personality traits (as measured with the personality inventory for the diagnostic and statistical manual of mental disorders 5 or PID-5 by Krueger et al. (Psychol Med 2012)) across a time span of 4 years in a sample of 243 children aged 8-14 years (57.2 % girls). The results showed that children assigned to the CBCL-DP class are at risk for elevated scores on a wide range of DSM-5 personality pathology features, including higher scores on hostility, risk taking, deceitfulness, callousness, grandiosity, irresponsibility, impulsivity and manipulativeness. These results are discussed in the context of identifying early manifestations of persistent regulation problems, because of their enduring impact on a child's personality development.

Cross-informant agreement on child and adolescent withdrawn behavior: a latent class approach

Withdrawn behavior (WB) relates to many developmental outcomes, including pervasive developmental disorders, anxiety, depression, psychosis, personality disorders and suicide. No study has compared the latent profiles of different informants' reports on WB. This study uses multi-informant latent class analyses (LCA) of the child behavior checklist (CBCL), teacher report form (TRF) and youth self-report (YSR) to examine phenotypic variance in WB. LCA was applied to the CBCL, TRF and YSR of 2,031 youth (ages 6-18); of which 276 children were clinically-referred. A 4-class solution for the CBCL and 3-class solutions for the YSR and TRF were optimal. The CBCL yielded low symptoms, predominantly shy or secretive moderate symptoms, and all symptoms classes. The TRF lacked the moderate--secretive class, and the YSR lacked the moderate--shy class. Agreement was low. LCA shows similar structure of withdrawn behavior across informants but characterizations of moderate WB vary.

Personal and familial correlates of bipolar (BP)-I disorder in children with a diagnosis of BP-I disorder with a positive child behavior checklist (CBCL)-severe dysregulation profile: a controlled study

BACKGROUND

Although the DSM-IV provides explicit criteria for the diagnosis of BP-I disorder, this is a complex diagnosis that requires high levels of clinical expertise. Previous work shows children with a unique profile of the CBCL of high scores (2SD) on the attention problems (AP), aggressive behavior (AGG), and anxious-depressed (AD) (A-A-A) subscales are more likely than other children to meet criteria for BP-I disorder in both epidemiological and clinical samples. However, since not all BP-I disorder children have a positive profile questions remain as to its informativeness, particularly in the absence of an expert diagnostician.

METHODS

Analyses were conducted comparing personal and familial correlates of BP-I disorder in 140 youth with a structured interview and an expert clinician based DSM-IV diagnosis of BP-I disorder with (N=80) and without (N=60) a positive CBCL- Severe Dysregulation profile, and 129 controls of similar age and sex without ADHD or a mood disorder. Subjects were comprehensively assessed with structured diagnostic interviews and wide range of functional measures. We defined the CBCL-severe dysregulation profile as an aggregate cut-off score of ≥ 210 on the A-A-A scales.

RESULTS

BP-I probands with and without a positive CBCL-severe dysregulation profile significantly differed from Controls in patterns of psychiatric comorbidity, psychosocial and psychoeducational dysfunction, and cognitive deficits, as well as in their risk for BP-I disorder in first degree relatives.

LIMITATIONS

Because the sample was referred and largely Caucasian, findings may not generalize to community samples and other ethnic groups.

CONCLUSION

A positive CBCL-severe dysregulation profile identifies a severe subgroup of BP-I disorder youth.

Comorbidity and phenomenology of bipolar disorder in children with ADHD

OBJECTIVE

To assess the comorbidity of bipolar disorder (BPD) in children with ADHD and to study the psychopathological profile of ADHD children with and without mania.

METHOD

A total of 100 children with ADHD were assessed with a semistructured diagnostic interview and questionnaires of mania, ADHD, and general psychopathology.

RESULTS

8% of children met criteria for BPD and 6% for BPD-not specified. ADHD children with bipolar spectrum disorder had greater comorbidity with disruptive behavior disorders and scored higher on the Young Mania Rating Scales and on the Child Behavior Checklist (CBCL) Scales of rule-breaking behavior, externalizing problems, and total problems; however, significance on the CBCL Scales was lost when controlling for disruptive behavior disorders.

CONCLUSION

BPD is frequently associated with ADHD; it has important implications for prognosis and choice of treatment. Differences on the CBCL Scales could be explained by the comorbidity with disruptive behavior disorders rather than by a specific manic profile.

Blunted HPA axis response to stress is related to a persistent Dysregulation Profile in youth

The Child Behavior Checklist Dysregulation Profile (DP) in youth has been shown to be a predictor of psychopathology later in life. We examined the activity of the hypothalamic pituitary adrenal (HPA) axis in youth with remitted, new, persistent, and no DP. Data from 489 youth (47% boys) participating in a Dutch longitudinal general population study were included (Wave 1 mean age=11.5, Wave 2=14.2). Wave 2 diurnal cortisol patterns and levels in response to a laboratory stress paradigm were compared in youth with DP at Wave 1 only, Wave 2 only, both Waves, and neither Wave. Youth with the DP at Wave 2 only or at both time points showed blunted cortisol responses to stress relative to the other two groups. There were no group or sex differences in diurnal cortisol activity. More research is needed to determine how the association between DP symptoms and HPA axis functioning changes over time.

