Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

The interplay between adolescent friendship quality and resilient functioning following childhood and adolescent adversity

Background

Child and adolescent adversity ('CA') is a major predictor of mental health problems in adolescence and early adulthood. However, not all young people who have experienced CA develop psychopathology; their mental health functioning can be described as resilient. We previously found that resilient functioning in adolescence following CA is facilitated by adolescent friendships.However, during adolescence, friendships undergo significant change. It is unknown whether resilient functioning after CA fluctuates with these normative changes in friendship quality.

Methods

We used Latent Change Score Modelling in a large sample of adolescents (i.e. the ROOTS cohort; N=1238) to examine whether and how emergent friendship quality and resilient functioning at ages 14 and 17 inter-relate and change together.

Results

We found that friendships quality and resilient functioning had strong associations at age 14, although friendships at 14 did not predict higher resilient functioning at 17. Higher resilient functioning in 14-year-olds with a history of CA was associated with a positive change in friendships from age 14 to 17. Finally, improvements in friendship quality and resilient functioning went hand in hand, even when taking into account baseline levels of both, the change within friendship quality or resilient functioning over time, and the association between resilient functioning and change in friendship quality over time.

Conclusions

We show that friendship quality and resilient functioning after CA inter-relate and change together between ages 14 and 17. Our results suggest that improving friendship quality or resilient functioning within this timeframe may benefit this vulnerable adolescent group, and this should be tested in future research.

Embracing the positive: an examination of how well resilience factors at age 14 can predict distress at age 17

One-in-two people suffering from mental health problems develop such distress before or during adolescence. Research has shown that distress can predict itself well over time. Yet, little is known about how well resilience factors (RFs), i.e. those factors that decrease mental health problems, predict subsequent distress. Therefore, we investigated which RFs are the best indicators for subsequent distress and with what accuracy RFs predict subsequent distress. We examined three interpersonal (e.g. friendships) and seven intrapersonal RFs (e.g. self-esteem) and distress in 1130 adolescents, at age 14 and 17. We estimated the RFs and a continuous distress-index using factor analyses, and ordinal distress-classes using factor mixture models. We then examined how well age-14 RFs and age-14 distress predict age-17 distress, using stepwise linear regressions, relative importance analyses, as well as ordinal and linear prediction models. Low brooding, low negative and high positive self-esteem RFs were the most important indicators for age-17 distress. RFs and age-14 distress predicted age-17 distress similarly. The accuracy was acceptable for ordinal (low/moderate/high age-17 distress-classes: 62-64%), but low for linear models (37-41%). Crucially, the accuracy remained similar when only self-esteem and brooding RFs were used instead of all ten RFs (ordinal = 62%; linear = 37%); correctly predicting for about two-in-three adolescents whether they have low, moderate or high distress 3 years later. RFs, and particularly brooding and self-esteem, seem to predict subsequent distress similarly well as distress can predict itself. As assessing brooding and self-esteem can be strength-focussed and is time-efficient, those RFs may be promising for risk-detection and translational intervention research.

A Network Model of Resilience Factors for Adolescents with and without Exposure to Childhood Adversity

Resilience factors (RFs) help prevent mental health problems after childhood adversity (CA). RFs are known to be related, but it is currently unknown how their interrelations facilitate mental health. Here, we used network analysis to examine the interrelations between ten RFs in 14-year-old adolescents exposed ('CA'; n = 638) and not exposed to CA ('no-CA'; n = 501). We found that the degree to which RFs are assumed to enhance each other is higher in the no-CA compared to the CA group. Upon correction for general distress levels, the global RF connectivity also differed between the two groups. More specifically, in the no-CA network almost all RFs were positively interrelated and thus may enhance each other, whereas in the CA network some RFs were negatively interrelated and thus may hamper each other. Moreover, the CA group showed more direct connections between the RFs and current distress. Therefore, CA seems to influence how RFs relate to each other and to current distress, potentially leading to a dysfunctional RF system. Translational research could explore whether intervening on negative RF interrelations so that they turn positive and RFs can enhance each other, may alter 'RF-mental distress' relations, resulting in a lower risk for subsequent mental health problems.

Multiple markers of cortical morphology reveal evidence of supragranular thinning in schizophrenia

In vivo structural neuroimaging can reliably identify changes to cortical morphology and its regional variation but cannot yet relate these changes to specific cortical layers. We propose, however, that by synthesizing principles of cortical organization, including relative contributions of different layers to sulcal and gyral thickness, regional patterns of variation in thickness of different layers across the cortical sheet and profiles of layer variation across functional hierarchies, it is possible to develop indirect morphological measures as markers of more specific cytoarchitectural changes. We developed four indirect measures sensitive to changes specifically occurring in supragranular cortical layers, and applied these to test the hypothesis that supragranular layers are disproportionately affected in schizophrenia. Our findings from the four different measures converge to indicate a predominance of supragranular thinning in schizophrenia, independent of medication and illness duration. We propose that these indirect measures offer novel ways of identifying layer-specific cortical changes, offering complementary in vivo observations to existing post-mortem studies.

Mood, anxiety and psychotic phenomena measure a common psychopathological factor

BACKGROUND

Psychotic phenomena are common in the general population but are excluded from diagnostic criteria for mild to moderate depression and anxiety despite their co-occurrence and shared risk factors. We used item response theory modelling to examine whether the co-occurrence of depressive, anxiety and psychotic phenomena is best explained by: (1) a single underlying factor; (2) two separate, uncorrelated factors; (3) two separate yet linked factors; or (4) two separate domains along with an underlying 'common mental distress' (CMD) factor. We defined where, along any latent continuum, the psychopathological items contributed most information.

