Exploring the interplay between psychotic experiences, functional somatic symptoms and health anxiety in childhood and adolescence - A longitudinal cohort study

BACKGROUND

Similarities exist between contemporary explanatory models underlying psychosis development, functional somatic symptoms, and health anxiety. The current study aimed to examine the potential interplay between psychotic experiences (and alternate measures of anomalous self-experiences and aberrant attribution of salience) and functional somatic symptoms on the outcome of health anxiety in youths.

METHODS

In a prospective general-population birth cohort, the Copenhagen Child Cohort 2000 (CCC2000), data from two time-points were available for 1122 individuals. We assessed the associations between psychotic experiences and functional somatic symptoms with health anxiety both cross-sectionally at ages 11- and 16-years, and longitudinally from age 11 to 16. Further, we examined if there was an interaction between these two domains on the outcome of health anxiety using the interaction contrast ratio.

RESULTS

Functional somatic symptoms and psychotic experiences were strongly cross-sectionally associated with health anxiety at both ages 11 and 16, even after adjustment for general psychopathology. In the longitudinal analyses, functional somatic symptoms, and psychotic experiences at age 11 were not individually associated with health anxiety at age 16 but having both functional somatic symptoms and psychotic experiences was: odds ratio 3.90, 95%CI 1.7-8.9, with suggestion of evidence for interaction beyond the additive effects. This association was attenuated after adjustment for general psychopathology: odds ratio 2.6, 95 % CI 1.0-6.4.

CONCLUSION

The strong associations between the domains support the idea of possible overlapping mechanisms underlying psychotic experiences, functional somatic symptoms, and health anxiety.

Early treatment response as predictor of long-term outcome in a clinical cohort of children with ADHD

This study investigates early onset of treatment response as predictor of symptomatic and functional outcome 3 years after initiation of methylphenidate (MPH) administration in a naturalistic, clinical cohort of children and adolescents with ADHD. Children were followed across an initial 12-week MPH treatment trial and after 3 years, with ratings of symptoms and impairment. Associations between a clinically significant MPH treatment response in week 3 (defined as ≥ 20% reduction in clinician-rated symptoms) and in week 12 (defined as ≥ 40% reduction), and 3-year outcome were tested in multivariate linear regression models, adjusting for sex, age, comorbidity, IQ, maternal education, parental psychiatric disorder, and baseline symptoms and function. We did not have information on treatment adherence or the nature of treatments beyond 12 weeks. 148 children, mean age 12.4 years (range 10-16 years), 77% males, participated in the follow-up. We found a significant decrease in symptom score from baseline [M = 41.9 (SD = 13.2)] to 3-year follow-up [M = 27.5 (SD = 12.7), p < 0.001, and in impairment score from baseline (M = 41.6 (SD = 19.4)] to 3-year follow-up [M = 35.6 (SD = 20.2), p = 0.005]. Treatment responses in week 3 and week 12 were significant predictors of the long-term outcome of symptoms, but not of impairment at 3-year follow-up, when adjusting for other well-known predictors. Early treatment response predicts long-term outcome over and above other well-known predictors. Clinicians should follow-up patients carefully, during the first months of treatment, and detect non-responders, since there might be a window of opportunity to alter the outcome, by changing the treatment strategy.Clinical trial registration: ClinicalTrials.gov, registration number NCT04366609, April 28, 2020 retrospectively registered.

Adverse events in cognitive behavioral therapy and relaxation training for children and adolescents with obsessive-compulsive disorder: A mixed methods study and analysis plan for the TECTO trial

Background

Knowledge on adverse events in psychotherapy for youth with OCD is sparse. No official guidelines exist for defining or monitoring adverse events in psychotherapy. Recent recommendations call for more qualitative and quantitative assessment of adverse events in psychotherapy trials. This mixed methods study aims to expand knowledge on adverse events in psychotherapy for youth with OCD.

Methods

This is an analysis plan for a convergent mixed methods study within a randomized clinical trial (the TECTO trial). We include at least 128 youth aged 8-17 years with obsessive-compulsive disorder (OCD). Participants are randomized to either family-based cognitive behavioral therapy (FCBT) or family-based psychoeducation and relaxation training (FPRT). Adverse events are monitored quantitatively with the Negative Effects Questionnaire. Furthermore, we assess psychiatric symptoms, global functioning, quality of life, and family factors to investigate predictors for adverse events. We conduct semi-structured qualitative interviews with all youths and their parents on their experience of adverse events in FCBT or FPRT. For the mixed methods analysis, we will merge 1) a qualitative content analysis with descriptive statistics comparing the types, frequencies, and severity of adverse events; 2) a qualitative content analysis of the perceived causes for adverse events with prediction models for adverse events; and 3) a thematic analysis of the participants' treatment evaluation with a correlational analysis of adverse events and OCD severity.

Discussion

The in-depth mixed methods analysis can inform 1) safer and more effective psychotherapy for OCD; 2) instruments and guidelines for monitoring adverse events; and 3) patient information on potential adverse events. The main limitation is risk of missing data.

Trial registration

ClinicalTrials.gov identifier: NCT03595098. Registered on July 23, 2018.

The occurrence of internalizing problems and chronic pain symptoms in early childhood: what comes first?

Chronic pain and internalizing problems are characterized by concurrent associations but the directionality of this relationship in early childhood remains unclear. This prospective study aimed to investigate the bidirectional effect of chronic pain and internalizing problems and test the persistence of pain over time in a population-based sample of preschoolers. The study was embedded in Generation R, a large population-based cohort. Mothers of 3,996 children assessed their child's experienced pain and internalizing problems at 3 and 6 years. At 3 years, paternal reports were available too. Reports of family functioning, discipline practices and parental psychopathology were also collected. The prevalence of chronic pain was 2.7% (106) and 8.0% (294) at baseline and follow-up, respectively. The presence of internalizing problems at child age 3 years predicted chronic pain at 6 years, for both maternal (OR 1.05, 95% CI 1.02,1.07, p < 0.001) and paternal (OR 1.03, 95%CI 1.00, 1.06, p < 0.05) internalizing problem reports, when adjusted for potential confounding factors. In contrast, chronic pain did not increase the likelihood of internalizing problems. The temporal relationship between chronic pain and internalizing problems appears to follow a largely unidirectional trend in early childhood, with internalizing problems increasing the likelihood of concurrent physical symptoms. Current understanding of the directionality of this relationship, highlights the importance for comprehensive assessment of psychiatric problems contributing to the manifestation of chronic pain.

Family-based cognitive behavioural therapy versus family-based relaxation therapy for obsessive-compulsive disorder in children and adolescents (the TECTO trial): a statistical analysis plan for the randomised clinical trial

Background

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder which affects up to 3% of children and adolescents. OCD in children and adolescents is generally treated with cognitive behavioural therapy (CBT), which, in more severely affected patients, can be combined with antidepressant medication. The TECTO trial aims to compare the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation/relaxation training (FPRT) in children and adolescents aged 8 to 17 years. This statistical analysis plan outlines the planned statistical analyses for the TECTO trial.