Separating the domains of oppositional behavior: comparing latent models of the conners' oppositional subscale

OBJECTIVE

Although oppositional defiant disorder (ODD) is usually considered the mildest of the disruptive behavior disorders, it is a key factor in predicting young adult anxiety and depression and is distinguishable from normal childhood behavior. In an effort to understand possible subsets of oppositional defiant behavior (ODB) that may differentially predict outcome, we used latent class analysis of mother report on the Conners' Parent Rating Scales Revised Short Forms (CPRS-R:S).

METHOD

Data were obtained from mother report for Dutch twins (7 years old, n = 7,597; 10 years old, n = 6,548; and 12 years old, n = 5,717) from the Netherlands Twin Registry. Samples partially overlapped at ages 7 and 10 years (19% overlapping) and at ages 10 and 12 years (30% overlapping), but not at ages 7 and 12 years. Oppositional defiant behavior was measured using the six-item Oppositional subscale of the CPRS-R:S. Multilevel LCA with robust standard error estimates was performed using the Latent Gold program to control for twin-twin dependence in the data. Class assignment across ages was determined and an estimate of heritability for each class was calculated. Comparisons with maternal report Child Behavior Checklist (CBCL) scores were examined using linear mixed models at each age, corrected for multiple comparisons.

RESULTS

The LCA identified an optimal solution of four classes across age groups. Class 1 was associated with no or low symptom endorsement (69-75% of the children); class 2 was characterized by defiance (11-12%); class 3 was characterized by irritability (9-11%); and class 4 was associated with elevated scores on all symptoms (5-8%). Odds ratios for twins being in the same class at each successive age point were higher within classes across ages than between classes. Heritability within the two "intermediate" classes was nearly as high as for the class with all symptoms, except for boys at age 12. Children in the Irritable class were more likely to have mood symptoms on the CBCL scales than children in the Defiant class but demonstrated similar scores on aggression and externalizing scales. Children in the All Symptoms class were higher in both internalizing and externalizing scales and subscales.

CONCLUSIONS

The LCA indicates four distinct latent classes of oppositional defiant behavior, in which the distinguishing feature between the two intermediate classes (classes 2 and 3) is the level of irritability and defiance. Implications for the longitudinal course of these symptoms, association with other disorders, and genetics are discussed.

The dysregulation profile predicts cannabis use in the offspring of teenage mothers

Background. Offspring of teenage mothers are at greater risk of early drug use. Research has identified a child behavior checklist (CBCL) profile for children with high levels of comorbid behavior problems, the dysregulation profile (DP), as another risk factor for drug use. Method. Teenage girls (12–18 years old; 71% African-American, 29% White) were recruited during pregnancy. Data were collected during pregnancy and when offspring were 6, 10, and 14 years old (n = 318). Mothers completed the CBCL when children were at ages 6 and 10, and children who scored 60 or higher on all 3 DP subscales (aggression, anxiety/depression, and attention problems) were categorized as dysregulated. At ages 10 and 14, the offspring (50% male, 50% female) reported on their cannabis use and completed the childhood depression inventory (CDI). Results. DP at age 6 and depressive symptoms at age 14 predicted recent cannabis use in the offspring. There was a significant interaction between race and pubertal timing such that White offspring who matured earlier were at greater risk of recent cannabis use. Conclusions. The results of this study suggest that it may be possible to identify a subset of children at risk of dual diagnosis as early as age 6.

Correlates of the CBCL-dysregulation profile in preschool-aged children

BACKGROUND

A growing literature indicates that the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) identifies youths with heightened risk for severe psychopathology, comorbidity, and impairment. However, this work has focused on school-age children and adolescents; no studies have examined whether preschool-aged children with the CBCL-DP exhibit a similar constellation of problems.

METHOD

Using a community sample of preschoolers, we compared children with (N = 61) and without (N = 488) the CBCL-DP on a broad range of variables assessed using multiple methods.

RESULTS

Univariate analyses revealed numerous differences between children with the CBCL-DP and their peers on psychiatric symptomatology, temperament, parenting behavior, and parental personality, psychopathology, and marital functioning. In multivariate analyses, children with the CBCL-DP exhibited greater temperamental negative affectivity and lower effortful control. They also had more depressive and oppositional defiant symptoms, as well as greater functional impairment. Parents of CBCL-DP children reported engaging in more punitive, controlling parenting behavior than parents of non-profile children.

CONCLUSIONS

In a non-clinical sample of preschoolers, the CBCL-DP is associated with extensive emotional and behavioral dysregulation and maladaptive parenting.

Temperamental profiles of dysregulated children

It is crucial to characterize self-regulation in children. We compared the temperamental profiles of children with the Child Behavior Checklist (CBCL) Dysregulation Profile (CBCL-DP) to profiles associated with other CBCL-derived syndromes. 382 children (204 boys; aged 5-18) from a large family study were examined. Temperamental profiles were based on the Juvenile Temperament and Character Inventory. Children with the CBCL-DP had a temperamental profile characterized by high Novelty Seeking, high Harm Avoidance, low Reward Dependence and low Persistence. Linear mixed models and regression-based models demonstrated that the CBCL-DP was associated with a "disengaged" temperamental profile. This profile is similar to the profile seen in adult disorders of self-regulation, including cluster B personality disorders. These results support the hypothesis that the CBCL-DP measures poor self-regulation.