METHOD

We performed a secondary analysis of cross-sectional, item-level information from measures of depression, anxiety and psychotic experiences in 6617 participants aged 13 years from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort and 977 participants aged 18 years from the ROOTS schools-based sample. We replicated results from one sample in the other and validated the latent factors against an earlier parental measure of mental state.

RESULTS

In both cohorts depression, anxiety and psychotic items were best represented as a bi-factor model with a single, unitary CMD factor on which psychotic items conveyed information about the more severe end (model 4); residual variation remained for psychotic items. The CMD factor was significantly associated with the prior parental measure.

CONCLUSIONS

Psychotic phenomena co-occur with depression and anxiety in teenagers and may be a marker of severity in a single, unitary dimension of CMD. Psychotic phenomena should be routinely included in epidemiological assessments of psychiatric morbidity, otherwise the most severe symptomatology remains unmeasured.

A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial

OBJECTIVES

To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes.

DESIGN

A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation.

SETTING

Six English CAMHS participated in the study.

PARTICIPANTS

A total of 208 patients aged between 11 and 17 years were recruited and randomised.

INTERVENTIONS

All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT.

MAIN OUTCOME MEASURES

The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS).

RESULTS

Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13).

CONCLUSIONS

For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.

Do corticosteroids damage the brain?

Corticosteroids are an essential component of the body's homeostatic system. In common with other such systems, this implies that corticosteroid levels in blood and, more importantly, in the tissues remain within an optimal range. It also implies that this range may vary according to circumstance. Lack of corticosteroids, such as untreated Addison's disease, can be fatal in humans. In this review, we are principally concerned with excess or disturbed patterns of circulating corticosteroids in the longer or shorter term, and the effects they have on the brain.

Self-devaluative dysphoric experience and the prediction of persistent first-episode major depressive disorder in adolescents

BACKGROUND

The quality of subjective experience of dysphoria may predict persistence of depression, independently of severity. This is tested in a clinic sample of adolescents with first episode of major depression using the Depressed States Checklist adapted for adolescents.

METHOD

Ninety-four adolescents with DSM-IV major depressive disorder (MDD) were followed up at 12 months. Self-devaluative components of dysphoric experience, ruminative style, over-general autobiographical memory, and self-reported and observer-rated measures of depression severity were assessed at presentation and evaluated as predictors of persistent MDD.

RESULTS

Persistent MDD was predicted by the independent additive effects of the higher self-devaluative component of dysphoria, lower general intelligence and greater observer-rated severity of depression at presentation. Neither self-reported depression score, overgeneral memory retrieval nor ruminative style contributed.

CONCLUSIONS

High levels of self-devaluative dysphoric experience increase the liability for persistence of first-episode MDD. Other affective-cognitive components also contribute. The adolescent version of the Depressed States Checklist is a useful brief measure of cognitive vulnerability for persistence in currently depressed young people.

Effects of induced rumination and distraction on mood and overgeneral autobiographical memory in adolescent Major Depressive Disorder and controls

BACKGROUND

In adults there is evidence that the affective-cognitive processes of rumination and overgeneral autobiographical memory retrieval may play a part in maintaining depression. This study investigated the effects of induced rumination as compared to distraction on mood and categoric overgeneral memory in adolescents with first episode Major Depressive Disorder (MDD), and the specificity of any effects to MDD.

METHOD

Three subject groups; adolescents with first episode MDD (N = 75), non-depressed psychiatric participants (N = 26) and community controls (N = 33) were recruited. An experimental design was used, with repeated measures of 'in the moment' depressed mood and categoric overgeneral memory before and after rumination and distraction, induced on separate occasions and counterbalanced in order across participants.

RESULTS

In adolescents with MDD, induced rumination as compared to distraction differentially increased depressed mood. There were no significant differences in this effect between full current MDD participants and those in partial remission. This differential effect was also seen in community controls but was absent in non-MDD psychiatric participants. In addition, rumination as compared to distraction increased overgeneral memories to negative cues in MDD participants, but this increase was not significantly related to mood change, and was specific to MDD, being absent in non-MDD psychiatric and community control groups.

CONCLUSIONS

Experimentally induced rumination as compared to distraction increases depressed mood and negative categoric memories in adolescents with first episode MDD. These results suggest that rumination has a deleterious effect on mood and memory retrieval processes in adolescents with first episode MDD. Increased negative overgeneral memories with rumination may be a process of particular importance for adolescents with MDD rather than psychiatric disorder in general. The findings imply that strategies to interrupt ruminative processes may be helpful in minimising persistence of first episode MDD in adolescence.

The aetiology of specific language impairment: no evidence of a role for obstetric complications

The role of obstetric complications (OC's) in Specific Language Impairment (SLI) has been investigated, but the relationship remains unclear. This study investigates the association between SLI and OC's in a sample of 194 children, participants in a family study of SLI. Initial analyses utilising a traditional case-control approach found no evidence of an association. The effect of changing the case criteria was explored, but the finding of no association remained. The relationship between OC's and various language measures was also investigated using continuous data analytic techniques. This supported the findings of the case control analysis of no association. Previous reports have suggested a specific role for either hypertension or toxaemia in pregnancy. This study found no evidence for an association between these complications of pregnancy and SLI. This study found no evidence to support an aetiological role of OC's in SLI.

Psychoendocrine antecedents of persistent first-episode major depression in adolescents: a community-based longitudinal enquiry

BACKGROUND

This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression.

METHOD

Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression.

