A systematic review exploring characteristics of youth with severe and enduring mental health problems (SEMHP)

A small group of youth and emerging adults deals with severe and enduring mental health problems (SEMHP). Current mental health care struggles to recognize and treat this group timely and adequately, leaving these youth between the cracks of the system. A first step to improve care for this group is to gain a deeper understanding of the characteristics of youth with SEMHP. Therefore, this study aimed at reviewing current literature about this target group and what is known so far about their characteristics. We included 39 studies with a focus on youth aged 12-25 years with SEMHP. After critical appraisal, a content analysis and in-depth thematic analysis were conducted. According to the included studies, youth with SEMHP were characterized by severe distress and recurrent comorbid mental health problems, with pervasive suicidality. Further, underlying trauma, family conflicts, peer rejection, deep feelings of hopelessness, and psychosocial malfunctioning characterized SEMHP. It was described that for youth with SEMHP a pervasive pattern of dysfunction in multiple domains is present leading to a detrimental impact. Subsequently, this pattern exerts a reciprocal influence on the mental health problems, causing a vicious circle further worsening SEMHP. Our findings emphasize the need for a holistic approach and to look beyond the traditional classification system in order to meet the needs of these youth with wide-ranging comorbid mental health problems.

[The impact of social media on youths with anorexia nervosa]

OBJECTIVE

To describe the impact of social media on youths with severe anorexia nervosa.

DESIGN

Qualitative study.

METHOD

Through semi-structured interviews with eleven youths diagnosed with anorexia nervosa, opinions and experiences surrounding the impact of social media on anorexia nervosa were collected, coded and analyzed using thematic analysis.

RESULTS

Social media are often used to compensate for social isolation or misunderstandings about anorexia nervosa from friends and family. Motivated youths experience recovery communities as helpful against social isolation and a good place to find motivation for recovery. Negative aspects of social media include the idealization of unhealthy body types, the competition to have the most severe anorexia and the ease with which pro-ana content is found online and imposes itself.

CONCLUSION

Preventive measures, including education about the dangers of social media can protect youths with anorexia nervosa in their social media use. Isolation from social media may lead to further social isolation.

Integrative multi-omics analysis of genomic, epigenomic, and metabolomics data leads to new insights for Attention-Deficit/Hyperactivity Disorder

The evolving field of multi-omics combines data and provides methods for simultaneous analysis across several omics levels. Here, we integrated genomics (transmitted and non-transmitted polygenic scores [PGSs]), epigenomics, and metabolomics data in a multi-omics framework to identify biomarkers for Attention-Deficit/Hyperactivity Disorder (ADHD) and investigated the connections among the three omics levels. We first trained single- and next multi-omics models to differentiate between cases and controls in 596 twins (cases = 14.8%) from the Netherlands Twin Register (NTR) demonstrating reasonable in-sample prediction through cross-validation. The multi-omics model selected 30 PGSs, 143 CpGs, and 90 metabolites. We confirmed previous associations of ADHD with glucocorticoid exposure and the transmembrane protein family TMEM, show that the DNA methylation of the MAD1L1 gene associated with ADHD has a relation with parental smoking behavior, and present novel findings including associations between indirect genetic effects and CpGs of the STAP2 gene. However, out-of-sample prediction in NTR participants (N = 258, cases = 14.3%) and in a clinical sample (N = 145, cases = 51%) did not perform well (range misclassification was [0.40, 0.57]). The results highlighted connections between omics levels, with the strongest connections between non-transmitted PGSs, CpGs, and amino acid levels and show that multi-omics designs considering interrelated omics levels can help unravel the complex biology underlying ADHD.

Stress, Eating Behavior and Adverse Health in Parents of Young Children with Autism Spectrum Disorder

Mothers of children with Autism Spectrum Disorder (ASD) often experience chronic stress and are at risk for adverse health. However, little is known about fathers, especially when their child is in early childhood. Parenting stress, eating behavior and physical health was evaluated in mothers (n = 48) and fathers (n = 43) of young children (3-7 years) with ASD by questionnaires and physical measurements. Mother's prevalence rates of obesity (39.1%), abdominal obesity (59.6%) and metabolic syndrome (21.6%) were higher than the norm. In fathers, the prevalence rate of clinical parenting stress (33%) was higher than the norm. Parenting stress was positively related to disinhibited eating in mothers, not in fathers. It is crucial to monitor stress and health of parents of children with ASD.