Childhood personality types: vulnerability and adaptation over time

BACKGROUND

  Substantial evidence suggests that a Five-Factor Model personality assessment generates a valid description of childhood individual differences and relates to a range of psychological outcomes. Less is known, however, about naturally occurring profiles of personality and their links to psychopathology. The current study explores whether childhood personality characteristics tend to cluster in particular personality profiles that show unique associations with psychopathology and quality of life across time.

METHODS

  Latent class analysis was conducted on maternal rated general personality of a Flemish childhood community sample (N = 477; mean age 10.6 years). The associations of latent class membership probability with psychopathology and quality of life 2 years later were examined, using a multi-informant perspective.

RESULTS

  Four distinguishable latent classes were found, representing a Moderate, a Protected, an Undercontrolled and a Vulnerable childhood personality type. Each of these types showed unique associations with childhood outcomes across raters.

CONCLUSIONS

  Four different personality types can be delineated at young age and have a significant value in understanding vulnerability and adaptation over time.

Dimensional psychopathology in offspring of parents with bipolar disorder

OBJECTIVES

To compare the dimensional psychopathology in offspring of parents with bipolar disorder (BP) with offspring of community control parents as assessed by the Child Behavior Checklist (CBCL).

METHODS

Offspring of parents with BP, who were healthy or had non-BP disorders (any psychiatric disorder other than BP; n = 319) or who had bipolar spectrum disorders (n = 35), and offspring of community controls (n = 235) ages 6-18 years were compared using the CBCL, the CBCL-Dysregulation Profile (CBCL-DP), and a sum of the CBCL items associated with mood lability. The results were adjusted for multiple comparisons and for any significant between-group demographic and clinical differences in both biological parents and offspring.

RESULTS

With few exceptions, several CBCL (e.g., Total, Internalizing, and Aggression Problems), CBCL-DP, and mood lability scores in non-BP offspring of parents with BP were significantly higher than in offspring of control parents. In addition, both groups of offspring showed significantly lower scores in most scales when compared with offspring of parents with BP who had already developed BP. Similar results were obtained when analyzing the rates of subjects with CBCL T-scores that were two standard deviations or higher above the mean.

CONCLUSIONS

Even before developing BP, offspring of parents with BP had more severe and higher rates of dimensional psychopathology than offspring of control parents. Prospective follow-up studies in non-BP offspring of parents with BP are warranted to evaluate whether these dimensional profiles are prodromal manifestations of mood or other disorders, and can predict those who are at higher risk to develop BP.

Genome-wide association study of the child behavior checklist dysregulation profile

OBJECTIVE

A potentially useful tool for understanding the distribution and determinants of emotional dysregulation in children is a Child Behavior Checklist profile, comprising the Attention Problems, Anxious/Depressed, and Aggressive Behavior clinical subscales (CBCL-DP). The CBCL-DP indexes a heritable trait that increases susceptibility for later psychopathology, including severe mood problems and aggressive behavior. We have conducted a genome-wide association study of the CBCL-DP in children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Families were ascertained at Massachusetts General Hospital and University of California, Los Angeles. Genotyping was conducted with the Illumina Human1M or Human1M-Duo BeadChip platforms. Genome-wide association analyses were conducted with the MQFAM multivariate extension of PLINK.

RESULTS

CBCL data were available for 341 ADHD offspring from 339 ADHD affected trio families from the UCLA (N = 128) and the MGH (N = 213) sites. We found no genome-wide statistically significant associations but identified several plausible candidate genes among findings at p < 5E-05: TMEM132D, LRRC7, SEMA3A, ALK, and STIP1.

CONCLUSIONS

We found suggestive evidence for developmentally expressed genes operant in hippocampal dependent memory and learning with the CBCL-DP.

Acupuncture for attention deficit hyperactivity disorder (ADHD): study protocol for a randomised controlled trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neuro-psychiatric problem, affecting 7-9% of children. Pharmacological interventions are widely used with behavioral treatments in ADHD. Still, the origin of ADHD is unclear, limiting pharmacological effectiveness and making adverse effects common. The use of complementary and alternative medicine (CAM) has increased, especially for developmental and behavioral disorders, such as ADHD. CAM is used by 60-65% of parents of children with ADHD to relieve ADHD-associated symptoms and to avoid the side effects of conventional medication. Acupuncture has been widely used to treat patients with ADHD, but the available evidence of its effectiveness is insufficient. Our aim was to evaluate the effectiveness and safety of acupuncture in patients (both and each treatment naive and conventional therapy children) with ADHD (any subtype) compared to the waitlist control.

METHODS/DESIGN

This study is a waitlist controlled open trial. We used a computer generated randomization scheme. This randomised, controlled trial had two parallel arms (acupuncture, and waitlist group). Each arm consisted of 40 participants. The acupuncture group received acupuncture treatment two times per week for a total of 12 sessions over 6 weeks. Post-treatment follow-up was performed 3 weeks later to complement the 12 acupuncture sessions. Participants in the waitlist group did not receive acupuncture treatments during the first six weeks but were only required to be assessed. After 6 weeks, the same treatments given to the acupuncture group were provided to the waitlist group. The primary outcome of this trial included differences in Korean version of ADHD-Rating Scale (K-ADHD-RS) before randomization, 3 weeks and 6 weeks after randomization, and 3 weeks after completing the treatment.