Methods

The TECTO trial is an investigator-initiated, independently funded, single-centre, parallel-group, superiority randomised clinical trial. Both groups undergo 14 sessions of 75 min each during a period of 16 weeks with either FCBT or FPRT depending on the allocation. Participants are randomised stratified by age and baseline Children’s Yale–Brown Obsessive-Compulsive Scale (CY-BOCS) score. The primary outcome is the CY-BOCS score. Secondary outcomes are health-related quality of life assessed using KIDSCREEN-10 and adverse events assessed by the Negative Effects Questionnaire (NEQ). Primary and secondary outcomes are assessed at the end of the intervention. Continuous outcomes will be analysed using linear regression adjusted for the stratification variables and baseline value of the continuous outcome. Dichotomous outcomes will be analysed using logistic regression adjusted for the stratification variables. The statistical analyses will be carried out by two independent blinded statisticians.

Discussion

This statistical analysis plan includes a detailed predefined description of how data will be analysed and presented in the main publication before unblinding of study data. Statistical analysis plans limit selective reporting bias. This statistical analysis plan will increase the validity of the final trial results.

Trial registration

ClinicalTrials.gov NCT03595098. July 23, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06799-4.

Family-based cognitive behavioural therapy versus family-based relaxation therapy for obsessive-compulsive disorder in children and adolescents: protocol for a randomised clinical trial (the TECTO trial)

BACKGROUND

Cognitive behavioural therapy (CBT) is the recommended first-line treatment for children and adolescents with obsessive-compulsive disorder (OCD), but evidence concerning treatment-specific benefits and harms compared with other interventions is limited. Furthermore, high risk-of-bias in most trials prevent firm conclusions regarding the efficacy of CBT. We investigate the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation and relaxation training (FPRT) in youth with OCD in a trial designed to reduce risk-of-bias.

METHODS

This is an investigator-initiated, independently funded, single-centre, parallel group superiority randomised clinical trial (RCT). Outcome assessors, data managers, statisticians, and conclusion drawers are blinded. From child and adolescent mental health services we include patients aged 8-17 years with a primary OCD diagnosis and an entry score of ≥16 on the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). We exclude patients with comorbid illness contraindicating trial participation; intelligence quotient < 70; or treatment with CBT, PRT, antidepressant or antipsychotic medication within the last 6 months prior to trial entry. Participants are randomised 1:1 to the experimental intervention (FCBT) versus the control intervention (FPRT) each consisting of 14 75-min sessions. All therapists deliver both interventions. Follow-up assessments occur in week 4, 8 and 16 (end-of-treatment). The primary outcome is OCD symptom severity assessed with CY-BOCS at end-of-trial. Secondary outcomes are quality-of-life and adverse events. Based on sample size estimation, a minimum of 128 participants (64 in each intervention group) are included.

DISCUSSION

In our trial design we aim to reduce risk-of-bias, enhance generalisability, and broaden the outcome measures by: 1) conducting an investigator-initiated, independently funded RCT; 2) blinding investigators; 3) investigating a representative sample of OCD patients; 3) using an active control intervention (FPRT) to tease apart general and specific therapy effects; 4) using equal dosing of interventions and therapist supervision in both intervention groups; 5) having therapists perform both interventions decided by randomisation; 6) rating fidelity of both interventions; 7) assessing a broad range of benefits and harms with repeated measures. The primary study limitations are the risk of missing data and the inability to blind participants and therapists to the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03595098, registered July 23, 2018.

Precursors of self-reported subclinical hypomania in adolescence: A longitudinal general population study

Symptoms of subclinical hypomania (SHM) are common in the general population of adolescents and young adults. SHM are most often transient yet might be risk markers of later bipolar disorder. The current study aimed to assess the clinical correlates of SHM at age 11 in the general population, examine the continuity of SHM from age 11-age 16 and explore the clinical precursors of age 16 SHM. As part of the Copenhagen Child Cohort 2000, 1,632 preadolescents participated in the examination of SHM and various clinical correlates at age 11, 893 were re-assessed for SHM at age 16 years. At age 11, SHM, psychotic experiences and depressive symptoms were assessed by semi-structured psychopathological interviews. Furthermore, the participants were diagnostically assessed by the Development and Well-Being Assessment and interviewed about sleep length. At age 16, SHM was assessed by self-report, using the Hypomania Checklist-32. Cannabis use occurring at age 15 or earlier was assessed at age 16. At age 11, SHM was associated with depressive disorders (Relative Risk [RR] = 2.96 [95% CI 1.26–6.96]), interview-based depressive symptoms (RR = 9.22 [5.93–14.34]), neurodevelopmental disorders (RR = 2.94 [1.66–5.20]), psychotic experiences (RR = 4.51 [2.90–7.01]) and insufficient sleep (RR = 2.10 [1.28–3.43]. In the longitudinal analyses, age 16 SHM was preceded by age 11 SHM (RR = 1.89 [1.02–3.49]), psychotic experiences (RR = 2.06, [1.28–3.33]), emotional disorders (RR = 1.77, [1.02–3.09]) and cannabis use (RR = 3.14, [1.93–5.10]), after mutual adjustment and adjustment for sex, and sociodemographic factors. In conclusion, age 11 SHM was statistically significantly associated with other types of psychopathology in cross-sectional analyses and showed some continuity with later self-reported SHM at age 16. Particularly early psychotic experiences and cannabis use stood out as independent precursors of self-reported SHM and might constitute important risk markers for the development of future SHM and bipolar disorder. An important potential caveat of the current study includes the self-report assessment of SHM.

Continuity of health anxiety from childhood to adolescence and associated healthcare costs: a prospective population-based cohort study

BACKGROUND

Severe health anxiety (HA) is characterized by excessive and impairing worry and preoccupation with health issues and can cause increased and unnecessary medical examinations. HA in childhood and adolescence is scarcely explored, hindering the potential for prevention and early intervention.

METHODS

HA was assessed in 1,278 children/youths at two time points at ages 11 and 16 years in a general population-based birth cohort. Register-based data on costs related to nonhospital-based primary and secondary somatic health services were obtained over the follow-up period. The presence of functional somatic symptoms, emotional disorders and chronic somatic illness at baseline were included as covariates.

RESULTS

High HA (top 10% score) at age 11 predicted high HA at age 16 (relative risk [RR] 2.03, 95% CI: 1.26-3.31). The group with persistent HA was small (n = 17, 1.3%), resulting in broad confidence intervals. The statistical effect of HA at age 11 on HA at age 16 was heavily reduced after adjustment for sex and all covariates (RR: 1.49, 95% CI: 0.85-2.60). In the adjusted model, somatic illness at age 11 (RR: 1.91, 95% CI: 1.22-2.98) and female sex (RR: 3.33, 95% CI: 2.01-5.50) were independently associated with HA at age 16. Persistent HA was associated with approximately doubled healthcare costs compared to the group with consistently low HA. Incident HA at age 16 was associated with increased costs over follow-up. The increased costs were not explained by chronic somatic illness.

CONCLUSIONS

A small subgroup of children had persistent high levels of HA from late childhood to adolescence and displayed increased healthcare costs. Female sex and chronic somatic disorders at age 11 were independent risk factors of HA at age 16. These findings provide potential means of early identification and of therapeutic levers. Further intervention development and evaluation are needed.

