Common transdiagnostic cognitive deficits among people with psychiatric disorders exposed to childhood maltreatment: a meta-analysis

Differential Psychological Treatment Effects in Patients With Late-Life Depression and a History of Childhood Maltreatment

OBJECTIVE

This is the first interventional study to assess the impact of childhood maltreatment (CM) on psychological treatment outcomes in patients with late-life depression (LLD).

METHODS

This is a secondary analysis of a multicenter, randomized controlled trial with 251 participants aged ≥60 years with moderate to severe depression. Participants were randomly assigned to cognitive behavioral therapy for late life depression (LLD-CBT) or to a supportive intervention (SUI). Treatment outcomes were measured by changes in the Geriatric Depression Scale (GDS).

RESULTS

In the intention-to-treat sample (n = 229), both LLD-CBT (n = 115) and SUI (n = 114) significantly reduced depressive symptoms in patients with CM, with large effects at post-treatment (d = 0.95 [95% CI: 0.65 to 1.25] in LLD-CBT; d = 0.82 [95% CI: 0.52 to 1.12] in SUI). A significant treatment group*CM interaction (F(1,201.31) = 4.71; p = .031) indicated greater depressive symptom reduction in LLD-CBT compared to SUI at week 5 and post-treatment for patients without CM, but not at 6-month follow-up. Across both treatments, higher severity of the CM subtype 'physical neglect' was associated with a smaller depressive symptom reduction (F(1,207.16) = 5.37; p = .021).

CONCLUSIONS

Specific and non-specific psychotherapy effectively reduced depressive symptoms in older individuals with depression and early trauma. For patients without early trauma, LLD-CBT may be preferable over SUI. Considering early trauma subtypes may contribute to develop personalized treatment approaches.

Trauma's distinctive and combined effects on subsequent substance use, mental health, and neurocognitive functioning with the NCANDA sample

PURPOSE

Traumatic brain injury (TBI) and potentially traumatic events (PTEs) contribute to increased substance use, mental health issues, and cognitive impairments. However, there's not enough research on how TBI and PTEs combined impact mental heath, substance use, and neurocognition.

METHODS

This study leverages a subset of The National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) multi-site dataset with 551 adolescents to assess the combined and distinctive impacts of TBI, PTEs, and TBI+PTEs (prior to age 18) on substance use, mental health, and neurocognitive outcomes at age 18.

RESULTS

TBI, PTEs, and TBI+PTEs predicted greater lifetime substance use and past-year alcohol and cannabis use. PTEs predicted greater internalizing symptoms, while TBI+PTEs predicted greater externalizing symptoms. Varying effects on neurocognitive outcomes included PTEs influencing attention accuracy and TBI+PTEs predicting faster speed in emotion tasks. PTEs predicted greater accuracy in abstraction-related tasks. Associations with working memory were not detected.

CONCLUSION

This exploratory study contributes to the growing literature on the complex interplay between TBI, PTEs, and adolescent mental health, substance use, and neurocognition. The developmental implications of trauma via TBIs and/or PTEs during adolescence are considerable and worthy of further investigation.

Childhood Adversity, Cognition, and Response to Cognitive Remediation in Major Depressive Disorder

ABSTRACT

Cognitive impairment is experienced by many individuals with major depressive disorder (MDD) and is significantly related to sustained disability. Recent work has begun to explore the relationship between childhood adversity (CA) and cognitive impairment in MDD, but this work is limited by unreliable measures of CA. Furthermore, no previous research has examined whether CA relates to cognitive remediation response. The current study clarifies how CA and clinical characteristics of illness explain cognitive variance. In addition, we investigate whether CA is associated with response to cognitive remediation. Thirty-nine individuals who completed cognitive remediation were rerecruited to complete a retrospective interview on CA. Results showed that CA, repeated depressive episodes, and earlier age at diagnosis were associated with poorer cognition. We did not observe a difference in treatment response based on CA. Findings suggest that CA is an important variable to consider when examining the expression of depressive illness and areas for intervention.