DISCUSSION

Subjective measurements, like K-ADHD-RS, are commonly used in ADHD. Although these measurements have adequate reliability and validity, lack of objective assessment in ADHD may lead to some disputes, like parental placebo effects. More objective measurements, like Computerized Neurocognitive function Test (CNT) in this study, are needed in ADHD trials. Furthermore, this trial will provide evidence for the effectiveness of acupuncture as a treatment for ADHD.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS) KCT0000019.

Childhood CBCL bipolar profile and adolescent/young adult personality disorders: a 9-year follow-up

BACKGROUND

To assess the late adolescent psychiatric outcomes associated with a positive Child Behavior Checklist-Juvenile Bipolar Disorder Phenotype (CBCL-JBD) in children diagnosed with ADHD and followed over a 9-year period.

METHODS

Parents of 152 children diagnosed as ADHD (ages 7-11 years) completed the CBCL. Ninety of these parents completed it again 9 years later as part of a comprehensive evaluation of Axis I and II diagnoses as assessed using semi-structured interviews. As previously proposed, the CBCL-JBD phenotype was defined as T-scores of 70 or greater on the Attention Problems, Aggression, and Anxiety/Depression subscales.

RESULTS

The CBCL-JBD phenotype was found in 31% of those followed but only 4.9% of the sample continued to meet the phenotype criteria at follow-up. Only two of the sample developed Bipolar Disorder by late adolescence and only one of those had the CBCL-JBD profile in childhood. The proxy did not predict any Axis I disorders. However, the CBCL-JBD proxy was highly predictive of later personality disorders.

LIMITATIONS

Only a subgroup of the original childhood sample was followed. Given this sample was confined to children with ADHD, it is not known whether the prediction of personality disorders from CBCL scores would generalize to a wider community or clinical population.

CONCLUSIONS

A positive CBCL-JBD phenotype profile in childhood does not predict Axis I Disorders in late adolescence; however, it may be prognostic of the emergence of personality disorders.

Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths

In recent years, increasing numbers of children have been diagnosed with bipolar disorder. In some cases, children with unstable mood clearly meet current diagnostic criteria for bipolar disorder, and in others, the diagnosis is unclear. Severe mood dysregulation is a syndrome defined to capture the symptomatology of children whose diagnostic status with respect to bipolar disorder is uncertain, that is, those who have severe, nonepisodic irritability and the hyperarousal symptoms characteristic of mania but who lack the well-demarcated periods of elevated or irritable mood characteristic of bipolar disorder. Levels of impairment are comparable between youths with bipolar disorder and those with severe mood dysregulation. An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood. Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups. No specific treatment for severe mood dysregulation currently exists, but verification of its identity as a syndrome distinct from bipolar disorder by further research should include treatment trials.

The Child Behavior Checklist-Dysregulation Profile predicts substance use, suicidality, and functional impairment: a longitudinal analysis

BACKGROUND

Recent studies have identified a Child Behavior Checklist profile that characterizes children with severe affective and behavioral dysregulation (CBCL-dysregulation profile, CBCL-DP). In two recent longitudinal studies the CBCL-DP in childhood was associated with heightened rates of comorbid psychiatric disorders, among them bipolar disorder, an increased risk for suicidality, and marked psychosocial impairment at young-adult follow-up. This is the first study outside the US that examines the longitudinal course of the CBCL-DP.

METHODS

We studied the diagnostic and functional trajectories and the predictive utility of the CBCL-DP in the Mannheim Study of Children at Risk, an epidemiological cohort study on the outcome of early risk factors from birth into adulthood. A total of 325 young adults (151 males, 174 females) participated in the 19-year assessment.

RESULTS

Young adults with a higher CBCL-DP score in childhood were at increased risk for substance use disorders, suicidality and poorer overall functioning at age 19, even after adjustment for parental education, family income, impairment and psychiatric disorders at baseline. Childhood dysregulation was not related to bipolar disorder in young adulthood. The CBCL-DP was neither a precursor of a specific pattern of comorbidity nor of comorbidity in general.

CONCLUSIONS

Children with high CBCL-DP values are at risk for later severe, psychiatric symptomatology. The different developmental trajectories suggest that the CBCL-DP is not simply an early manifestation of a single disease process but might rather be an early developmental risk marker of a persisting deficit of self-regulation of affect and behavior.

Assessment of dysregulated children using the Child Behavior Checklist: a receiver operating characteristic curve analysis

Disorders of self-regulatory behavior are common reasons for referral to child and adolescent clinicians. Here, the authors sought to compare 2 methods of empirically based assessment of children with problems in self-regulatory behavior. Using parental reports on 2,028 children (53% boys) from a U.S. national probability sample of the Child Behavior Checklist (CBCL; T. M. Achenbach & L. A. Rescorla, 2001), the receiver operating characteristic curve analysis was applied to compare scores on the Posttraumatic Stress Problems Scale (PTSP) of the CBCL with the CBCL Dysregulation Profile (DP), identified using latent class analysis of the Attention Problems, Aggressive Behavior, and Anxious/Depressed scales of the CBCL. The CBCL-PTSP score demonstrated an area under the curve of between .88 and .91 for predicting membership in the CBCL-DP profile for boys and for girls. These findings suggest that the CBCL-PTSP, which others have shown does not uniquely identify children who have been traumatized, does identify the same profile of behavior as the CBCL-DP. Therefore, the authors recommend renaming the CBCL-PTSP the Dysregulation Short Scale and provide some guidelines for the use of the CBCL-DP scale and the CBCL-PTSP in clinical practice.