Recurrent canards producing relaxation oscillations

For three three-dimensional chaotic systems (Sprott NE1, NE8, and NE9) with only linear and quadratic terms and one parameter, but without equilibria, we consider the second order asymptotic approximations in the case that the parameter is small and near the origin of phase-space. The calculation leads to the existence and approximation of periodic solutions with neutral stability for systems NE1, NE9, and asymptotic stability for system NE8. Extending to a larger neighborhood in phase-space, we find a new type of relaxation oscillations with pulse behavior that can be understood by identifying hidden canards. The relaxation dynamics coexists with invariant tori and chaos in the systems.

Aggressive behavior, emotional, and attention problems across childhood and academic attainment at the end of primary school

PURPOSE

To assess whether aggressive behavior and emotional problems from early childhood onwards are related to academic attainment at the end of primary education, and whether these associations are independent of attention problems.

METHODS

Data on 2546 children participating in a longitudinal birth cohort in Rotterdam were analyzed. Aggressive behavior, attention and emotional problems at ages 1½, 3, 5 and 10 years were assessed with the Child Behavior Checklist. Academic attainment at the end of primary school (12 years of age) was measured with the CITO test, a national Dutch academic test score.

RESULTS

Aggressive behavior from age 1½ to 10 years was negatively associated with academic attainment, but these associations attenuated to non-significance when accounting for comorbid attention problems. For emotional problems, first, only problems at 10 years were associated with poorer academic attainment. Yet, when accounting for attention problems, the association reversed: more emotional problems from 1½ to 10 years were associated with a better academic attainment. Attention problems at ages 1½ to 10 years were negatively associated with academic attainment, independent of comorbid emotional problems or aggressive behavior.

CONCLUSIONS

Attention problems across childhood are related to a poorer academic attainment, while emotional problems predicted better academic attainment. Moreover, the relationship between aggressive behavior and academic attainment was explained by comorbid attention problems. Future research should determine the mechanisms through which attention problems and emotional problems affect academic attainment, to inform strategies for the promotion of better educational attainment.

Healthcare Costs, School Performance, and Health-related Quality of Life in Adolescence Following Psychotic Experiences in Preadolescence: A Longitudinal Cohort Study

Psychotic experiences (PEs) are common in the general population in preadolescence. The implications of PEs on socioeconomic outcomes, including educational attainment, are scarcely described. We aimed to estimate how preadolescent PEs were associated with later healthcare costs, school performance, and health-related quality of life (HRQoL) in adolescence. A total of 1607 preadolescents from the general population Copenhagen Child Cohort 2000 were assessed for PEs at age 11-12 years and followed up over 5 years using register-based data on mental and somatic healthcare costs, and school performance at age 16. Furthermore, HRQoL was assessed for a subsample of the children at age 16-17. We adjusted for perinatal and family sociodemographic adversities, prior parental mental illness and healthcare use, child IQ-estimate at age 11-12, and parent-rated general psychopathology of their child. PEs were associated with slightly poorer school performance. However, preadolescents with PEs more often reported HRQoL within the lowest 10th percentile (OR = 2.74 [95% CI 1.71-4.37]). Preadolescents who reported PEs had higher average total healthcare costs over the following 5 years. The costs for individuals with PEs were higher for mental healthcare services across primary to tertiary care, but not for somatic care. After adjustments, PEs remained independently associated with higher costs and poorer HRQoL, but not with poorer school performance. In conclusion, PEs are important in mental health screening of preadolescents and identify a group of young people with increased healthcare service-use throughout adolescence and who report poorer HRQoL in adolescence, over and above parent-rated general psychopathology of their child.

Psychotic experiences from preadolescence to adolescence: when should we be worried about adolescent risk behaviors?

Psychotic experiences (PE), below the threshold of psychotic disorder, are common in the general population. PE are associated with risk behaviors such as suicidality, non-suicidal self-injury (NSSI) and substance use. However, PE as specific or causal phenomena of these risk behaviors are still debated. We aimed to examine the longitudinal trajectories of PE from preadolescence to adolescence and their associated risk behaviors in adolescence. A total of 1138 adolescents from the Copenhagen Child Cohort 2000 were assessed for PE and risk behaviors (NSSI, suicide ideation and -attempts and substance use) at age 11 and 16 years, along with measures of general psychopathology and depressive symptoms specifically. Self-reported impact of general psychopathology tended to be associated with more PE persistence. PE were associated with all risk behaviors in cross section at both follow-ups. Persistent PE from ages 11 to 16 and incident PE at age 16 were associated with risk behaviors at age 16, whereas remitting PE from age 11 to 16 were not. After adjustment for co-occurring depressive symptoms and general psychopathology, all associations were markedly reduced. After exclusion of preadolescents who already had expressed risk behavior at age 11, PE in preadolescence did not stand out as an independent predictor of incident adolescent risk behaviors. The current study suggests that PE in preadolescence and adolescence may not play a direct causal role regarding NSSI, suicidality, and substance use. However, PE are still useful clinical markers of severity of psychopathology and associated risk behaviors.

Validation of the Transition Readiness and Appropriateness Measure (TRAM) for the Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare in Europe (MILESTONE) study

OBJECTIVE

Young people moving from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) are faced with significant challenges. To improve this state of affairs, there needs to be a recognition of the problem and initiatives and an urgent requirement for appropriate tools for measuring readiness and outcomes at the transfer boundary (16-18 years of age in Europe). The objective of this study was to develop and validate the Transition Readiness and Appropriateness Measure (TRAM) for assessing a young person's readiness for transition, and their outcomes at the transfer boundary.

DESIGN

MILESTONE prospective study.

SETTING

Eight European Union (EU) countries participating in the EU-funded MILESTONE study.

PARTICIPANTS

The first phase (MILESTONE validation study) involved 100 adolescents (pre-transition), young adults (post-transition), parents/carers and both CAMHS and AMHS clinicians. The second phase (MILESTONE cohort study and nested cluster randomised trial) involved over 1000 young people.

RESULTS

The development of the TRAM began with a literature review on transitioning and a review of important items regarding transition by a panel of 34 mental health experts. A list of 64 items of potential importance were identified, which together comprised the TRAM. The psychometric properties of the different versions of the TRAM were evaluated and showed that the TRAM had good reliability for all versions and low-to-moderate correlations when compared with other established instruments and a well-defined factor structure. The main results of the cohort study with the nested cluster randomised trial are not reported.

CONCLUSION

The TRAM is a reliable instrument for assessing transition readiness and appropriateness. It highlighted the barriers to a successful transition and informed clinicians, identifying areas which clinicians on both sides of the transfer boundary can work on to ease the transition for the young person.

TRIAL REGISTRATION NUMBER

ISRCTN83240263 (Registered 23 July 2015), NCT03013595 (Registered 6 January 2017); Pre-results.

Mental Health Service Use and Psychopharmacological Treatment Following Psychotic Experiences in Preadolescence

OBJECTIVE

Psychotic experiences affect more than 10% of children and often co-occur with nonpsychotic mental disorders. However, longitudinal studies of the outcome of psychotic experiences based on unbiased information on mental health service use and psychotropic medications are scarce. The authors investigated whether psychotic experiences at ages 11-12 predicted a psychiatric diagnosis or treatment with psychotropic medications by ages 16-17.

METHODS

In a longitudinal register-based follow-up study of the Copenhagen Child Cohort 2000, a total of 1,632 children ages 11-12 were assessed for psychotic experiences in face-to-face interviews. The children were also assessed for mental disorders and IQ. National registries provided information on perinatal and sociodemographic characteristics, on psychiatric disorders diagnosed at child and adolescent mental health services, and on prescribed psychotropic medications through ages 16-17.