Neurocognition and its association with adverse childhood experiences and familial risk of mental illness

Environmental factors such as adverse childhood experiences (ACEs) may affect neurocognition, an endophenotype for several mental illnesses. This study examines the effect of ACEs on neurocognitive performance in first-degree relatives (FDRs) of patients with severe mental illness to determine whether familial risk has a moderating effect on the relationship between ACEs and neurocognition. Unaffected FDRs from multiplex families with severe mental illnesses (schizophrenia, bipolar disorder, obsessive-compulsive disorder, or alcohol use disorder) (n = 324) and healthy controls (with no familial risk) (n = 188) underwent neurocognitive tests for processing speed, new learning, working memory and Theory of Mind. ACEs were measured using the WHO ACE-International Questionnaire (ACE-IQ). Regression models were done to predict each neurocognitive domain by the effect of familial risk, ACE-IQ Score and their interaction (familial risk*ACE-IQ score). The main effect of familial risk predicted poor performance in all domains of neurocognition (p < 0.01), and the interaction had a negative association with global neurocognition (β = -0.093, p = 0.009), processing speed (β = -0.109, p = 0.003) and working memory (β = -0.092, p = 0.01). Among the ACEs sub-domains, only maltreatment (specifically the main effect of physical neglect and the interaction effect of sexual abuse with familial risk) predicted poorer neurocognition. In FDRs of schizophrenia and bipolar disorder, only the main effects of familial risk were significantly associated with poorer neurocognition. We conclude that there is a relationship between ACEs (especially maltreatment) and neurocognitive functioning, which is moderated by the familial risk of mental illnesses. Genetic/familial vulnerability may have a stronger association with neurocognition in schizophrenia and bipolar disorder.

Dimensions of cognition, behaviour, and mental health in struggling learners: A spotlight on girls

Background

Fewer girls than boys are identified as struggling at school for suspected problems in attention, learning and/or memory. The objectives of this study were to: i) identify dimensions of cognition, behaviour and mental health in a unique transdiagnostic sample of struggling learners; ii) test whether these constructs were equivalent for boys and girls, and; iii) compare their performance across the dimensions.

Methods

805 school-aged children, identified by practitioners as experiencing problems in cognition and learning, completed cognitive assessments, and parents/carers rated their behaviour and mental health problems.

Results

Three cognitive [Executive, Speed, Phonological], three behavioural [Cognitive Control, Emotion Regulation, Behaviour Regulation], and two mental health [Internalising, Externalising] dimensions distinguished the sample. Dimensions were structurally comparable between boys and girls, but differences in severity were present: girls had greater impairments on performance-based measures of cognition; boys were rated as having more severe externalising problems.

Conclusions

Gender biases to stereotypically male behaviours are prevalent among practitioners, even when the focus is on identifying cognitive and learning difficulties. This underscores the need to include cognitive and female-representative criteria in diagnostic systems to identify girls whose difficulties could go easily undetected.

Inpatient psychotherapy for depression in a large routine clinical care sample: A Bayesian approach to examining clinical outcomes and predictors of change

BACKGROUND

A routinely collected dataset was analyzed (1) to determine the naturalistic effectiveness of inpatient psychotherapy for depression in routine psychotherapeutic care, and (2) to identify potential predictors of change.

METHODS

In a sample of 22,681 inpatients with depression, pre-post and pre-follow-up effect sizes were computed for various outcome variables. To build a probabilistic model of predictors of change, an independent component analysis generated components from demographic and clinical data, and Bayesian EFA extracted factors from the available pre-test, post-test and follow-up questionnaires in a subsample (N = 6377). To select the best-fitted model, the BIC of different path models were compared. A Bayesian path analysis was performed to identify the most important factors to predict changes.

RESULTS

Effect sizes were large for the primary outcome and moderate for various secondary outcomes. Almost all pretreatment factors exerted significant influences on different baseline factors. Several factors were found to be resistant to change during treatment: suicidality, agoraphobia, life dissatisfaction, physical disability and pain. The strongest cross-loadings were observed from suicidality on negative cognitions, from agoraphobia on anxiety, and from physical disability on perceived disability.

LIMITATIONS

No causal conclusions can be drawn directly from our results as we only used cross-lagged panel data without control group.

CONCLUSIONS

The results indicate large effects of inpatient psychotherapy for depression in routine clinical care. The direct influence of pretreatment factors decreased over the course of treatment. However, some factors appeared stable and difficult to treat, which might hinder treatment outcome. Findings of different predictors of change are discussed.

Association of Adverse Childhood Experiences With Poor Neuropsychiatric Health and Dementia Among Former Professional US Football Players

IMPORTANCE

Childhood adversities, including neglect, abuse, and other indicators of family dysfunction, are associated in adulthood with risk factors for poor cognitive and mental health. However, the extent to which these experiences are associated with adulthood cognition-related quality of life and risk for dementia is unknown.