Adult outcomes of childhood dysregulation: a 14-year follow-up study

OBJECTIVE

Using a general population sample, the adult outcomes of children who presented with severe problems with self-regulation defined as being concurrently rated highly on attention problems, aggressive behavior, and anxious-depression on the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) were examined.

METHOD

Two thousand seventy-six children from 13 birth cohorts 4 to 16 years of age were drawn from Dutch birth registries in 1983. CBCLs were completed by parents at baseline when children from the different cohorts were 4 to 16 years of age and sampled every 2 years for the next 14 years. At year 14 the CBCL and DSM interview data were collected. Logistic regression was used to compare and contrast outcomes for children with and without dysregulation, as measured by the latent-class-defined CBCL-DP. Sex and age were covaried and concurrent DSM diagnoses were included in regression models.

RESULTS

Presence of childhood CBCL-DP at wave 1 was associated with increased rates of adult anxiety disorders, mood disorders, disruptive behavior disorders, and drug abuse 14 years later. After controlling for co-occurring disorders in adulthood, associations with anxiety and disruptive behavior disorders with the CBCL-DP remained, whereas the others were not significant.

CONCLUSIONS

A child reported to be in the CBCL-DP class is at increased risk for problems with regulating affect, behavior, and cognition in adulthood.

Cross-informant agreement of the Dysregulation Profile of the Child Behavior Checklist

The Dysregulation Profile (DP) of the Child Behavior Checklist (CBCL) (previously called the CBCL-Juvenile Bipolar Disorder or CBCL-JBD profile) characterized by elevated scores on CBCL attention problems, aggressive behavior, and anxious/depressed scales is associated with severe psychopathology and suicidal behavior. The stability of this profile across informants has not been established. In this study, agreement across parent, teacher, and self-reports was examined for the Dysregulation Profile phenotype derived using latent class analysis of a national probability sample of 2031 children aged 6-18. The Dysregulation Profile latent class was found for each informant and accounted for 6-7% of the sample. There was mild to fair agreement on the Dysregulation Profile latent class between parents and youth (Kappa=0.22-0.25), parents and teachers (Kappa=0.14-0.24) and youth and teachers (Kappa=0.19-0.28). When parents and youth reports both placed children into the Dysregulation Profile latent class, 42% of boys and 67% of girls reported suicidal thoughts or behavior. We conclude that the Dysregulation Profile latent class is identified across informants although agreement of specific individuals is mild. Children in this class as identified by parental and youth reports have a very high risk for suicidal thoughts and behaviors.

Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) and CBCL Posttraumatic Stress Problems (CBCL-PTSP) scales are measures of a single dysregulatory syndrome

BACKGROUND

The Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) profile and Posttraumatic Stress Problems (CBCL-PTSP) scale have been used to assess juvenile bipolar disorder (JBD) and posttraumatic stress disorder (PTSD), respectively. However, their validity is questionable according to previous research. Both measures are associated with severe psychopathology often encompassing multiple DSM-IV diagnoses. Further, children who score highly on one of these scales often have elevated scores on the other, independent of PTSD or JBD diagnoses. We hypothesized that the two scales may be indicators of a single syndrome related to dysregulated mood, attention, and behavior. We aimed to describe and identify the overlap between the CBCL-JBD profile and CBCL-PTSP scales.

METHOD

Two thousand and twenty-nine (2029) children from a nationally representative sample (1073 boys, 956 girls; mean age = 11.98; age range = 6-18) were rated on emotional and behavior problems by their parents using the CBCL. Comparative model testing via structural equation modeling was conducted to determine whether the CBCL-JBD profile and CBCL-PTSP scale are best described as measuring separate versus unitary constructs. Associations with suicidality and competency scores were also examined.

RESULTS

The CBCL-JBD and CBCL-PTSP demonstrated a high degree of overlap (r = .89) at the latent variable level. The best fitting, most parsimonious model was one in which the CBCL-JBD and CBCL-PTSP items identified a single latent construct, which was associated with higher parental endorsement of child suicidal behavior, and lower functioning.

CONCLUSIONS

The CBCL-JBD profile and CBCL-PTSP scale overlap to a remarkable degree, and may be best described as measures of a single syndrome. This syndrome appears to be related to severe psychopathology, but may not conform to traditional DSM-IV classification. These results contribute to the ongoing debate about the utility of the CBCL-JBD and CBCL-PTSP profiles, and offer promising methods of empirically based measurement of disordered self-regulation in youth.

The Child Behavior Checklist-Pediatric Bipolar Disorder profile predicts a subsequent diagnosis of bipolar disorder and associated impairments in ADHD youth growing up: a longitudinal analysis

OBJECTIVE

To examine the predictive utility of the Child Behavior Checklist-Pediatric Bipolar Disorder (CBCL-PBD) profile to help identify children at risk for bipolar disorder.

METHOD

Subjects were ascertained from 2 identically designed longitudinal case-control family studies of subjects (males and females aged 6-18 years) with DSM-III-R attention-deficit/hyperactivity disorder (ADHD). Based on data from the baseline assessment, ADHD subjects without a lifetime diagnosis of bipolar disorder were stratified by the presence (CBCL-PBD positive, N=28) or absence (CBCL-PBD negative, N=176) of a CBCL-PBD score > or = 210 (total of attention, aggression, and anxious/depressed subscales). Subjects were comprehensively assessed at follow-up with structured psychiatric interviews. Data were collected from April 1988 to February 2003.