RESULTS

Compared to the never depressed (N = 30) and remitted adolescents (N = 19), persistently depressed cases (N = 11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence.

CONCLUSIONS

In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.

Categoric overgeneral autobiographical memory in adolescents with major depressive disorder

BACKGROUND

Categoric, overgeneral autobiographical memory is more common in depressed adults than controls and predicts persistence of depression. This cross-sectional study investigated whether, compared with non-depressed psychiatric cases and community controls, first episode major depressive disorder (MDD) in adolescents is associated with categoric overgeneral memory retrieval.

METHODS

Ninety-six clinically referred adolescents (aged 12-17 years) with MDD, 26 non-depressed psychiatric cases and a sample of 33 community controls were recruited. All subjects were assessed using the Kiddie-Schedule for Schizophrenia and Affective Disorders, and completed Williams' cued Autobiographical Memory Test and the Mood and Feelings Questionnaire. Hamilton Depression Rating Scales were completed with MDD subjects, as an index of depression severity.

RESULTS

Adolescents with current first episode MDD retrieved more categoric overgeneral memories than controls, but not than non-depressed psychiatric cases. Adolescents in full remission from a recent episode of MDD retrieved more categoric memories to positive cues than controls. Categoric memory in MDD was related to observer-rated and self-reported severity, but not to the pattern of co-morbid diagnoses. There were negative correlations between IQ and categoric memories in both clinical cases and controls. A positive correlation between categoric memory to negative cues and self-reported depressive symptoms was found in clinical cases (but not controls).

CONCLUSIONS

In adolescents, increased categoric overgeneral memory is associated with, but not specific to first episode MDD. Positive categoric memories are also increased in fully remitted MDD as compared to controls.

Psychosocial and endocrine features of chronic first-episode major depression in 8-16 year olds

BACKGROUND

Psychoendocrine processes may have a role in explaining individual differences in the outcome of major depression in 8-16-year-old school children.

METHODS

Salivary cortisol and dehydroepiandrosterone (DHEA) levels at 8:00 AM and 8:00 PM, life events, and comorbidity were assessed at presentation, 36, and 72 weeks in 47 (60%) of 78 clinically referred subjects with a first episode of major depression. Comparisons were made between chronic and nonchronic major depression.

RESULTS

Chronic depression was characterized by being older, cortisol hypersecretion at 8:00 PM at all three assessments, increasing depression-dependent life events over the follow-up period, and comorbid obsessive-compulsive disorder (OCD) at presentation and at 36 weeks. Chronicity may be best predicted by increasing depression-dependent events over the 72-week period. Such events are more likely in cases with evening cortisol hypersecretion at entry and persistent OCD. Variations in DHEA levels were not associated with chronicity or increasing life events.

CONCLUSIONS

During adolescence, but not childhood, the persistence of major depression may occur through an increase of risk for further and particular types of depression-dependent undesirable life events (personal disappointments and/or dangers to the self), that are more likely in those subjects with persisting cortisol hypersecretion and unresolved comorbid OCD.

Family functioning in adolescents at high and low risk for major depressive disorder

Families of two subgroups of adolescents in the community, at high and low risk for major depressive disorder, were compared on the McMaster Family Assessment Device (FAD) and the General Health Questionnaire (GHQ). Families of high-risk adolescents who became depressed by follow-up at one year were compared with other families of high-risk subjects. The only significant difference on FAD ratings for high- and low-risk groups was on the sub-scale Roles as reported by mothers. FAD ratings showed that, compared with mothers, fathers of high-risk adolescents held significantly worse views of their families' functioning on the sub-scales Problem Solving, Affective Responsiveness and Behaviour Control. There were no such differences between low-risk parents. Both mothers and fathers of high-risk adolescents reported their own mental health as significantly poorer than mothers and fathers of low-risks. The mental health of mothers in the high-risk group only was significantly associated with their FAD ratings. Adolescents rated their families as significantly worse on the FAD than their parents and the lower their mood and self-esteem, the worse they rated their families on the FAD. Subsequent MDD in adolescents by follow-up at one year was not associated with the FAD scores of any family member, nor with either parent's mental health.

Possible role of cortisol and dehydroepiandrosterone in human development and psychopathology

BACKGROUND

The characteristics of adrenal hormone secretion change markedly during infancy. Disturbances in basal levels may precipitate psychological dysfunction and are associated with psychopathology in young people.

AIMS

To relate three aspects of behavioural endocrinology: developmental changes in cortisol and dehydroepiandrosterone (DHEA), the role of these hormones in the psychopathology of young people, and the action of these steroids in the brain.

METHOD

A selective review from the human developmental, psychiatric and neurosciences literature.

RESULTS

There are developmentally mediated changes in brain sensitivity following excess exposure to cortisol. This may result in impairments of mental and behavioural function. DHEA and gonadal steroids may modulate the actions of cortisol.

CONCLUSIONS

Steroid hormones contribute to shaping behavioural function during early development and act as risk factors for psychopathology.

Recent life events, cortisol, dehydroepiandrosterone and the onset of major depression in high-risk adolescents

BACKGROUND

It is not clear whether cortisol or dehydroepiandrosterone (DHEA) hypersecretion increases the risk for major depression in the presence of undesirable life events.

AIMS

To determine whether there is a specific pattern of psychoendocrine factors that predicts the onset of major depressive disorder.

METHOD

180 adolescents (73 boys, 107 girls) at high risk for psychopathology were assessed for cortisol, DHEA, depressive symptoms, life events and psychiatric disorder at entry and 12 months later.