OBJECTIVE

To determine the association of 10 adverse childhood experiences (ACEs) with neuropsychiatric outcomes among former National Football League (NFL) players.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used data from the Football Player's Health Study at Harvard University, an ongoing longitudinal cohort study from January 30, 2015, to November 19, 2021, of former NFL players.

EXPOSURES

Ten ACEs were assessed using the Adverse Childhood Experiences Questionnaire.

MAIN OUTCOMES AND MEASURES

Dementia symptoms were assessed using the AD8: The Washington University Dementia Screening Test; cognition-related quality of life was assessed with the short form of the Quality of Life in Neurological Disorders; depression was assessed with the Patient Health Questionnaire-9; anxiety was assessed with the Generalized Anxiety Disorder-7; and pain intensity and pain interference in daily life were assessed with the Brief Pain Inventory. Risk ratios (RRs) assessing the association between ACEs and neuropsychiatric outcomes were estimated using generalized estimating equations, adjusted for age, race, and childhood socioeconomic status, and further adjusted for playing position, concussions incurred during football play, and number of seasons played in the NFL.

RESULTS

A total of 1755 men (mean [SD] age, 57.2 [13.5] years) who were former professional football players were included in the analysis. Five hundred twenty players (29.6%) identified as Black, 1160 (66.1%) identified as White, and 75 (4.3%) identified as other race or ethnicity. Players with 4 or more ACEs were at 48% greater risk of a positive screen for dementia (RR, 1.48 [95% CI, 1.22-1.79]), and at significantly greater risk of every other neuropsychiatric outcome except anxiety (RR range, 1.62 [95% CI, 1.09-2.39] to 1.74 [95% CI, 1.27-2.40]) compared with players with no ACEs. Further adjustment for concussions incurred during playing years attenuated these associations, although some were still significant (adjusted RR range, 1.32 [95% CI, 1.10-1.58] to 1.56 [95% CI, 1.15-2.11]). ACEs were also associated with concussion symptoms; players with 4 or more ACEs had a 60% increased risk of being in the top quartile of concussion symptoms (RR, 1.60; 95% CI, 1.12-2.28) compared with players with no ACEs.

CONCLUSIONS AND RELEVANCE

These findings suggest that ACEs may be associated with dementia symptoms among former NFL players. Moreover, ACEs should be investigated among professional football players and other populations as a prospective indicator of persons at high risk of concussion. These findings further suggest that treatment of psychological trauma in addition to treatment of physical injury may improve neuropsychiatric health in former NFL players.

Childhood Abuse and Cognitive Function in a Large Cohort of Middle-Aged Women

Cognitive function at middle age is of particular public health interest, as it strongly predicts later dementia. Children who have experienced abuse subsequently have worse cognitive function than those who have not. However, it remains unclear whether the association of abuse with cognitive function persists into middle age. In 2014-2016, 14,151 women ages 49-69 years who had previously responded to a childhood abuse questionnaire completed a cognitive battery. In models adjusted for childhood socioeconomic status and head trauma, combined physical, emotional, and sexual abuse was associated with lower scores on both Learning/Working Memory (severe abuse, lower scores similar to that observed in women 4.8 years older in our data) and Psychomotor Speed/Attention (severe abuse, lower scores similar to that observed in women to 2.9 years older in our data). Adjustment for adulthood socioeconomic status and health factors (e.g., smoking, hypertension) slightly attenuated associations. In exploratory analyses further adjusted for psychological distress, associations were attenuated. Women exposed versus unexposed to childhood abuse had poorer cognitive function at mid-life. Associations were particularly strong for learning and working memory and were not accounted for by adulthood health factors. Childhood abuse should be investigated as a potential risk factor for cognitive decline and dementia in old age.

Determining prognostic variables of treatment outcome in obsessive-compulsive disorder: effectiveness and its predictors in routine clinical care