A multi-omics data analysis workflow packaged as a FAIR Digital Object

BACKGROUND

Applying good data management and FAIR (Findable, Accessible, Interoperable, and Reusable) data principles in research projects can help disentangle knowledge discovery, study result reproducibility, and data reuse in future studies. Based on the concepts of the original FAIR principles for research data, FAIR principles for research software were recently proposed. FAIR Digital Objects enable discovery and reuse of Research Objects, including computational workflows for both humans and machines. Practical examples can help promote the adoption of FAIR practices for computational workflows in the research community. We developed a multi-omics data analysis workflow implementing FAIR practices to share it as a FAIR Digital Object.

FINDINGS

We conducted a case study investigating shared patterns between multi-omics data and childhood externalizing behavior. The analysis workflow was implemented as a modular pipeline in the workflow manager Nextflow, including containers with software dependencies. We adhered to software development practices like version control, documentation, and licensing. Finally, the workflow was described with rich semantic metadata, packaged as a Research Object Crate, and shared via WorkflowHub.

CONCLUSIONS

Along with the packaged multi-omics data analysis workflow, we share our experiences adopting various FAIR practices and creating a FAIR Digital Object. We hope our experiences can help other researchers who develop omics data analysis workflows to turn FAIR principles into practice.

Towards identifying the characteristics of youth with severe and enduring mental health problems in practice: a qualitative study

A group of youth with severe and enduring mental health problems (SEMHP) falls between the cracks of the child-and-adolescent psychiatry (CAP) system. An insufficient understanding of these youth's mental health problems results in a failure to accurately identify and provide support to these youth. To gain a deeper understanding, the aim of this study is to explore characteristics of youth with SEMHP in clinical practice based on the experiences of youth and clinicians in CAP. This qualitative study consisted of 20 semi-structured interviews with 10 youth with lived experience and 10 specialized clinicians in CAP. Both a thematic and content analysis was conducted to identify, assess, and report themes associated with youth with SEMHP. Themes were individual characteristics such as trauma, masking, self-destructive behavior, interpersonal distrust as well as environmental and systematic characteristics including parental stressors, social isolation and societal stressors, which go beyond the existing classifications. These characteristics profoundly impact youth's daily functioning across various life domains, creating an interactive process, ultimately leading to elusive mental health problems and overwhelming feelings of hopelessness. The authors recommend proper assessment of characteristics in all life domains affected and their perpetuating effect on SEMHP during diagnostics in CAP. Engaging in a dialogue with youth themselves is crucial due to the nature of youth's characteristics, which frequently transcend traditional classifications and may not be immediately discernible. It also requires an integrated care approach, entailing collaborations between educational institutions and mental healthcare providers, and attention to potential indicators of deficits in the healthcare system and society.

Neuroimaging-based classification of PTSD using data-driven computational approaches: A multisite big data study from the ENIGMA-PGC PTSD consortium

BACKGROUND

Recent advances in data-driven computational approaches have been helpful in devising tools to objectively diagnose psychiatric disorders. However, current machine learning studies limited to small homogeneous samples, different methodologies, and different imaging collection protocols, limit the ability to directly compare and generalize their results. Here we aimed to classify individuals with PTSD versus controls and assess the generalizability using a large heterogeneous brain datasets from the ENIGMA-PGC PTSD Working group.

METHODS

We analyzed brain MRI data from 3,477 structural-MRI; 2,495 resting state-fMRI; and 1,952 diffusion-MRI. First, we identified the brain features that best distinguish individuals with PTSD from controls using traditional machine learning methods. Second, we assessed the utility of the denoising variational autoencoder (DVAE) and evaluated its classification performance. Third, we assessed the generalizability and reproducibility of both models using leave-one-site-out cross-validation procedure for each modality.

RESULTS

We found lower performance in classifying PTSD vs. controls with data from over 20 sites (60 % test AUC for s-MRI, 59 % for rs-fMRI and 56 % for d-MRI), as compared to other studies run on single-site data. The performance increased when classifying PTSD from HC without trauma history in each modality (75 % AUC). The classification performance remained intact when applying the DVAE framework, which reduced the number of features. Finally, we found that the DVAE framework achieved better generalization to unseen datasets compared with the traditional machine learning frameworks, albeit performance was slightly above chance.

CONCLUSION

These results have the potential to provide a baseline classification performance for PTSD when using large scale neuroimaging datasets. Our findings show that the control group used can heavily affect classification performance. The DVAE framework provided better generalizability for the multi-site data. This may be more significant in clinical practice since the neuroimaging-based diagnostic DVAE classification models are much less site-specific, rendering them more generalizable.

Do parental attachment and prosocial behavior moderate the impairment from depression symptoms in adolescents who seek mental health care?