RESULTS

Among children who had not been previously diagnosed, and after adjustment for sociodemographic and perinatal adversities and IQ, psychotic experiences at ages 11-12 predicted receiving a psychiatric diagnosis in child and adolescent mental health services before ages 16-17 (adjusted hazard ratio=3.13, 95% CI=1.93, 5.07). The risk was increased if the child met criteria for a co-occurring mental disorder (not diagnosed in mental health settings) at baseline compared with no psychotic experiences or diagnosis at baseline (adjusted hazard ratio=7.85, 95% CI=3.94, 15.63), but having psychotic experiences alone still marked a significantly increased risk of later psychiatric diagnoses (adjusted hazard ratio=2.76, 95% CI=1.48, 5.13). Similar patterns were found for treatment with psychotropic medications.

CONCLUSIONS

Psychotic experiences in childhood predict mental health service use and use of psychotropic medications during adolescence. The study findings provide strong evidence that psychotic experiences in preadolescence index a transdiagnostic vulnerability for diagnosed psychopathology in adolescence.

Transition as a topic in psychiatry training throughout Europe: trainees' perspectives

The majority of adolescents with mental health problems do not experience continuity of care when they reach the transition boundary of their child and adolescent mental health service. One of the obstacles for a smooth transition to adult mental health services concerns the lack of training for health-care professionals involved in the transition process. This study aims to seek psychiatric trainees' opinions regarding training on transition and the knowledge and skills required for managing transition. A survey was distributed to trainees residing in European countries. Trainees from 36 countries completed the questionnaire, of which 63% reported that they came into contact with youth and young adults (16-26 years) during their clinical practice. Twenty-seven percent of trainees stated they have good to very good knowledge about the transition process. Theoretical training about transition was reported in only 17% of the countries, and practical training in 28% of the countries. Ninety-four percent of trainees indicated that further training about transition is necessary. The content of subsequent transition-related training can be guided by the findings of the MILESTONE project.

Training-induced white matter microstructure changes in survivors of neonatal critical illness: A randomized controlled trial

In a nationwide randomized controlled trial, white matter microstructure was assessed before and immediately after Cogmed Working-Memory Training (CWMT) in school-age neonatal critical illness survivors. Eligible participants were survivors (8-12 years) with an IQ ≥ 80 and a z-score of ≤ -1.5 on (working)memory test at first assessment. Diffusion Tensor Imaging was used to assess white matter microstructure. Associations between any training-induced changes and improved neuropsychological outcome immediately and one year post-CWMT were evaluated as well. The trial was conducted between October 2014-June 2017 at Erasmus MC-Sophia, Rotterdam, Netherlands. Researchers involved were blinded to group allocation. Participants were randomized to CWMT(n = 14) or no-intervention(n = 20). All children completed the CWMT. Global fractional anisotropy(FA) increased significantly post-CWMT compared to no-intervention(estimated-coefficient = .007, p = .015). Increased FA(estimated coefficient = .009, p = .033) and decreased mean diffusivity(estimated-coefficient = -.010, p = .018) were found in the left superior longitudinal fasciculus(SFL) post-CWMT compared no-intervention. Children after CWMT who improved with >1SD on verbal working-memory had significantly higher FA in the left SLF post-CWMT(n = 6; improvement = .408 ± .01) than children without this improvement post-CWMT(n = 6; no-improvement = .384 ± .02), F(1,12) = 6.22, p = .041, ηp2 = .47. No other structure-function relationships were found post-CWMT. Our findings demonstrate that white matter microstructure and associated cognitive outcomes are malleable by CWMT in survivors of neonatal critical illness.

Psychotic experiences are associated with health anxiety and functional somatic symptoms in preadolescence

BACKGROUND

Health anxiety (HA) is an increasing public health problem related to increased health service costs, and associated with functional somatic symptoms (FSS) and considerable personal suffering. Abnormal bodily experiences which may resemble HA and FSS are common in psychotic disorders, but a potential link between HA and psychosis vulnerability in childhood is largely unexplored. The current study estimates the association between subclinical psychotic experiences (PE) and HA and FSS in a general population cohort of preadolescents.

METHODS

The study population consisted of 1,572 11-12-year-old children from the Copenhagen Child Cohort 2000. PE were comprehensibly assessed as either present or not present using the Kiddie Schedule of Affective Disorders and Schizophrenia psychosis section. HA and FSS were assessed by self-report on validated questionnaires. Additional variables on general psychopathology, puberty, and chronic somatic illness were also obtained.

RESULTS

Psychotic experiences were associated with the top 10% high scores of HA (Odds Ratio (OR) 3.2; 95% CI: 2.1-4.8) and FSS (OR 4.6; 95% CI: 3.1-6.9) in univariate analyses. After mutual adjustment, the association was reduced to (HA: OR 2.3; 95% CI: 1.5-3.5; FSS: OR 3.7; 95% CI: 2.4-4.7), suggesting interdependence. Further adjustment for potential confounders and general psychopathology only reduced the associations slightly: HA OR 2.2 (95% CI: 1.4-3.4); FSS OR 3.3 (95% CI: 2.1-5.2). Secondary analyses of subdimensions of HA showed that PE were associated with fears (OR 3.0; 95% CI: 2.0-4.6) and daily impact of HA symptoms (OR 5.0; 95% CI: 3.4-7.5), but not help seeking (OR 1.2; 95% CI: 0.7-2.1).

CONCLUSIONS

This is the first study to investigate the associations between PE and HA and FSS, respectively. PE were significantly associated with HA and FSS over and above general psychopathology in preadolescence. Individuals with PE expressed high levels of health-related fears and daily impact, but no corresponding help-seeking behavior.

Correction to: The interface between child/adolescent and adult mental health services: results from a European 28‑country survey

The original version of this article contained an error in Table 1. The correct table is presented below.

The Problem of Same-Rater Bias

The diagnostic process in child and adolescent psychiatry relies heavily on information from multiple informants, including parents, teachers, and the child itself. It has long been well known that information from informants who see the child in different settings may differ, but that each type of informant may contribute useful and unique information to the prediction of mental health problems.¹ The diagnosis of attention-deficit/hyperactivity disorder (ADHD) depends on reports from informants who see the child in different settings. This is illustrated in the DSM-5, in which the diagnostic criteria require several inattentive or hyperactive-impulsive symptoms to be present in two or more settings.

Differential patterns of age-related cortical and subcortical functional connectivity in 6-to-10 year old children: A connectome-wide association study

INTRODUCTION

Typical brain development is characterized by specific patterns of maturation of functional networks. Cortico-cortical connectivity generally increases, whereas subcortico-cortical connections often decrease. Little is known about connectivity changes amongst different subcortical regions in typical development.

METHODS

This study examined age- and gender-related differences in functional connectivity between and within cortical and subcortical regions using two different approaches. The participants included 411 six- to ten-year-old typically developing children sampled from the population-based Generation R study. Functional connectomes were defined in native space using regions of interest from subject-specific FreeSurfer segmentations. Connections were defined as: (a) the correlation between regional mean time-series; and (b) the focal maximum of voxel-wise correlations within FreeSurfer regions. The association of age and gender with each functional connection was determined using linear regression. The preprocessing included the exclusion of children with excessive head motion and scrubbing to reduce the influence of minor head motion during scanning.