The objectives of this study were to investigate the naturalistic effectiveness of routine inpatient treatment for patients with obsessive-compulsive disorder (OCD) and to identify predictors of treatment outcome. A routinely collected data set of 1,596 OCD inpatients (M = 33.9 years, SD = 11.7; 60.4% female) having received evidence-based psychotherapy based on the cognitive-behavioral therapy (CBT) in five German psychotherapeutic clinics was analyzed. Effect sizes (Hedges' g) were calculated for several outcome variables to determine effectiveness. Predictor analyses were performed on a subsample (N = 514; M = 34.3 years, SD = 12.2; 60.3% female). For this purpose, the number of potential predictors was reduced using factor analysis, followed by multiple regression analysis to identify robust predictors. Effect sizes of various outcome variables could be classified as large (g = 1.34 of OCD-symptom change). Predictors of changes in OCD and depressive symptoms were symptom severity at admission and general psychopathological distress. In addition, patients with higher social support and more washing compulsions benefited more from treatment. Subgroup analyses showed a distinct predictor profile of changes in compulsions and obsessions. The results indicate that an evidence-based psychotherapy program for OCD can be effectively implemented in routine inpatient care. In addition to well-established predictors, social support, and washing compulsions in particular were identified as important positive predictors. Specific predictor profiles for changes in obsessions and compulsions are discussed.

Associations of Early-Life Threat and Deprivation With Executive Functioning in Childhood and Adolescence: A Systematic Review and Meta-analysis

IMPORTANCE

Many studies have demonstrated an association between early-life adversity (ELA) and executive functioning in children and adolescents. However, the aggregate magnitude of this association is unknown in the context of threat and deprivation types of adversity and various executive functioning domains.

OBJECTIVE

To test the hypothesis that experiences of deprivation are more strongly associated with reduced executive functioning compared with experiences of threat during childhood and adolescence.

DATA SOURCES

Embase, ERIC, MEDLINE, and PsycInfo databases were searched from inception to December 31, 2020. Both forward and reverse snowball citation searches were performed to identify additional articles.

STUDY SELECTION

Articles were selected for inclusion if they (1) had a child and/or adolescent sample, (2) included measures of ELA, (3) measured executive functioning, (4) evaluated the association between adversity and executive functioning, (5) were published in a peer-reviewed journal, and (6) were published in the English language. No temporal or geographic limits were set. A 2-reviewer, blinded screening process was conducted.

DATA EXTRACTION AND SYNTHESIS

PRISMA guidelines were used to guide data extraction and article diagnostics (for heterogeneity, small study bias, and p-hacking). Article quality was assessed, and data extraction was performed by multiple independent observers. A 3-level meta-analytic model with a restricted maximum likelihood method was used. Moderator analyses were conducted to explore heterogeneity.

MAIN OUTCOMES AND MEASURES

Primary outcomes included measures of the 3 domains of executive functioning: cognitive flexibility, inhibitory control, and working memory.

RESULTS

A total of 91 articles were included, representing 82 unique cohorts and 31 188 unique individuals. Deprivation, compared with threat, was associated with significantly lower inhibitory control (F1,90 = 5.69; P = .02) and working memory (F1,54 = 5.78; P = .02). No significant difference was observed for cognitive flexibility (F1,36 = 2.38; P = .12). The pooled effect size of the association of inhibitory control with deprivation was stronger (Hedges g = -0.43; 95% CI, -0.57 to -0.29) compared with threat (Hedges g = -0.27; 95% CI, -0.46 to -0.08). The pooled effect size of the association of working memory with deprivation was stronger (Hedges g = -0.54; 95% CI, -0.75 to -0.33) compared with threat (Hedges g = -0.28; 95% CI, -0.51 to -0.05).

CONCLUSIONS AND RELEVANCE

Experiences of both threat and deprivation in childhood and adolescence were associated with reduced executive functioning, but the association was stronger for exposure to deprivation. Efforts to address the consequences of ELA for development should consider the associations between specific dimensions of adversity and specific developmental outcomes.

Higher-order dimensions of psychopathology in a neurodevelopmental transdiagnostic sample

Hierarchical dimensional models of psychopathology derived for adult and child community populations offer more informative and efficient methods for assessing and treating symptoms of mental ill health than traditional diagnostic approaches. It is not yet clear how many dimensions should be included in models for youth with neurodevelopmental conditions. The aim of this study was to delineate the hierarchical dimensional structure of psychopathology in a transdiagnostic sample of children and adolescents with learning-related problems, and to test the concurrent predictive value of the model for clinically, socially, and educationally relevant outcomes. A sample of N = 403 participants from the Centre for Attention Learning and Memory (CALM) cohort were included. Hierarchical factor analysis delineated dimensions of psychopathology from ratings on the Conner's Parent Rating Short Form, the Revised Children's Anxiety and Depression Scale, and the Strengths and Difficulties Questionnaire. A hierarchical structure with a general p factor at the apex, broad internalizing and broad externalizing spectra below, and three more specific factors (specific internalizing, social maladjustment, and neurodevelopmental) emerged. The p factor predicted all concurrently measured social, clinical, and educational outcomes, but the other dimensions provided incremental predictive value. The neurodevelopmental dimension, which captured symptoms of inattention, hyperactivity, and executive function and emerged from the higher-order externalizing factor, was the strongest predictor of learning. This suggests that in struggling learners, cognitive and affective behaviors may interact to influence learning outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cognitive Dimensions of Learning in Children With Problems in Attention, Learning, and Memory