RESULTS

Major depression was predicted for both genders by the additive effects of: higher depressive symptoms; personal disappointments and losses only in the month before onset; one or more daily levels of cortisol at 08.00 h or DHEA at 20.00 h greater than the 80th percentile of the daily mean.

CONCLUSIONS

A subgroup of adolescents may carry a physiological risk for major depression which may be either of genetic and/or earlier psychosocial origin.

Clinical guidelines for depressive disorders in childhood and adolescence

Major depressive and dysthymic disorders are recurrent and sometimes persistent unipolar mood disorders, which often present in childhood and adolescence. Depressive episodes may increase in severity and duration with recurrence and are associated with substantial morbidity and risk of suicide. The role of child and adolescent mental health services in early intervention and management is thus of major importance. This paper draws together current research evidence and common clinical practice, in guidelines for the specialist management of depressive disorders in childhood and adolescence. Both psychotherapy and pharmacotherapy have been found to be beneficial for the acute treatment of children and adolescents with depressive disorders. Based on current evidence, psychotherapy may be the first treatment for most depressed youngsters, but antidepressants should be considered for those with severe depression. All patients need continuation therapy, and some will need maintenance treatment. Evidence supporting the efficacy of psychological and psychopharmacological treatments are reviewed. An integration of approaches is suggested as a guideline for treatment planning.

Specific language impairment with or without hyperactivity: neuropsychological evidence for frontostriatal dysfunction

A neuropsychological investigation of the association between specific language impairment (SLI) and hyperactivity was conducted on four groups of 6-year-old children. The groups, each consisting of five boys and five girls, were: children with SLI alone, hyperactivity alone, both SLI and hyperactivity, and neither disorder (controls). Cognitive functioning was examined using selected non-verbal tests from the Cambridge Neuropsychological Test Automated Battery. SLI was not associated with significantly reduced performance on any of the neuropsychological measures. However, hyperactivity was associated with deficits on a test of attentional set shifting previously demonstrated to be sensitive to frontostriatal dysfunction. Further, hyperactive children showed significantly reduced spatial spans on a test of spatial working memory thought to measure parietal lobe functioning. There were no substantial differences between the groups on tests of frontal lobe function except for reduced performance on a task of attention in the hyperactive group. There were no significant interactions between hyperactivity and SLI on any of the neuropsychological measures. The pattern of neuropsychological deficits shown by children with attention-deficit-hyperactivity disorder (ADHD) suggests relatively specific problems in inhibitory control of attentional selection. This cognitive deficit implicates brain areas including basal ganglia and ventro-lateral prefrontal cortical areas in ADHD, thus providing evidence for disruption of frontostriatal functional loops. SLI and hyperactivity can occur as comorbid syndromes or symptom complexes and this should be noted when interpreting results of tests measuring cognitive performance. The findings suggest that these two groups of disorders have different cognitive correlates.

First-episode major depression in adolescents. Affective, cognitive and endocrine characteristics of risk status and predictors of onset

BACKGROUND

There is little information on whether patterns of steroids precede and are associated with depressive onset.

AIMS

To establish whether there is an association between salivary cortisol and/or dihydroepiandrosterone (DHEA) levels and depression independent of psychosocial risk.

METHOD

Two subgroups of adolescents in the community at high (n = 181) and low (n = 65) risk for psychopathology were interviewed for recent psychiatric disorder at entry and again at 12 months. Salivary samples (08.00 and 20.00 h) for hormone estimations and self-reports on current mood and cognitive style were obtained at both assessments.

RESULTS

Neither hormone was associated with risk status, current mood or cognitive style at entry. Of 31 onsets of major depression that occurred over the next 12 months, 30 came from the high-risk group but were not associated with any particular pattern of risk. Increased negative mood and feelings and DHEA (08.00 h) hypersecretion at entry were associated with subsequent major depression.

CONCLUSIONS

Both negative mood and feelings and alterations in adrenal steroid function precede the onset of first-episode major depression in adolescents. Variation in levels of hormones may arise from more distal origins than recent life events and current ongoing difficulties.

Latent negative self-schema and high emotionality in well adolescents at risk for psychopathology

Teasdale's (1988) differential activation hypothesis proposes that a tendency for negative mood to activate latent negative self-schemas characterises people at risk for depression. The current study tested predictions from this hypothesis in a community sample of 102 adolescents who were free from history of psychiatric illness, and who were subdivided according to level of emotionality, a temperamental style as assessed by parental questionnaire. A musical mood induction task was used to induce temporary mild dysphoria, and the effect of mood induction on self-schemas was assessed. There was no difference between high and low emotionality groups in the liability to sad mood induction. However, adolescents with high emotionality endorsed significantly more negative self-descriptors after dysphoric, but not after neutral, mood induction. This was not accounted for by level of self-reported depressive symptoms over the previous week. This suggests that a " dysphoric mood induction challenge" may provide important information about vulnerability to depression that is not identified by routine self-report of mood or cognitions.

Post-traumatic stress disorder in children and adolescents following road traffic accidents

BACKGROUND

Post-traumatic stress disorder (PTSD) can be a persistent and disabling psychiatric disorder. There is little systematic research into the psychiatric consequences of road traffic accidents (RTAs) in children and adolescents.

METHOD

A consecutive sample of 8-16-year-olds attending an accident and emergency department following RTAs were screened for PTSD. Potential cases and their parent(s) were interviewed with semi-structured research instruments about six weeks and six months after the accident.