RESULTS

Over a mean follow-up period of 7.4 years, a positive CBCL-PBD score predicted subsequent diagnoses of bipolar disorder, major depressive disorder, and conduct disorder, as well as impaired psychosocial functioning and higher risk for psychiatric hospitalization.

CONCLUSION

This work suggests that a positive CBCL-PBD score based on elevations on the attention problems, aggressive behavior, and anxious/depressed subscales predicts subsequent pediatric bipolar disorder and associated syndrome-congruent impairments. If confirmed in other studies, the CBCL-PBD score has the potential to help identify children at high risk to develop bipolar disorder.

Attention deficit-hyperactivity disorder and early-onset bipolar disorder: two facets of one entity?

Early-onset bipolar disorder (BD) and attention-deficithyperactivity disorder (ADHD) have recently been the subject of highly controversial debate, due to theories regarding underlying pathophysiological processes and a clinical overlap of symptoms. Epidemiological data, clinical aspect, neuroimaging, neurochemical, and genetic studies suggest that there may be a possible relationship between biological factors and clinical characteristic in the development of symptoms. However, longitudinal data supporting the hypothesis of a diagnostic shift from BD to ADHD symptoms and vice versa are currently not available. These would be essential to enable further investigations into whether these two disorders possibly represent two different aspects of an underlying common psychopathophysioiogical entity.

Family and genetic association studies of bipolar disorder in children

The risk of bipolar disorder (BPD) (15-42%) in first-degree relatives of children with BPD are consistently larger than the 8.7% estimate of recurrence risk of BPD in first-degree relatives of adult BPD cases. There have been no family linkage studies of pediatric BPD, but secondary analyses of adult linkage samples suggest that early-onset BPD both increases the strength of associations in linkage studies. Positive associations with pediatric BPD and the BDNF gene (Vall66), the GAD1 gene (4s2241165), and the dopamine transporter gene (rs41084) have been reported but none of these associations have been replicated in independent samples. The number of informative families examined so far is quite small and studies were vastly underpowered to detect small effects. An adequately powered sample will likely require collaborative ascertainment of cases and families from multiple sites using valid and accepted measures of pediatric BPD.

Long-term outcomes of youth who manifested the CBCL-Pediatric Bipolar Disorder phenotype during childhood and/or adolescence

OBJECTIVE

Recent studies have identified a Child Behavior Checklist (CBCL) profile that characterizes children with severe aggression, inattention, and mood instability. This profile has been coined the CBCL-Pediatric Bipolar Disorder (PBD) phenotype, because it is commonly seen among children with bipolar disorder. However, mounting evidence suggests that the CBCL-PBD may be a better tool for identifying children with severe functional impairment and broad-ranging psychiatric comorbidities rather than bipolar disorder itself. No studies have followed individuals with the CBCL-PBD profile through adulthood, so its long-term implications remain unclear. The present authors examined diagnostic and functional trajectories of individuals with the CBCL-PBD profile from early childhood through young adulthood using data from a longitudinal high-risk study.

METHOD

Participants (n=101) are part of a 23-year study of youth at risk for major mood disorder who have completed diagnostic and functional assessments at regular intervals.

RESULTS

Across development, participants with the CBCL-PBD phenotype exhibited marked psychosocial impairment, increased rates of suicidal thoughts and behaviors and heightened risk for comorbid anxiety, bipolar disorder, cluster B personality disorders and ADHD in young adulthood, compared to participants without this presentation. However, diagnostic accuracy for any one particular disorder was found to be low.

CONCLUSIONS

Children with the CBCL-PBD profile are at risk for ongoing, severe, psychiatric symptomatology including behavior and emotional comorbidities in general, and bipolar disorder, anxiety, ADHD, cluster B personality disorders in particular. However, the value of this profile may be in predicting ongoing comorbidity and impairment, rather than any one specific DSM-IV diagnosis.

AACAP 2006 Research Forum--Advancing research in early-onset bipolar disorder: barriers and suggestions

OBJECTIVE

The 2006 Research Forum addressed the goal of formulating a research agenda for early-onset bipolar disorder (EOBP) and improving outcome by understanding the risk and protective factors that contribute to its severity and chronicity.

METHOD

Five work groups outlined barriers and research gaps in EOBP genetics, neuroimaging, prodromes, psychosocial factors, and pharmacotherapy.

RESULTS

There was agreement that the lack of consensus on the definition and diagnosis of EOBP is the primary barrier to advancing research in BP in children and adolescents. Related issues included: the difficulties in managing co-morbidity both statistically and clinically; acquiring adequate sample sizes to study the genetics, biology, and treatment; understanding the EOBP's developmental aspects; and identifying environmental mediators and moderators of risk and protection. Similarly, both psychosocial and medication treatment strategies for children with BP are hamstrung by diagnostic issues. To advance the research in EOBP, both training and funding mechanisms need to be developed with these issues in mind.