A data-driven, transdiagnostic approach was used to identify the cognitive dimensions linked with learning in a mixed group of 805 children aged 5 to 18 years recognised as having problems in attention, learning and memory by a health or education practitioner. Assessments included phonological processing, information processing speed, short-term and working memory, and executive functions, and attainments in word reading, spelling, and maths. Data reduction methods identified three dimensions of phonological processing, processing speed and executive function for the sample as a whole. This model was comparable for children with and without ADHD. The severity of learning difficulties in literacy was linked with phonological processing skills, and in maths with executive control. Associations between cognition and learning were similar across younger and older children and individuals with and without ADHD, although stronger links between learning-related problems and both executive skills and processing speed were observed in children with ADHD. The results establish clear domain-specific cognitive pathways to learning that distinguish individuals in the heterogeneous population of children struggling to learn.

Childhood maltreatment and cognitive functioning: the role of depression, parental education, and polygenic predisposition

Childhood maltreatment is associated with cognitive deficits that in turn have been predictive for therapeutic outcome in psychiatric patients. However, previous studies have either investigated maltreatment associations with single cognitive domains or failed to adequately control for confounders such as depression, socioeconomic environment, and genetic predisposition. We aimed to isolate the relationship between childhood maltreatment and dysfunction in diverse cognitive domains, while estimating the contribution of potential confounders to this relationship, and to investigate gene-environment interactions. We included 547 depressive disorder and 670 healthy control participants (mean age: 34.7 years, SD = 13.2). Cognitive functioning was assessed for the domains of working memory, executive functioning, processing speed, attention, memory, and verbal intelligence using neuropsychological tests. Childhood maltreatment and parental education were assessed using self-reports, and psychiatric diagnosis was based on DSM-IV criteria. Polygenic scores for depression and for educational attainment were calculated. Multivariate analysis of cognitive domains yielded significant associations with childhood maltreatment (η²p = 0.083, P < 0.001), depression (η²p = 0.097, P < 0.001), parental education (η²p = 0.085, P < 0.001), and polygenic scores for depression (η²p = 0.021, P = 0.005) and educational attainment (η²p = 0.031, P < 0.001). Each of these associations remained significant when including all of the predictors in one model. Univariate tests revealed that maltreatment was associated with poorer performance in all cognitive domains. Thus, environmental, psychopathological, and genetic risk factors each independently affect cognition. The insights of the current study may aid in estimating the potential impact of different loci of interventions for cognitive dysfunction. Future research should investigate if customized interventions, informed by individual risk profiles and related cognitive preconditions, might enhance response to therapeutic treatments.

Childhood maltreatment interacts with hypothalamic-pituitary-adrenal axis negative feedback and major depression: effects on cognitive performance

Background: Childhood maltreatment (CM) is associated with impaired hypothalamic-pituitary-adrenal (HPA) axis negative feedback and cognitive dysfunction, resembling those abnormalities linked to major depressive disorder (MDD). Objectives: We aimed to assess the potential modulating effects of MDD diagnosis or HPA axis function in the association between different types of CM and cognitive performance in adulthood. Methods: Sixty-eight MDD patients and 87 healthy controls were recruited. CM was assessed with the Childhood Trauma Questionnaire. We obtained three latent variables for neuropsychological performance (verbal memory, visual memory and executive function/processing speed) after running a confirmatory factor analysis with cognitive tests applied. Dexamethasone suppression test ratio (DSTR) was performed using dexamethasone 0.25 mg. Results: Different types of CM had different effects on cognition, modulated by MDD diagnosis and HPA axis function. Individuals with physical maltreatment and MDD presented with enhanced cognition in certain domains. The DSTR differentially modulated the association between visual memory and physical neglect or sexual abuse. Conclusions: HPA axis-related neurobiological mechanisms leading to cognitive impairment might differ depending upon the type of CM. Our results suggest a need for early assessment and intervention on cognition and resilience mechanisms in individuals exposed to CM to minimize its deleterious and lasting effects.