RESULTS

Fifty-three (45%) of the 119 subjects fell above PTSD cut-off on the Frederick's Reaction Index. Thirty-three (75%) of the 44 cases met DSM-IV criteria for PTSD. In half of these other psychiatric disorders were present, including major depressive disorder and anxiety disorders. Being female, involvement in car accidents and pre-existing depression and anxiety were associated with developing PTSD. Seventeen per cent of the sample continued to be symptomatic six months after the accident.

CONCLUSIONS

PTSD is a common consequence of RTAs. Liaison with accident and emergency departments would enhance the early detection and follow-up of children at risk of developing PTSD.

Adrenal steroid secretion and major depression in 8- to 16-year-olds, III. Influence of cortisol/DHEA ratio at presentation on subsequent rates of disappointing life events and persistent major depression

BACKGROUND

An investigation of the association between diurnal changes in cortisol and DHEA levels, or in the cortisol/DHEA ratio at five different time points at presentation, and the occurrence of undesirable life events (losses, dangers to self and others, disappointments) during follow-up, and the outcome of major depression at 36 weeks were investigated.

METHODS

Psychosocial and endocrine assessment of a consecutive cohort (N = 68) of 8- to 16-year-old subjects with first episode major depression reassessed 12 months after presentation using a repeat measures design.

RESULTS

Higher cortisol/DHEA ratios at 20.00 or 24.00 h predicted persistent major depression. Basal levels of either hormone alone or cortisol/DHEA ratios at the other three time points (08.00, 12.00 or 16.00 h) did not. High cortisol/DHEA ratios (i.e. values greater than the 60th percentile) at both evening points (20.00 and 24.00 h) also predicted the occurrence of subsequent disappointing life events but no other category of undesirable event. Both high evening cortisol/DHEA ratio at 20.00 h and one or more severely disappointing life events between presentation and follow-up predicted persistent major depression: 86% of subjects with both of these factors were still depressed at 36 weeks whereas 81% with neither factor were not.

CONCLUSIONS

The finding that it is depressed subjects with high cortisol/DHEA ratios at presentation who are specifically at risk for subsequent disappointing life events suggests a putative role for these adrenal steroids in abnormal cognitive or emotional processes associated with disturbed interpersonal behaviour.

Family functioning and parent general health in families of adolescents with major depressive disorder

Family functioning and parent mental health in families of adolescents with major depressive disorder (n = 61) were compared with a community control sample (n = 34) using the McMaster Family Assessment Device (FAD) and the General Health Questionnaire (GHQ). Mean FAD and GHQ scores for clinic families were significantly worse than controls. 56% of clinic and 29% of control families met operational criteria for current dysfunction. In the clinic group family dysfunction was associated with the additive effects of comorbid Oppositional Defiant disorder in the adolescent and mother's current poor mental health, while father's current mental health had no associations with family functioning.

Short-term outcome of major depression: II. Life events, family dysfunction, and friendship difficulties as predictors of persistent disorder

OBJECTIVE

To determine whether there is a pattern of social characteristics that specifically predicts persistent major depression at 36 weeks follow-up.

METHOD

Sixty-eight consecutive cases with a first-episode DSM-III-R diagnosis of major depression completed a life events and friendship difficulties interview at presentation and again at 36 weeks.

RESULTS

Four factors were associated with persistent psychiatric disorder in general: lack of a maternal confiding relationship with current partner, family dysfunction and poor friendships at presentation, and severely disappointing events between presentation and follow-up. There was no association between these adverse experiences. No combination of long-term or recent life events or difficulties was, however, specifically associated with persistent depression.

CONCLUSION

Nonsocial factors may need to be taken into account to specifically explain the phenotypic persistence of major depressive disorder in first-episode nonrecovered cases within a year of presentation. Psychosocial interventions with first-degree relatives and current close friendships should be considered as a part of the treatment strategy for first-episode major depression.

Short-term outcome of major depression: I. Comorbidity and severity at presentation as predictors of persistent disorder

OBJECTIVE

To determine whether there is a pattern of clinical characteristics at presentation that specifically predicts persistent major depression at 36 weeks follow-up.

METHOD

Sixty-eight consecutive cases with a first episode DSM-III-R diagnosis of major depression were interviewed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode version and completed the mood and feelings self-report depression questionnaire (MFQ) at presentation and again at 36 weeks.

RESULTS

At presentation, 63 (93%) had one or more comorbid psychiatric disorders (median = 3). At 36 weeks, 17 (25%) cases were recovered; 17 (25%) continued to meet criteria for one or more psychiatric disorder but not major depression; 34 (50%) still met criteria for DSM-III-R major depression, of whom 25 (73%) had been persistently depressed and 9 (27%) had recovered and subsequently relapsed. Major depression at follow-up was specifically predicted by the additive effect of three features at presentation, comorbid obsessive-compulsive disorder, higher MFQ score, and being older. Comorbid oppositional defiant disorder at presentation was a significant predictor of persistent psychiatric disorder. Individuals with persistent depression (n = 25) were more likely to have a longer duration of illness before presentation.

CONCLUSION

Systematic assessment of comorbid psychiatric conditions at initial interview, together with the use, in older subjects, of a self-report questionnaire to determine subjective severity, will provide valid clinical information concerning the potential short-term outcome of major depression.