We investigated parental attachment and prosocial behavior as social protective indicators in adolescents (age 11-17) with symptoms of depression in a clinical setting. Specifically, we tested the moderating effect of these factors on the relation between symptoms of depression and their impairment on daily life. The Development and Well-Being Assessment, as completed by children, mothers, and fathers, was used, and hierarchical multiple regression analyses were conducted for these three perspectives. From the adolescents' reports we only found a significant effect of symptoms on impairment indicating that a higher number of symptoms were related to higher impairment. For the mothers and fathers, a higher score on the adolescents' prosocial behavior was related to a lower impairment from depression symptoms on the daily life of the adolescent and the family. Only for the mothers did a higher score on prosocial behavior buffered the effect of symptoms on impairment, while a higher parental attachment score was associated with a lower impairment. Further, when examining maternal and paternal attachment separately, we found that, only the mothers, reported less impairment from the symptoms when they perceived that the adolescent was attached to the father, and paternal attachment even buffered the effect of symptoms on impairment. To conclude, our results indicate that social protective factors, from the parent's perspective, are likely to have a beneficial effect in clinical practice and should be taken into account when examining impairment scores. Future studies should investigate whether additional protective indicators from the adolescents' perspective, such as quality of parental attachment or family climate, may have a positive impact on their daily functioning.

Psychological, behavioural and biological factors associated with gastrointestinal symptoms in autistic adults and adults with autistic traits

LAY ABSTRACT

Little is known about factors related to the increased risk for gastrointestinal symptoms in adults with an autism spectrum disorder (ASD), while the negative impact of gastrointestinal symptoms is evident. Especially, the relationship between gastrointestinal symptoms and psychological, behavioural, and biological risk factors in adults with ASD (traits) is unclear. Autistic peer support workers and autism-advocates also emphasised the importance of identifying risk factors, because of the high prevalence of gastrointestinal problems in people with ASD. Therefore, our study investigated which psychological, behavioural, and biological factors are associated with gastrointestinal symptoms in adults with ASD or with autistic traits. We analysed data from 31,185 adults in the Dutch Lifelines Study. Questionnaires were used to evaluate the presence of an autism spectrum disorder diagnosis, autistic traits, gastrointestinal symptoms, psychological and behavioural factors. Biological factors were examined with body measurements. We found that not only adults with ASD but also adults with higher levels of autistic traits were at increased risk for gastrointestinal symptoms. Adults with ASD who experienced psychological problems (psychiatric problems, worse perceived health, chronic stress) had a higher risk for gastrointestinal symptoms than adults with ASD without these psychological problems. Moreover, adults with higher levels of autistic traits were less physically active, which was also associated with gastrointestinal symptoms. In conclusion, our study highlights the relevance of identifying psychological problems and evaluating physical activity when trying to help adults with ASD or autistic traits and gastrointestinal symptoms. This suggests that healthcare professionals should be more aware of behavioural and psychological risk factors when evaluating gastrointestinal symptoms in adults with ASD (traits).

Likelihood of identifying autistic traits with the autism spectrum quotient (AQ) in male juveniles with autism spectrum disorder (ASD) and severe behavioral problems (SBPs)

BACKGROUND

When screening for autism spectrum disorders (ASD), the Autism Spectrum Quotient (AQ) is generally considered to be useful. Whether the AQ is also a suitable screener for ASD in juveniles with severe behavioral problems (SBPs) is unknown. Due to the overlap of symptoms between ASD and SBPs, particularly in juveniles low on empathy, the screening capacity of the AQ might be constrained. The aim of the present study was to investigate whether (comorbid) SBPs affect the screening capacity of the AQ. The hypothesis is that male juveniles with SBPs - but without a diagnosis of ASD - will score higher than male juveniles without both SBPs and ASD.

METHOD

The AQ was completed by 216 male juveniles aged 15-18 years treated at an outpatient department of child and adolescent psychiatry. The 216 participants were categorized into four groups according to a clinical diagnosis of ASD and SBPs (defined as disruptive behavior disorder and/or delinquent behavior). Using multinomial logistic regression, we investigated whether the four identified groups, based on a diagnosis of ASD and SBPs, scored differently for the total score and subscales of the AQ.

RESULTS

Participants in the group with ASD (ASD+) but without SBPs (SBP-) were more likely to report higher levels of autistic traits than the reference group without both ASD and SBPs (ASD-SBP-), except for the subscale on attention to detail (ASD+SBP- OR = 1.04; 95%CI = 0.98-1.11). Participants in the group with both ASD and SBPs were more likely to report higher levels for the total AQ score (ASD+SBP+ OR = 1.03; 95%CI = 1.00-1.05) and the communication subscale of the AQ (ASD+SBP+ OR = 1.18; 95%CI = 1.07-1.31) than the reference group without both ASD and SBPs.