CONCLUSIONS

EOBP constitutes a significant public health concern. Barriers are significant but identifiable and thus are not insurmountable. To advance the understanding of EOBP, the field must be committed to resolving diagnostic and assessment issues. Once achieved, with adequate personnel and funding resources, research into the field of EOBP will doubtless be advanced at a rapid pace.

Refining the tobacco dependence phenotype using the Wisconsin Inventory of Smoking Dependence Motives

The construct of tobacco dependence is important from both scientific and public health perspectives, but it is poorly understood. The current research integrates person-centered analyses (e.g., latent profile analysis) and variable-centered analyses (e.g., exploratory factor analysis) to clarify the latent structure of nicotine dependence and to guide distillation of the phenotype. Using data from 4 samples of smokers, latent profiles were derived using the Wisconsin Inventory of Smoking Dependence Motives subscale scores. Across all 4 samples, results revealed a unique latent profile that had relative elevations on 4 subscales (Automaticity, Craving, Loss of Control, and Tolerance). Variable-centered analyses supported the uniqueness of these 4 subscales as they constituted a distinct common factor and were the strongest predictors of relapse and other dependence criteria. Conversely, the remaining 9 motives carried little unique predictive validity regarding dependence. Applications of a factor mixture model further supported the presence of a unique class of smokers in relation to a common factor underlying the 4 subscales. The results suggest that a pattern of smoking that is heavy, pervasive, automatic, and relatively unresponsive to instrumental contingencies is a necessary and sufficient condition for severe nicotine dependence.

Latent class analysis of the Child Behavior Checklist Obsessive-Compulsive Scale

The Obsessive-Compulsive Scale (OCS) of the Child Behavior Checklist (CBCL) predicts obsessive-compulsive disorder and is highly heritable. Latent class analysis (LCA) of the OCS was used to identify profiles within this 8-item scale and to examine heritability of those profiles. The LCA was performed on maternal CBCL reports of their 6- to 18-year-old children from 2 US nationally representative samples from 1989 (n = 2475, 50% male) and 1999 (n = 2029, 53% male) and from Dutch twins in the Netherlands Twin Registry at ages 7 (n = 10 194, 49.3% male), 10 (n = 6448, 48.1% male), and 12 (n = 3674, 48.6% male) years. The heritability of the resultant classes was estimated using odds ratios of twin membership across classes. A 4-class solution fitted all samples best. The resulting classes were a "No or Few Symptoms" class, a "Worries and Has to Be Perfect" class, a "Thought Problems" class, and an "OCS" class. Within-class odds ratios were higher than across-class odds ratios and were higher for monozygotic than dizygotic twins. We conclude that LCA identifies an OCS class and that class is highly heritable using across-twin comparisons.

CBCL pediatric bipolar disorder profile and ADHD: comorbidity and quantitative trait loci analysis

OBJECTIVE

The pediatric bipolar disorder profile of the Child Behavior Checklist (CBCL-PBD), a parent-completed measure that avoids clinician ideological bias, has proven useful in differentiating patients with attention-deficit/hyperactivity disorder (ADHD). We used CBCL-PBD profiles to distinguish patterns of comorbidity and to search for quantitative trait loci in a genomewide scan in a sample of multiple affected ADHD sibling pairs.

METHOD

A total of 540 ADHD subjects ages 5 to 18 years were assessed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version and CBCL. Parents were assessed with the Schedule for Affective Disorders and Schizophrenia-Lifetime version supplemented by the Schedule for Affective Disorders and Schizophrenia for School-Age Children for disruptive behavioral disorders. Patterns of psychiatric comorbidity were contrasted based on the CBCL-PBD profile. A quantitative trait loci variance component analysis was used to identify potential genomic regions that may harbor susceptibility genes for the CBCL-PBD quantitative phenotype.

RESULTS

Bipolar spectrum disorders represented less than 2% of the overall sample. The CBCL-PBD classification was associated with increased generalized anxiety disorder (p =.001), oppositional defiant disorder (p =.008), conduct disorder (p =.003), and parental substance abuse (p =.005). A moderately significant linkage signal (multipoint maximum lod score = 2.5) was found on chromosome 2q.

CONCLUSIONS

The CBCL-PBD profile distinguishes a subset of ADHD patients with significant comorbidity. Linkage analysis of the CBCL-PBD phenotype suggests certain genomic regions that merit further investigation for genes predisposing to severe psychopathology.

Pre-pubertal paediatric bipolar disorder: a controversy from America

OBJECTIVE

The aim of this paper was to explore the rapid rise in the diagnosis of bipolar disorder (BD) in the paediatric, particularly pre-pubertal, age group, in the USA over the past decade and to look at associated controversies.

CONCLUSIONS

There has been a very marked rise in the diagnosis of BD among pre-pubertal children, and to a lesser extent adolescents, in the USA since the mid 1990s. The rise appears to have been driven by a reconceptualizing of clusters of emotional and behavioural symptoms in the paediatric age group by some academic child psychiatry departments, most notably in St Louis, Boston and Cincinnati. There is controversy in both the academic literature and public media centring on diagnostic methods, epidemiological studies, adverse effects of medication including media-reported fatalities, and pharmaceutical company influence. With some exceptions, the traditional view of BD as being very rare prior to puberty and uncommon in adolescence appears accepted beyond the USA, though whether this is changing is as yet uncertain, and thus there are implications for Australian and New Zealand child and adolescent psychiatry.