Cortisol, dehydroepiandrosterone (DHEA), and DHEA sulfate in the cerebrospinal fluid of man: relation to blood levels and the effects of age

The relation between blood and cerebrospinal fluid (CSF) concentrations of cortisol, dehydroepiandrosterone (DHEA), and its sulfate (DHEAS) was measured in 62 subjects aged 3-85 yr old, fitted with ventriculo-peritoneal or lumbar-peritoneal shunts for a variety of diagnoses. There were 36 males and 36 females. Forty-eight subjects were not taking exogenous corticosteroids; the other 14 were receiving either systemic or local steroids. A single sample of blood and CSF was taken from each subject within 10 min for measurement of cortisol, DHEA, and DHEAS. The proportional levels of cortisol (5.8%) and DHEA (5.4%) in the CSF compared with those in the blood were similar in subjects not taking steroids. However, CSF DHEAS levels were only 0.15% of those in the blood. Because DHEAS blood levels were so much greater than DHEA, DHEAS in the CSF was still higher than DHEA despite the reduced penetration of the sulfated steroid. The blood/CSF ratios were similar in subjects taking steroids. There were significant correlations in steroid-free subjects between blood and CSF levels for DHEA (r = 0.65) and DHEAS (r = 0.88) but not for cortisol (r = 0.26). Steroid treatment significantly lowered blood cortisol, DHEA and DHEAS, and CSF DHEA, but not CSF cortisol or DHEAS compared with an age- and sex-matched sample of steroid-free subjects. In steroid-free adults (18 yr and over; n = 37), blood cortisol showed no age-related change. However, CSF cortisol was markedly raised in a proportion of steroid-free subjects over the age of 60 yr. Levels of corticoid-binding globulin in plasma did not alter with age. As expected, there were significant age-related decrements in both blood DHEA and DHEAS. CSF DHEA (r = 0.42) and CSF DHEAS (r = 0.39) were significantly negatively correlated with age. In steroid-free juveniles (n = 11) there were no age-related changes in either blood or CSF cortisol, but significant increases with age in DHEA and DHEAS in both blood and CSF. Calculation of the cortisol/DHEA and cortisol/ DHEAS molar ratios in the CSF showed both to be raised in the very young (3-8 yr) and the elderly (60 yr and over) by a factor of 4-5 compared with young adults aged 18-39. There were no sex differences in any of the parameters measured. These findings show that the relation between levels in the blood and CSF differ for each of these three neuroactive steroids. The brain is exposed to relatively high levels of DHEA and DHEAS during later childhood and early adulthood but to relatively or absolutely high levels of cortisol during infancy and older age. In view of the known antiglucocorticoid action of DHEA and DHEAS, and the direct action of these steroids on membrane-bound transmitter events (such as gamma-aminobutyric acidA receptors), these changes may have important implications for age-related alterations in brain function.

Temperament and psychopathology amongst siblings of probands with depressive and anxiety disorders

Thirteen (42%) of 31 siblings of 29 probands with depression (n = 21) or anxiety disorders (n = 8) attending a clinic met DSM-IIIR criteria for psychiatric disorder, a rate nearly three times greater than reported from community studies. The diagnoses were heterogeneous. Compared with probands, sibling cases had half the level of comorbidity and significantly lower levels of psychosocial impairment. Comparisons of temperamental characteristics showed that higher levels of emotionality, but no other aspect of temperament, was associated with an increased likelihood of a sibling being a case. Higher emotionally in all cases (sibs and probands) was associated with greater comorbidity in general and the diagnoses of dysthymia and separation anxiety in particular.

Adrenal secretion and major depression in 8- to 16-year-olds, II. Influence of co-morbidity at presentation

The association between high evening cortisol and low morning DHEA and the pattern of co-morbid diagnoses in 82 cases of major depressive disorder in 8- to 16-year-olds has been analysed. There was a significant association between the presence of high evening cortisol and co-morbid dysthymia. This was independent of age or sex. No positive association was found between the presence of low morning DHEA and any co-morbid diagnosis. However, co-morbid panic or phobic disorder was significantly associated with the absence of this endocrine abnormality. These findings suggest that specific endocrine disturbances may be associated with different patterns of co-morbidity during an episode of major depression in this age group.

Adrenal secretion during major depression in 8- to 16-year-olds, I. Altered diurnal rhythms in salivary cortisol and dehydroepiandrosterone (DHEA) at presentation

The association between basal cortisol, dehydroepiandrosterone (DHEA), its sulphate (DHEAS) and major depression was investigated in 8- to 16-year-olds. Eighty-two subjects with major depression, 25 non-depressed psychiatric cases and 40 community controls were systematically assessed for current mental state and hormone levels at 08.00, 12.00 and 20.00 h, assayed from salivary samples collected over a 48 h period. The average mean of the two time points was compared between the three groups. Evening cortisol hypersecretion and morning DHEA hyposecretion were significantly, and independently, associated with major depression. High evening cortisol (> 0.594 ng/mL) and low morning DHEA (< 0.200 ng/mL) identified subgroups of depressives with different types of adrenal hormone dysregulation. The association between high evening cortisol or low morning DHEA and MDD was not affected by either age or gender.

Recent undesirable life events: their influence on subsequent psychopathology

Life events appear to exert a range of effects on subsequent behaviour through their impact on affective-cognitive processes. Their effects on those physiological processes pertinent to psychopathology have yet to be investigated. Single events do not exert much risk for subsequent disorder. It is the pattern of adverse life experiences, of which recent life events is frequently a component, that determines the degree of risk and the mechanisms and processes that may lead to subsequent psychopathology. Recall of events that occurred in the recent past may be influenced independently by the age of the individual and a previous episode of psychiatric disorder. Longitudinal studies determining the impact of life events on subsequent behaviour will need to take these features into account. There remains no specificity between particular types of recent undesirable life events and anxious or depressive disorders. Future longitudinal research should employ modern methods of life event data collection and measurement. The goal of future longitudinal research should be to determine the relative contribution of undesirable and desirable recent life events in the presence and absence of other putative casual factors from different domains. This should necessarily include social (e.g. long-term difficulties), psychological (e.g, temperament (18) or self esteem) and physiological (e.g. hypercortisolaemia in adolescent major depression (14, 11) elements. It is only through this combination of longitudinal design, together with sensitive and concurrent multiple repeat measurements that a greater understanding of the mechanisms and processes that determine psychopathology over the course of development will occur.