RESULTS

Cortico-cortical associations echoed previous findings that connectivity shifts from short to long-range with age. Subcortico-cortical associations with age were primarily negative in the focal network approach but were both positive and negative in the mean time-series network approach. Between subcortical regions, age-related associations were negative in both network approaches. Few connections had significant associations with gender.

CONCLUSIONS

The present study replicates previously reported age-related patterns of connectivity in a relatively narrow age-range of children. In addition, we extended these findings by demonstrating decreased connectivity within the subcortex with increasing age. Lastly, we show the utility of a more focal approach that challenges the spatial assumptions made by the traditional mean time series approach.

Gestational vitamin D deficiency and autism-related traits: the Generation R Study

There is intense interest in identifying modifiable risk factors associated with autism-spectrum disorders (ASD). Autism-related traits, which can be assessed in a continuous fashion, share risk factors with ASD, and thus can serve as informative phenotypes in population-based cohort studies. Based on the growing body of research linking gestational vitamin D deficiency with altered brain development, this common exposure is a candidate modifiable risk factor for ASD and autism-related traits. The association between gestational vitamin D deficiency and a continuous measure of autism-related traits at ~6 years (Social Responsiveness Scale; SRS) was determined in a large population-based cohort of mothers and their children (n=4229). 25-hydroxyvitamin D (25OHD) was assessed from maternal mid-gestation sera and from neonatal sera (collected from cord blood). Vitamin D deficiency was defined as 25OHD concentrations less than 25 nmol l^-1. Compared with the 25OHD sufficient group (25OHD>50 nmol l^-1), those who were 25OHD deficient had significantly higher (more abnormal) SRS scores (mid-gestation n=2866, β=0.06, P<0.001; cord blood n=1712, β=0.03, P=0.01). The findings persisted (a) when we restricted the models to offspring with European ancestry, (b) when we adjusted for sample structure using genetic data, (c) when 25OHD was entered as a continuous measure in the models and (d) when we corrected for the effect of season of blood sampling. Gestational vitamin D deficiency was associated with autism-related traits in a large population-based sample. Because gestational vitamin D deficiency is readily preventable with safe, cheap and accessible supplements, this candidate risk factor warrants closer scrutiny.

The bidirectional association between sleep problems and autism spectrum disorder: a population-based cohort study

Background

Sleep difficulties are prevalent in children with autism spectrum disorder (ASD). The temporal nature of the association between sleep problems and ASD is unclear because longitudinal studies are lacking. Our aim is to clarify whether sleep problems precede and worsen autistic traits and ASD or occur as a consequence of the disorder.

Methods

Repeated sleep measures were available at 1.5, 3, 6, and 9 years of age in 5151 children participating in the Generation R Study, a large prospective birth cohort in the Netherlands. Autistic traits were determined with the Pervasive Developmental Problems score (PDP) of the Child Behavior Checklist (CBCL) at 1.5 and 3 years and the Social Responsiveness Scale (SRS) at 6 years. This cohort included 81 children diagnosed with ASD.

Results

Sleep problems in early childhood were prospectively associated with a higher SRS score, but not when correcting for baseline PDP score. By contrast, a higher SRS score and an ASD diagnosis were associated with more sleep problems at later ages, even when adjusting for baseline sleep problems. Likewise, a trajectory of increasing sleep problems was associated with ASD.

Conclusions

Sleep problems and ASD are not bidirectionally associated. Sleep problems do not precede and worsen autistic behavior but rather co-occur with autistic traits in early childhood. Over time, children with ASD have an increase in sleep problems, whereas typically developing children have a decrease in sleep problems. Our findings suggest that sleep problems are part of the construct ASD.

Memory deficits following neonatal critical illness: a common neurodevelopmental pathway

Over the past decade, evidence has emerged that children growing up after neonatal critical illness, irrespective of underlying diagnosis, are at risk of memory impairment and academic problems. These difficulties are manifest even when intelligence is within the normal range. In this Review, we propose a common neurodevelopmental pathway following neonatal critical illness by showing that survivors of preterm birth, congenital heart disease, and severe respiratory failure share an increased risk of long-term memory deficits and associated hippocampal alterations. Rather than a consequence of underlying diagnosis, we suggest that this shared vulnerability is probably related to common conditions associated with neonatal critical illness, including hypoxia, neuroinflammation, stress, exposure to anaesthetics, or a complex interplay of these factors at different postconceptional ages. Future work should be aimed at improvement of early identification of patients at risk and evaluation of intervention modalities, such as exercise or cognitive training.

Architecture and functioning of child and adolescent mental health services: a 28-country survey in Europe

The WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed.

Familial confounding of the association between maternal smoking during pregnancy and internalizing disorders in offspring

BACKGROUND

Maternal smoking has consistently been associated with multiple adverse childhood outcomes including externalizing disorders. In contrast the association between maternal smoking during pregnancy (MSDP) and internalizing (anxiety and depressive) disorders in offspring has received less investigation.

METHOD

We conducted a nationwide cohort study including 957635 individuals born in Denmark between 1991 and 2007. Data on MSDP and diagnoses of depression or anxiety disorders were derived from national registers and patients were followed up from the age of 5 years to the end of 2012. Hazard rate ratios (HRRs) were estimated using stratified Cox regression models. Sibling data were used to disentangle individual- and familial-level effects of MSDP and to control for unmeasured familial confounding.

RESULTS

At the population level, offspring exposed to MSDP were at increased risk for both severe depression [HRR 1.29, 95% confidence interval (CI) 1.22-1.36] and severe anxiety disorders (HRR 1.26, 95% CI 1.20-1.32) even when controlling for maternal and paternal traits. However, there was no association between MSDP and internalizing disorders when controlling for the mother's propensity for MSDP (depression: HRR 1.11, 95% CI 0.94-1.30; anxiety disorders: HRR 0.94, 95% CI 0.80-1.11) or comparing differentially exposed siblings (depression: HRR 1.18, 95% CI 0.75-1.89; anxiety disorders: HRR 0.87, 95% CI 0.55-1.36).

CONCLUSIONS

The results suggest that familial background factors account for the association between MSDP and severe internalizing disorders not the specific exposure to MSDP.

Gestational vitamin D deficiency and autism spectrum disorder

BACKGROUND

There is growing interest in linking vitamin D deficiency with autism spectrum disorders (ASDs). The association between vitamin D deficiency during gestation, a critical period in neurodevelopment, and ASD is not well understood.

AIMS

To determine the association between gestational vitamin D status and ASD.

METHOD

Based on a birth cohort (n=4334), we examined the association between 25-hydroxyvitamin D (25OHD), assessed from both maternal mid-gestation sera and neonatal sera, and ASD (defined by clinical records; n=68 cases).

RESULTS

Individuals in the 25OHD-deficient group at mid-gestation had more than twofold increased risk of ASD (odds ratio (OR)=2.42, 95% confidence interval (CI) 1.09 to 5.07, P=0.03) compared with the sufficient group. The findings persisted in analyses including children of European ethnicity only.