Prevalence of the Child Behavior Checklist-pediatric bipolar disorder phenotype in a German general population sample

BACKGROUND

In children with pediatric bipolar disorder (PBD), a consistent pattern of elevations in inattention/hyperactivity, depression/anxiety, and aggression has been identified on the Child Behavior Checklist (CBCL-PBD profile). In Germany, no epidemiological study has included PBD to date.

OBJECTIVES

To estimate the six-month prevalence of the CBCL-PBD profile in Germany in a large normative general population sample, and to examine subjects with CBCL-PBD profile with regard to symptoms assumed to coexist with PBD (e.g., suicidality, decreased need for sleep, and hypersexuality).

METHODS

We studied a nationwide representative general population sample of 2,856 children and adolescents aged 4-18 years.

RESULTS

A total of 21 subjects [0.7% of the sample; 95% confidence interval (CI) = 0.5-1.1] met the criteria for the CBCL-PBD phenotype. CBCL-PBD subjects were more pervasively disturbed than clinical controls (n = 118; 4.1% of total sample; 95% CI = 3.4-4.9), demonstrated in significantly more social problems and delinquent behavior, and showed significantly higher rates of suicidality, decreased need for sleep and hypersexual behavior.

CONCLUSIONS

The prevalence of CBCL-PBD subjects in the general German population compares to rates of PBD in US and Dutch epidemiological samples. Regardless of whether these subjects are affected by 'real' PBD or 'severe, pervasive ADHD' with pronounced emotional dysregulation, they constitute a group of seriously disturbed children and adolescents. The high rate of suicidality among CBCL-PBD subjects emphasizes the need for the identification and adequate treatment of children meeting this profile.

Does the Child Behavior Checklist juvenile bipolar disorder phenotype identify bipolar disorder?

BACKGROUND

A profile of Child Behavior Checklist(CBCL) T-scores>or=70 on the attention problems, aggression, and anxious/depressed subscales has been proposed to identify juvenile bipolar disorder(JBD). We tested this hypothesis in a population-based sample.

METHODS

Data for this analysis come from a birth-records-based twin sample having semi-structured interview and CBCL data (N=1,346). We compared prevalence of DSM-IV psychiatric disorders and suicidal behaviors in CBCL-JBD and non-CBCL-JBD subjects. Twin modeling assessed genetic and environmental contributions to CBCL-JBD. Associations with DRD4 and DAT1 were examined using chi-square tests.

RESULTS

The prevalence of CBCL-JBD was 2.5%. No subjects with CBCL-JBD met criteria for bipolar or other mood disorders. CBCL-JBD subjects had more oppositional defiant disorder (ODD), conduct disorder(CD), and attention deficit hyperactivity disorder(ADHD). The CBCL-JBD profile was uncommon in these disorders. CBCL-JBD subjects more frequently endorsed suicidal behaviors. The CBCL-JBD profile was heritable and associated with the number of DAT1 9-repeat 3' untranslated region alleles.

CONCLUSIONS

The CBCL-JBD phenotype does not correspond with a semi-structured interview assessment of JBD. ADHD, CD, and ODD are common in children with CBCL-JBD but do not account for the profile. Increased suicidal behaviors indicate substantial impairment in CBCL-JBD subjects.

A dimensional approach to developmental psychopathology

The expression psychopathology in general and child psychopathology in particular, is affected by multiple sources of variance. Some of these sources include gender differences, informant differences, and age-related differences. In this paper, we discuss how these sources of variance complicate both research and clinical management. We argue that the current diagnostic system would be aided by the inclusion of a quantitative axis that can take these sources of variance into account. We reason that the fields of genomics and neuroscience are prepared to move the field of developmental psychopathology forward, but need a diagnostic system that allows for these sources of variance to be controlled. We demonstrate how in Conduct Disorder, inclusion of dimensional information would allow the clinician or researcher to demonstrate not only the presence or absence of pathology, but also the degree to which the disorder is manifested in a particular individual. Because dimensional approaches are already used widely as an alternative measure of psychopathology, we argue that there is reason to consider dimensionalizing some aspects of the DSM.

Longitudinal stability of the CBCL-juvenile bipolar disorder phenotype: A study in Dutch twins

BACKGROUND

The Child Behavior Checklist-juvenile bipolar disorder phenotype (CBCL-JBD) is a quantitative phenotype that is based on parental ratings of the behavior of the child. The phenotype is predictive of DSM-IV characterizations of BD and has been shown to be sensitive and specific. Its genetic architecture differs from that for inattentive, aggressive, or anxious-depressed syndromes. The purpose of this study is to assess the developmental stability of the CBCL-JBD phenotype across ages 7, 10, and 12 years in a large population-based twin sample and to examine its genetic architecture.

METHODS

Longitudinal data on Dutch mono- and dizygotic twin pairs (N = 8013 pairs) are analyzed to decompose the stability of the CBCL-JBD phenotype into genetic and environmental contributions.

RESULTS

Heritability of the CBCL-JBD increases with age (from 63% to 75%), whereas the effects of shared environment decrease (from 20% to 8%). The stability of the CBCL-JBD phenotype is high, with correlations between .66 and .77 across ages 7, 10, and 12 years. Genetic factors account for the majority of the stability of this phenotype. There were no sex differences in genetic architecture.

CONCLUSIONS

Roughly 80% of the stability in childhood CBCL-JBD is a result of additive genetic effects.