Temperament and major depression in 11 to 16 year olds

Temperament (EAS teacher and parent questionnaire) and mental state (modified DISC-C interview with adolescent) was systematically assessed in 193 11 to 16 year olds (112 girls, 81 boys) screened for major depression in the community. Sex differences in the structure of temperament were noted from both parent and teacher reports. High (negative) emotionality alone was associated with major depression, particularly (but not exclusively) in girls.

Depression in 11-16-year-old girls: the role of past parental psychopathology and exposure to recent life events

Interviews with parents of a non-referred sample of 11-16-year-old girls (n = 82) revealed that a significantly greater proportion of mothers with a lifetime history of any psychiatric disorder also reported one or more recent undesirable life events focused on the adolescent compared with mothers with no such history. Lifetime episodes of maternal depression and recent undesirable life events exerted significant additive effects on the likelihood of depression occurring in the previous 12 months in adolescent girls. Some families may be "life event prone" as a consequence of lifetime episodes of parental psychopathology.

Recent stressful life events: Their long term effects

The long-term effects of undesirable life events are reviewed. Two forms of major event that are outside the child's control, divorce and war, are discussed together with the literature investigating the impact of undesirable life events on subsequent risk for psychopathology and maladjustment. The impact of any event cannot be easily predicted without a substantial knowledge of its antecedents, nature and consequences for the child's current environmental circumstances. The indications are that some children may be life event prone as a consequence of either not being protected from adverse circumstances in the family or peer group; or contributing, through their own behavioural style, to an increased likelihood of life event occurrence. The evidence supports the notion that, whatever the origins of life events, they increase the risk of subsequent psychopathology or poor adaptation to subsequent environmental demands such as school achievement. There are marked individual differences in outcome from exposure to similar severe events. The degree of risk for either subsequent psychopathology or poor adaptation is best determined by a knowledge of life events in association with other forms of adverse or ameliorating circumstances rather than by life events alone. Psychological and physiological responses to events, as well as measures of the environment, should be incorporated in future longitudinal research to assist in explaining individual differences in outcome to similar undesirable circumstances.

Lifetime exit events and recent social and family adversities in anxious and depressed school-age children and adolescents--I

The number of lifetime exit events occurring over the lives of 7-16-year-old children was compared between cases with new onset episodes of anxiety and depression (n = 100) and community controls (n = 100). The reporting of events by adult responders appears reliable and not subject to distortions of recall. Overall the likelihood of experiencing exit events increases with age. A significant association was found between current disorder and two or more previous lifetime exit events. There is, however, a non-significant trend for those cases who experience multiple lifetime exits to be younger than the controls and to be female rather than male. These findings are uninfluenced by pubertal stage at time of onset of disorder or by diagnosis.

Lifetime exit events and recent social and family adversities in anxious and depressed school-age children and adolescents--II

The relative contribution made by three sets of social adversities preceding the onset of anxiety and depression in 8-16-year-olds is reported. These three sets of adversities are (i) lifetime exit events over the whole of the subject's life excluding those in the 12 months before onset of disorder in cases or day of interview for controls; (ii) recent family adversities; (iii) recent friendship difficulties and an absence of social achievements. Three cases compared with 35 controls experienced none of these sets of adverse social variables. Lifetime exit events exert significant independent effects on the likelihood of being a case in the presence or absence of the other two sets of factors. This suggests that the impact of multiple lifetime exits is not explained by the presence of recent adversities measured in this study. Twenty controls however experienced two or more of these sets of adversities with four experiencing all three. This suggests that some children appear protected from the pathological effects of these social adversities. The findings are not influenced by the sex or pubertal stage of the subjects and appear with equal likelihood in both anxious and depressive cases.

Annotation: recent life events and psychiatric disorder in school age children

Life events research in school age children using semi-structured interview techniques has only just begun. The advantages, however, for investigating the role of events and difficulties in children's lives outweigh the problems of data collection and training involved in the technique. Improving the collection of information also improves sensitivity at the level of measurement through a consideration of the personal meaning of social experiences. It is already apparent that recent undesirable life events effects of some importance in the genesis of anxious and depressive disorders in school age children. Investigating the social origins of emotional and behavioural disorders, and determining the role of recent social factors in the course and outcome of these conditions, will be substantially advanced by the application of these techniques in future studies.

Anorexia nervosa and food avoidance emotional disorder

A retrospective and longitudinal study was carried out on all children and adolescents who presented to a child psychiatry service over a period of 26 years to identify the nature, course, and outcome of cases meeting criteria for anorexia nervosa (n = 27). Two groups of the same age were identified for comparison, firstly those with food avoidance and emotional disorders (n = 23), and secondly those with emotional disorders but no symptoms associated with eating (n = 22). The results confirm previous reports that early onset anorexia nervosa shows a similar nature, course, and outcome to the adult disease. Being tall at presentation seems to be associated with a poor outcome. Self starvation of early onset may result in short stature in some cases. There seem to be more boys among the group in whom the disease was of early onset than would be predicted from the sex ratio among adult patients. In addition boys with anorexia nervosa may have a better prognosis than girls. Children with food avoidance emotional disorders seem to have a worse prognosis than expected for childhood emotional disorders. They may represent a middle group between those with anorexia nervosa and those with emotional disorders but no symptoms associated with eating.