CONCLUSIONS

Mid-gestational vitamin D deficiency was associated with an increased risk of ASD. Because gestational vitamin D deficiency is readily preventable with safe, inexpensive and readily available supplementation, this risk factor warrants closer scrutiny.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Prevalence and predictors of vitamin D deficiency based on maternal mid-gestation and neonatal cord bloods: The Generation R Study

BACKGROUND

Population-based studies have confirmed that the prevalence of vitamin D deficiency is substantial in many societies, and is of particular concern in pregnant women. Vitamin D deficiency during pregnancy is associated with a wide range of adverse maternal and offspring health outcomes. To date, studies of vitamin D deficiency during pregnancy have focused on measurements at one or two time points in isolation. We examined both midgestation and cord blood 25 hydroxyvitamin D (25OHD) concentration and explored the prevalence and correlates of vitamin D deficiency in a large ethnically diverse cohort of pregnant women and their infants in the Netherlands.

METHODS

This study was embedded in the Generation R Study, a population-based prospective cohort from fetal life onwards in Rotterdam, The Netherlands. Using a highly sensitive tandem mass spectroscopy-based assay, we measured 25OHD in 7256 midgestation samples (mean gestation 20.6 weeks) and 5023 neonatal cord blood samples (mean gestation 40.0 weeks). Using a conservative threshold of less than 25nmol/L to define vitamin D deficiency, we examined the prevalence and socio-demographic correlates of vitamin D deficiency in mothers and infants. We also derived a measure of vitamin D deficiency based on the two time points in order to explore persistent vitamin D deficiency in mother-infant pairs.

RESULTS

The prevalence of vitamin D deficiency at midgestation was 26%, while in neonates 46% were deficient. 21% of the mother-infant pairs had persistent vitamin D deficiency (i.e., deficient in maternal and cord samples) and an additional 29% were vitamin D deficient in one of the two samples only. Persistent vitamin D deficiency was strongly associated with non-European ancestry and spring birth.

CONCLUSIONS

A sizeable proportion of women and their neonatal offspring in the Generation R cohort were vitamin D deficient. In light of the large body of evidence linking vitamin D deficiency with adverse health outcomes for pregnant women and their offspring, our findings indicate a large unmet need in this population. In particular, women and infants from non-European ethnic background are at high risk of vitamin D deficiency.

[Supporting patients in self-management: moving to a personalised approach]

OBJECTIVE

The aim of this research was to assess the effect of providing personalised self-management support on patient activation (knowledge, skills, self-efficacy) and self-management behaviour.

DESIGN

Cluster randomised trial in 15 general practices (Dutch Trial Register No.: NTR 3960).

METHOD

Patients aged 18 years or older with a chronic condition were invited to participate in the study. The Self-Management Screening (SeMaS) questionnaire - which illustrates barriers to self-management - was used as a tool for personalised self-management support. Nurse practitioners in the intervention practices were trained for 2 hours in using SeMaS and personalising self-management support on the basis of the SeMaS profile. At baseline and after 6 months, patients filled in questionnaires on patient activation (PAM-13) and lifestyle. Using data from the questionnaires and medical records, the use of individual care plans, referrals to self-management interventions, self-monitoring and healthcare use were assessed. We used a multiple multilevel regression model for data analysis.

RESULTS

After 6 months, no difference was found in patient activation between the control group (n = 348) and the intervention group (n = 296). 29.4% of the patients in the intervention group performed self-monitoring, versus 15.2% in the control group (regression coefficient r = 0.9, p = 0.01). In the per-protocol analysis (control n = 348; intervention n = 136), the number of individual care plans (r = 1.3, p = 0.04) and the number of patients performing self-monitoring (r = 1.0; p = 0.01) were higher in the intervention group.

CONCLUSION

Personalised self-management support with the use of the SeMaS method stimulates self-monitoring and the use of individual care plans. The intervention had no effect on patient activation or lifestyle. Given the positive secondary outcomes, the further potential of the tool should be researched.

Validation of Self-Management Screening (SeMaS), a tool to facilitate personalised counselling and support of patients with chronic diseases

Background

A rising number of people with chronic conditions is offered interventions to enhance self-management. The responsiveness of individuals to these interventions depends on patient characteristics. We aimed to develop and validate a tool to facilitate personalised counselling and support for self-management in patients with chronic diseases in primary care.

Methods

We drafted a prototype of the tool for Self-Management Screening (SeMaS), comprising 27 questions that were mainly derived from validated questionnaires. To reach high content validity, we performed a literature review and held focus groups with patients and healthcare professionals as input for the tool. The characteristics self-efficacy, locus of control, depression, anxiety, coping, social support, and perceived burden of disease were incorporated into the tool. Three items were added to guide the type of support or intervention, being computer skills, functioning in groups, and willingness to perform self-monitoring. Subsequently, the construct and criterion validity of the tool were investigated in a sample of 204 chronic patients from two primary care practices. Patients filled in the SeMaS and a set of validated questionnaires for evaluation of SeMaS. The Patient Activation Measure (PAM-13), a generic instrument to measure patient health activation, was used to test the convergent construct validity.

Results

Patients had a mean age of 66.8 years and 46.6 % was female. 5.9 % did not experience any barrier to self-management, 28.9 % experienced one minor or major barrier, and 30.4 % two minor or major barriers. Compared to the criterion measures, the positive predictive value of the SeMaS characteristics ranged from 41.5 to 77.8 % and the negative predictive value ranged from 53.3 to 99.4 %. Crohnbach’s alpha for internal consistency ranged from 0.56 to 0.87, except for locus of control (α = 0.02). The regression model with PAM-13 as a dependent variable showed that the SeMaS explained 31.7 % (r² = 0.317) of the variance in the PAM-13 score.

Conclusions

SeMaS is a short validated tool that can signal potential barriers for self-management that need to be addressed in the dialogue with the patient. As such it can be used to facilitate personalised counselling and support to enhance self-management in patients with chronic conditions in primary care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0381-z) contains supplementary material, which is available to authorized users.

Functioning of cannabis abuse and dependence criteria across two different countries: the United States and The Netherlands

BACKGROUND

Cross-national differences could affect the likelihood of endorsement of DSM cannabis abuse and dependence criteria. The present study examines whether cannabis abuse and dependence criteria function differently across U.S. and Dutch cannabis users.

METHOD

Data on lifetime endorsement of DSM-IV cannabis abuse/dependence criteria were utilized from U.S. cannabis users who participated in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) and from Dutch cannabis users who participated in the Zuid-Holland study. In total, 1,568 cannabis users participated in the NESARC sample, and 359 cannabis users participated in the Zuid-Holland sample. The DSM-IV cannabis abuse/dependence criteria as well as cannabis withdrawal were determined using face-to-face computer-assisted personal interviews.

RESULTS

Using Restricted Factor Analysis with Latent Moderated Structures, the cannabis abuse/dependence criteria legal problems (β = -0.43), failed quit attempts (β = -1.09), use despite problems (β = -0.32), and withdrawal (β = -0.53) showed measurement bias, and were more likely to be endorsed by U.S. than by Dutch cannabis users. Also, men were more likely than women to endorse the criteria hazardous use (β = -0.27), legal problems (β = -0.49) and tolerance (β = -0.20). Findings on failed quit attempts and withdrawal were replicated in matched subsamples, while results on legal problems (country and gender) were partly replicated.

CONCLUSIONS

Several CUD criteria showed measurement bias across two countries and between males and females. Therefore, differences between countries and gender in prevalence rates of CUD should be regarded with caution.