Childhood maltreatment and cognitive functioning in patients with major depressive disorder: a CAN-BIND-1 report

BACKGROUND

Patients with major depressive disorder (MDD) display cognitive deficits in acutely depressed and remitted states. Childhood maltreatment is associated with cognitive dysfunction in adults, but its impact on cognition and treatment related cognitive outcomes in adult MDD has received little consideration. We investigate whether, compared to patients without maltreatment and healthy participants, adult MDD patients with childhood maltreatment display greater cognitive deficits in acute depression, lower treatment-associated cognitive improvements, and lower cognitive performance in remission.

METHODS

Healthy and acutely depressed MDD participants were enrolled in a multi-center MDD predictive marker discovery trial. MDD participants received 16 weeks of standardized antidepressant treatment. Maltreatment and cognition were assessed with the Childhood Experience of Care and Abuse interview and the CNS Vital Signs battery, respectively. Cognitive scores and change from baseline to week 16 were compared amongst MDD participants with (DM+, n = 93) and without maltreatment (DM-, n = 90), and healthy participants with (HM+, n = 22) and without maltreatment (HM-, n = 80). Separate analyses in MDD participants who remitted were conducted.

RESULTS

DM+ had lower baseline global cognition, processing speed, and memory v. HM-, with no significant baseline differences amongst DM-, HM+, and HM- groups. There were no significant between-group differences in cognitive change over 16 weeks. Post-treatment remitted DM+, but not remitted DM-, scored significantly lower than HM- in working memory and processing speed.

CONCLUSIONS

Childhood maltreatment was associated with cognitive deficits in depressed and remitted adults with MDD. Maltreatment may be a risk factor for more severe and persistent cognitive deficits in adult MDD.

Predictors of outcome during inpatient psychotherapy for posttraumatic stress disorder: a single-treatment, multi-site, practice-based study

Objective: The aims of this study were to determine the effectiveness of a routine clinical care treatment and to identify predictors of treatment outcome in PTSD inpatients. Methods: A routinely collected data set of 612 PTSD inpatients (M = 42.3 years [SD = 11.6], 75.7% female) having received trauma-focused psychotherapy was analyzed. Primary outcome was the clinical symptom severity change score, secondary outcomes were assessed using functional, anxiety, and depression change scores. Hedges g-corrected pre-post effect sizes (ES) were computed for all outcomes. Elastic net regulation as a data-driven, stability-based machine-learning approach was used to build stable clinical prediction models. Results: Hedges g ES indicated medium to large effects on all outcomes. The results of the predictor analyses suggested that a combined predictor model with sociodemographic, clinical, and psychometric variables contribute to predicting different treatment outcomes. Across the clinical and functional outcome, psychoticism, total number of diagnoses, and bronchial asthma consistently showed a stable negative predictive relationship to treatment outcome. Conclusion: Trauma-focused psychotherapy could effectively be implemented in a routine inpatient setting. Some important prognostic variables could be identified. If the proposed models of predictors are replicated, they may help personalize treatment for patients receiving routine clinical care.

Transdiagnostic associations across communication, cognitive, and behavioural problems in a developmentally at-risk population: a network approach

BACKGROUND

Communication, behavioural, and executive function problems often co-occur in childhood. Previous attempts to identify the origins of these comorbidities have typically relied on comparisons of different deficit groups and/or latent variable models. Here we apply a network approach to a heterogeneous sample of struggling learners to conceptualise these comorbidities as a dynamic system of interacting difficulties.

METHODS

714 children struggling with attention, learning, and/or memory were included. The sample consisted of children with both diagnosed (41%) and undiagnosed difficulties. The conditional independence network of parent ratings of everyday behaviour, cognition, and communication was estimated.

RESULTS

A clustering coefficient identified four interconnected areas of difficulty: (1) structural language and learning; (2) pragmatics and peer relationships; (3) behavioural and emotional problems; and (4) cognitive skills. Emotional and behavioural symptoms shared multiple direct connections with pragmatic abilities and cognitive problems, but not with structural language skills or learning problems. Poor structural language and cognitive skills were associated with learning problems. Centrality indices highlighted working memory and language coherence as symptoms bridging different problem areas.

CONCLUSION

The network model identified four areas of difficulty and potential bridging symptoms. Although the current analytic framework does not provide causal evidence, it is possible that bridging symptoms may be the origins of comorbidities observed on a dimensional level; problems in these areas may cascade and activate problems in other areas of the network. The potential value of applying a dynamic systems network approach to symptoms of developmental disorders is discussed.