Recent friendships in anxious and depressed school age children

A consecutive series of school age children (7 to 16 years) with emotional disorders (N = 100) were compared with a series of community controls (N = 100) matched for age, sex and social class for the quality of their friendships. A semi-structured interview was developed to measure the quality of friendship for this purpose. Significantly more (48%) children with emotional disorder were likely to be rated as experiencing moderate to poor friendships in the 12 months prior to the onset of symptoms than were controls (16%) in the 12 months prior to interview. Prepubertal children with moderate to poor friendship patterns were classified as either predominantly anxious or depressed. Postpubertal children with moderate to poor friendships patterns were, in contrast, predominantly anxious. These findings suggest that puberty denotes a point of change for the impact of friendship deficits on the psychopathology of emotional disorder. There were no sex differences in the clinical classification of children with moderate or poor friendship patterns.

Somatic emotional disorders in childhood and adolescence

We conducted a short-term follow-up study of severe somatic emotional disorders in 93 children and adolescents. Our aim was to investigate whether the type of physical presentation influenced the outcome in terms of symptoms and subsequent use of medical services. Three groups of patients were identified. Two groups presented with neurological symptoms and were divided into a pseudo-epilepsy group (n = 23) and other hysterias (n = 30); and a third presented with non-neurological symptoms which we termed 'other somatic presentations' (n = 40). Cases in the hysteria groups were significantly more likely to be female and post-pubertal. Polysymptomatic presentations accounted for 85% of all cases and were as common in boys as in girls at all ages. The greatest number of symptoms was found in the pseudo-epilepsy group. None of the hysterias met DSM III-R criteria for somatization disorder. Outcome in terms of residual physical symptoms and subsequent use of medical services was poorest for the pseudo-epilepsy group, and nearly 40% of these patients were judged by their general practitioner to be unchanged since discharge. By comparison, 85% of all other somatic cases were judged improved since discharge from hospital out-patients. Neither polysymtomatic presentations nor persistent physical symptoms at discharge predicted a poor outcome in any group. The general practitioners considered the psychiatric treatment to have been helpful in the majority of cases, even when the somatic outcome was rated as unchanged.

Maternal adversity and recent stressful life events in anxious and depressed children

Poor confiding relations in mothers' own lives, the presence of maternal distress and recent stressful life events focussed on children are all significantly and independently associated with emotional disorder in the school-age child. The probability of being a case is best predicted by considering the contribution of all three factors. When this is done, an additive rather than multiplicative interaction for the three variables is found. The association between these maternal factors and events focussed on the child varies with the presence or absence of caseness. There appears to be no greater probability of being anxious rather than depressed as a consequence of these three stressful factors occurring in the lives of school-age children.

The value of a neuropsychiatric examination of children with complex severe epilepsy

The feasibility and utility of a neuropsychiatric assessment in a cohort of severely impaired children with long-standing epilepsy (n = 96) is tested. This assessment is described, and some results reported in this highly selected group. Substantial difficulties in coordination were present in nearly three-quarters of the sample, and dysarthria identified in two-thirds. Psychiatric interviewing identified cases of mood disturbance that altered overall treatment of that child, and a more systematic behavioural assessment permitted clearer management of behavioural problems already known to staff. This research supports previous findings that a full neuropsychiatric evaluation is both practical and has an important place in the early assessment and ongoing management of complex childhood epilepsy.

Salivary cortisol hypersecretion in juvenile depression

Thirty depressed inpatients aged 7-16 yrs were compared for salivary hypercortisolism with a control group of 16 inpatients of mixed diagnosis matched for age and sex. Four cortisol samples were taken over a 48 hr period: 8 a.m. and 11 p.m. on the first day; then, with 1 mg of dexamethasone given immediately after the second sample, at 4 p.m. and 11 p.m. on the second day. All except the 8 a.m. value were significantly greater (P less than 0.03) in the depressed group. A 4 nmol/l cutoff for the 4 p.m. sample gave 48% sensitivity and 91% specificity for discriminating depressed cases (P = 0.03). The results indicate that the salivary method for estimating cortisol levels in children and adolescents with depression warrants further study.

The impact of recent undesirable life events on psychiatric disorders in childhood and adolescence

The timing and number of recent stressful life events occurring in the year before onset of emotional or behavioural disorder was examined in a consecutive sample of children. Overall, events increase the relative risk of psychiatric disorder by 3-6 times. Events occur throughout the 12 months, but tend to cluster in the 16 weeks nearest onset of symptoms. The number of events influences the onset of disorder: cases with multiple events are more likely to have an event within 16 weeks of onset; cases with single events are more likely to have the event 36-52 weeks before onset. Cases whose onset occurs within 4 weeks of an event may have experienced single or multiple events. The results support the concept of additivity of recent stressful events in some cases of emotional and behavioural disorders in childhood.

Do age and sex influence the association between recent life events and psychiatric disorders in children and adolescents?--A controlled enquiry

In a consecutive sample of school-aged children attending a routine child psychiatry clinic, four clinical groups were classified based on presenting signs and symptoms, conduct (N = 44), mild emotional (N = 55), severe emotional (N = 32) and somatic (N = 26). The groups were divided by age and sex and comparisons made between the groups and community subjects (N = 76) for the number of children experiencing one or more recent stressful life events. The results indicated that with the possible exception of severe emotional disorders, neither age nor sex substantially influenced the association between events and psychiatric disorder.