Physical activity and onset of depression in adolescents: a prospective study in the general population cohort TRAILS

Although it has often been suggested that physical activity and depression are intertwined, only few studies have investigated whether specific aspects of physical activity predict the incidence of major depression in adolescents from the general population. Therefore the aim of this study was to investigate the effects of nature, frequency, duration and intensity of physical activity during early adolescence on the onset of a major depressive episode in early adulthood. In a population sample of adolescents (N = 1396), various aspects of physical activity were assessed at early adolescence (mean age 13.02, SD = 0.61). Major depressive episode onset was assessed using the Composite International Diagnostic Interview. A Cox regression model was performed to investigate whether physical activity characteristics and their interactions with gender predicted a major depressive episode onset up until mean age 18.5 (SD = 0.61). The individual characteristics of physical activity (nature, frequency, duration and intensity) or their interactions with gender did not predict a major depressive episode onset (p values >0.05). So far, there is no prospective evidence that physical activity protects against the development of adolescent depressive episodes in either boys or girls.

Identifying target groups for the prevention of depression in early adolescence: the TRAILS study

BACKGROUND

Depression in adolescence is associated with long-term adverse consequences. The aim of the present study is to identify target groups at increased risk of developing depression in early adolescence, such that prevention is associated with the largest health benefit at population-level for the least effort.

METHODS

The analyses were conducted on data of the first (age range 10-12) and fourth (age range 17-20) wave of a population-based cohort study (N=1538). The Composite International Diagnostic Interview (CIDI) was used to assess onset of major depression in early adolescence. High-risk groups were identified using exposure rate, incidence rate and population attributable fraction.

RESULTS

Prevention of depression onset in early adolescence is best targeted at children with one of the following risk profiles: a high body mass index in combination with (1) maternal depression (2) female gender, and (3) parental emotional rejection.

LIMITATIONS

Age of onset of depression was assessed retrospectively.

CONCLUSIONS

Only a few risk indicators are needed to identify a relatively small group which accounts for a substantial percentage of the new cases of depression in early adolescence.

Childhood problem behavior and parental divorce: evidence for gene-environment interaction

OBJECTIVE

The importance of genetic and environmental influences on children's behavioral and emotional problems may vary as a function of environmental exposure. We previously reported that 12-year-olds with divorced parents showed more internalizing and externalizing problems than children with married parents, and that externalizing problems in girls precede and predict later parental divorce. The aim of the current study was to investigate as to whether genetic and environmental influences on internalizing and externalizing problems were different for children from divorced versus non-divorced families.

METHODS

Maternal ratings on internalizing and externalizing problems were collected with the Child Behavior Checklist in 4,592 twin pairs at ages 3 and 12 years, of whom 367 pairs had experienced a parental divorce between these ages. Variance in internalizing and externalizing problems at ages 3 and 12 was analyzed with biometric models in which additive genetic and environmental effects were allowed to depend on parental divorce and sex. A difference in the contribution of genetic and environmental influences between divorced and non-divorced groups would constitute evidence for gene-environment interaction.

RESULTS

For both pre- and post-divorce internalizing and externalizing problems, the total variances were larger for children from divorced families, which was mainly due to higher environmental variances. As a consequence, heritabilities were lower for children from divorced families, and the relative contributions of environmental influences were higher.

CONCLUSIONS

Environmental influences become more important in explaining variation in children's problem behaviors in the context of parental divorce.

Children's perceptions of dissimilarity in parenting styles are associated with internalizing and externalizing behavior

The purpose of this study was to examine the relationship between children's perception of dissimilarity in parenting styles, and internalizing and externalizing problems in children. Children from the general population (n = 658) reported on the level of emotional warmth, rejection, and overprotection of both parents by filling out the child version of the Egna Minnen Beträffande Uppfostran (EMBU-C) and mothers completed the child behavior checklist (CBCL). Intraclass correlations were computed as measures of dissimilarity between parenting styles of mothers and fathers. Children's perceived dissimilarity in parental emotional warmth is associated with internalizing and externalizing problems (β = 0.092, p < 0.05; β = 0.091, p < 0.05). Perceived dissimilarity between parents' overprotection is associated with externalizing problems (β = 0.097, p < 0.05). Perceived dissimilarity between parenting styles is associated with externalizing and internalizing problems, over and above the effects of the level of the parenting styles. The results highlight the negative consequences of perceived dissimilarity between parents. To conclude, children have more internalizing and externalizing problems when they perceive their parents as more dissimilar in parenting styles.

Intrauterine effects of maternal prepregnancy overweight on child cognition and behavior in 2 cohorts

OBJECTIVE

Greater maternal prepregnancy adiposity has been associated with behavioral problems, such as attention-deficit/hyperactivity disorder, and lower intellectual function in offspring. However, few studies of humans have explored this, and it is unclear if intrauterine mechanisms or confounding factors drive these associations.

PATIENTS AND METHODS

Parental adiposity and offspring verbal skills, nonverbal skills, and behavioral problems were assessed in the British Avon Longitudinal Study of Parents and Children (N = ∼5000) and Dutch Generation R (N = ∼2500) cohorts. We aimed to determine the plausibility of intrauterine effects by (1) adjusting for multiple confounders, (2) comparing associations between maternal and paternal overweight with offspring cognition/behaviors, and (3) searching for cross-cohort consistency.

RESULTS

Maternal prepregnancy overweight was associated with reduced child verbal skills (unadjusted). However, after adjusting for confounders, this result was not consistently observed in both cohorts. Maternal overweight was also associated with child total behavior problems and externalizing problems even after adjusting for confounders. However, this was observed in Generation R only and was not replicated in the British Avon Longitudinal Study of Parents and Children. No associations of maternal overweight with child attention problems, emotional/internalizing problems, or nonverbal skills were observed in either cohort. Paternal overweight was not associated with any of the child outcomes but was also less strongly related to potential confounding factors than was maternal overweight.

CONCLUSIONS

Overall, we found little consistent evidence of intrauterine effects of maternal prepregnancy overweight on child cognition and behavior. Some associations initially observed were not consistently replicated across cohorts or robust to adjustment for confounding factors and, thus, are likely to reflect confounding by socioeconomic or postnatal factors.

Reduced autonomic flexibility as a predictor for future anxiety in girls from the general population: The TRAILS study

The present study investigated whether autonomic flexibility predicted future anxiety levels in adolescent boys and girls. This study is part of the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective cohort study of Dutch adolescents. The current study included a subsample of 965 individuals. Measures of autonomic flexibility, i.e., heart rate (HR) and respiratory sinus arrhythmia (RSA), were determined during the first assessment wave (T1: participants 10-12 years old). Self-reported anxiety was assessed at the first and second assessment wave (T2: participants 12-14 years old). Possible gender differences and co-occurring depressive problems were examined. In girls, low RSA predicted anxiety levels 2 years later. In boys, no associations between HR and RSA and future anxiety were found. We conclude that in adolescent girls from the general population, signs of reduced autonomic flexibility (i.e., low RSA) predict future anxiety levels. Since the effect size was small, at this point, RSA reactivity alone cannot be used to identify individuals at risk for anxiety, but should be regarded as one factor within a large group of risk factors. However, if the present findings are replicated in clinical studies, intervention programmes - in the future - aimed at normalising autonomic functioning may be helpful.

Predicting adult emotional and behavioral problems from externalizing problem trajectories in a 24-year longitudinal study

The aim of this study was to examine the prediction of adult behavioral and emotional problems from developmental trajectories of externalizing behavior in a 24-years longitudinal population-based study of 2,076 children. The adult psychiatric outcome of these trajectories has not yet been examined. Trajectories of the four externalizing behavior types: aggression, opposition, property violations and status violations were determined separately through latent class growth analysis using data of five waves, covering ages 4-18 years. We used regression analyses to determine the associations between children's trajectories and adults' psychiatric problems based on the Adult Self-Report. The developmental trajectories of the four types of externalizing behavior mostly predicted intrusive, aggressive and rule-breaking behavior in adulthood. Non-destructive behaviors in childhood such as opposition and status violations predict adult problems to a larger extent than destructive behaviors such as aggression and property violations. In general, children who develop through high-level trajectories are likely to suffer from both internalizing and externalizing problem behavior in adulthood, regardless the direction of change (i.e. increasing/decreasing/persisting) of the high-level trajectory. We can conclude that the level rather than the developmental change of externalizing behavior problems has a larger impact on adult outcome.

Determinants of somatic complaints in 18-month-old children: the generation R study

OBJECTIVE

To investigate the effect of child temperament, maternal psychologic symptoms, maternal chronic pain, and parenting stress on children's somatic complaints.

METHODS

The study was embedded in the Generation R Study, a population-based cohort study. Child somatic complaints were assessed via mother-report in 5,171 children of 18 months of age. Questionnaires assessed maternal somatic symptoms, symptoms of depression, anxiety during pregnancy and 2 months after delivery, maternal chronic pain during pregnancy, parenting stress 18 months after birth, and mother-reported child temperament 6 months after birth, as the determinants.

RESULTS

Fearful temperament, temperamental falling reactivity, maternal somatic symptoms, anxiety symptoms, and parenting stress each independently and prospectively increased the likelihood of children's somatic complaints at 18 months of age.

CONCLUSIONS

In toddlers, temperament, maternal stress, and maternal somatic symptoms seem particularly important for the development of somatic complaints, but long-term research is needed to establish causality and predictive value of these factors.

Child to adult continuities of psychopathology: a 24-year follow-up

OBJECTIVE

To determine continuities of mental health problems of children across a 24-year follow-up period.

METHOD

In 1983, parent ratings of emotional and behavioral problems were collected with the Child Behavior Checklist (CBCL) in a general population sample of 2076 children. Twenty-four years later, 1365 participants completed Adult Self-Reports (ASR) to assess emotional and behavioral problems.

RESULTS

Of the participants who were classified as deviant in childhood, 22.2% were also classified as deviant in adulthood. Both homotypic and heterotypic continuity was found. Childhood aggressive, delinquent, and anxious/depressed problems were associated with most adult psychopathology. Attention problems did not predict later problems independently.

CONCLUSION

Even though assessed with parent-reports in childhood and analogous self-reports in adulthood, and over a large period of 24 years, continuity of psychopathology was found from childhood into adulthood. Anxious/depressed problems, delinquent behavior and aggressive behavior in childhood are core predictors for adult psychopathology.

Epidemiological comparisons of problems and positive qualities reported by adolescents in 24 countries

In this study, the authors compared ratings of behavioral and emotional problems and positive qualities on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) by adolescents in general population samples from 24 countries (N = 27,206). For problem scales, country effect sizes (ESs) ranged from 3% to 9%, whereas those for gender and age ranged from less than 1% to 2%. Scores were significantly higher for girls than for boys on Internalizing Problems and significantly higher for boys than for girls on Externalizing Problems. Bicountry correlations for mean problem item scores averaged .69. For Total Problems, 17 of 24 countries scored within one standard deviation of the overall mean of 35.3. In the 19 countries for which parent ratings were also available, the mean of 20.5 for parent ratings was far lower than the self-report mean of 34.0 in the same 19 countries (d = 2.5). Results indicate considerable consistency across 24 countries in adolescents' self-reported problems but less consistency for positive qualities.

Phenotypic subtypes in attention deficit hyperactivity disorder in an isolated population

We address the use of two informants in genetic studies and whether familial aggregation is similar for the three phenotypic subtypes of ADHD. Lifetime ADHD was diagnosed in a Dutch isolated population using parents and teachers as informants, creating two subgroups (one or two informants), then further divided into three phenotypic categories (inattentive, hyperactive/impulsive, combined). Genealogy was collected for all patients. Mean kinship coefficients for the subgroups were calculated. Fifteen of 26 children were linked to a common ancestor within 10 generations. The mean kinship coefficient of patients confirmed by two informants was significantly higher than in patients only scored positive by one informant (p = 0.03). All patients of the inattentive subtype were connected to a common ancestor, which was significantly higher (p = 0.03) than expected. Eighty-one percent of these patients derive of consanguineous marriages, also higher than expected. This means that recessive mutations may be involved in the inattentive subtype. These patients were more closely related than those with the other phenotypes (p<0.01). Our data suggests that using two informants in diagnosing ADHD helps identify a phenotype with a strong genetic component. The inattentive phenotype showed strong familial clustering and evidence of a recessive origin.

Mental health in immigrant children in the Netherlands

BACKGROUND

Background In the past decades, the ethnic diversity of the population in the Netherlands has rapidly grown. At present, approximately 10% of all people in the Netherlands belong to immigrant families that originate from a very large variety of non-Western nations. Although it is often assumed that migration has a stress-inducing effect, leading to heightened levels of mental health problems in both immigrant children and their parents, research into this group of children is very scarce in Europe. In this paper, we want to report on the mental health of immigrant children originating from non-Western countries enrolled in a large cohort study in the Netherlands.

METHOD

A large sample of 11-year-old children in the Netherlands (n=2230) participated in the TRacking Adolescents' Individual Lives Survey (TRAILS). Approximately 10% of these children (n=230) belong to immigrant families originating from non-Western countries. Mental health problems were assessed using self-report measures (Youth Self-Report), using parent-report measures (Child Behaviour Check List) and using teacher report (Teacher Checklist for Psychopathology). In this paper, we report on the mental health problems of these children from all three perspectives (child, parent, teacher). In analysing the impact of immigrant status, the effect of gender and of socio-economic inequality was taken into account.

RESULTS

According to self-report measures, mean level of mental health problems in immigrant children is comparable to that in non-immigrant children. Immigrant parents report higher problem rates for their daughters, in particular for internalising problem behaviours, social problems and attention problems, but not for their sons. In contrast, teachers perceive higher levels of externalising problem behaviour, but lower levels of anxious/depressed problems, social problems and thought problems in immigrant children. This last effect is most strongly found with respect to boys: teachers perceive less withdrawn/depressed problems, social problems, thought problems and attention problems in immigrant boys.

CONCLUSIONS

Children from immigrant families do not appear to experience more problems than their non-immigrant peers. However, parents from immigrant families do report more problems in their daughters than non-immigrant parents, in contrast to teachers who perceive lower levels of internalising, social and thought problems in particular in boys, and higher levels of externalising problems in both immigrant boys and girls. In describing problem behaviour in immigrant children, the effect of diverging social contexts for and multiple perspectives on immigrant youth has to be taken into account.