CONCLUSION

In outpatient male juveniles, SBPs do not affect the screening capacity of the AQ for autistic traits. In spite of the well-known overlap of symptoms between ASD and SBPs, male juveniles with SBPs but without a diagnosis of ASD do not score higher on the AQ than male juveniles without SBPs and without a diagnosis of ASD.

Improving Collaboration Between Youth Peer Support Workers and Non-peer Colleagues in Child and Adolescent Mental Health Services

The involvement of youth peer workers (YPSWs) in child and adolescent mental health services (CAMHS) stimulates hope, destigmatization, and more culturally and developmentally appropriate support. Nevertheless, the collaboration between YPSWs and non-peer colleagues remains challenging, as it requires services to embed a new type of expert into practice. To stimulate the involvement of YPSWs in practice, this study reports on 27 semi-structured interviews with YPSWs and non-peer colleagues to provide insight into the barriers and facilitators in the collaboration process. The study took place in the Netherlands. A total of 10 interviews with YPSWs, and 17 interviews with non-peer colleagues in different healthcare occupations in CAMHS were conducted. Overall, the participants perceived relatively more barriers compared to facilitators in the collaboration process. Barriers to operate efficiently with YPSWs in multidisciplinary teams included: condescending attitudes and professional stigma towards YPSWs; concerns for YPSW boundaries; bureaucratic and clinical language usage by non-peer colleagues; conflicts due to different sets of expertise; and, lack of role clarity and guidelines for YPSWs. To improve the partnership between YPSWs and non-peer colleagues, participants described the importance of supervision and monitoring of YPSW activities. Moreover, participants also stressed the need for clear guidelines, and introduction and evaluation sessions to facilitate the collaboration process. While YPSWs seem to be an asset to CAMHS, there are a number of barriers to overcome. To overcome these barriers, organizational commitment, supervision (especially from peer colleagues), flexibility by non-peer colleagues, training non-peer staff to support YPSWs, and consistent evaluation of the implementation of YPSWs in services is recommended.

The impact of the COVID-19 pandemic on psychiatric emergency consultations in adolescents

BACKGROUND

There is growing evidence that the COVID-19 pandemic, and its associated social distancing measures, affect adolescents' mental health. We wanted to examine whether and how the number and characteristics of adolescents' psychiatric emergency presentations have changed throughout the pandemic.

METHODS

We extracted data from the records of 977 psychiatric emergency consultations of adolescents aged 12- 19 who had been referred to the mobile psychiatric emergency services in Rotterdam, the Netherlands between January 1^st 2018 and January1^st 2022. Demographic, contextual, and clinical characteristics were recorded. Time-series-analyses were performed using quasi-Poisson Generalized Linear Model to examine the effect of the first and second COVID-19 lockdown on the number of psychiatric emergency consultations, and to explore differences between boys and girls and internalizing versus externalizing problems.

RESULTS

The number of psychiatric emergency consultations regarding adolescents increased over time: from about 13 per month in 2018 to about 29 per month in 2021. During the COVID-19 pandemic, the increase was tempered. In the second wave a pronounced increase of psychiatric emergencies among adolescents with internalizing problems but not with externalizing problems was found.

CONCLUSION

Despite the reported increase of mental health problems in adolescents during the COVID-19 pandemic, we did find a smaller increase in psychiatric emergency consultations in this group then would be expected considering the overall trend. Besides changes in help-seeking and access to care, a possible explanation may be that a calmer, more orderly existence, or more parental supervision led to less psychiatric emergency situations in this age group. In the second wave the number of emergency consultations increased especially among girls with internalizing problems. While there has been a particular fall in emergency referrals of adolescents with externalizing problems since the start of the pandemic it is still too early to know whether this is a structural phenomenon. It would be important to elucidate whether the changes in emergency referrals reflect a true change in prevalence of urgent internalizing and externalizing problems in adolescents during the pandemic or a problem related to access to care.

Neurobiological correlates of antisociality across adolescence and young adulthood: a multi-sample, multi-method study

BACKGROUND

Antisociality across adolescence and young adulthood puts individuals at high risk of developing a variety of problems. Prior research has linked antisociality to autonomic nervous system and endocrinological functioning. However, there is large heterogeneity in antisocial behaviors, and these neurobiological measures are rarely studied conjointly, limited to small specific studies with narrow age ranges, and yield mixed findings due to the type of behavior examined.

METHODS

We harmonized data from 1489 participants (9-27 years, 67% male), from six heterogeneous samples. In the resulting dataset, we tested relations between distinct dimensions of antisociality and heart rate, pre-ejection period (PEP), respiratory sinus arrhythmia, respiration rate, skin conductance levels, testosterone, basal cortisol, and the cortisol awakening response (CAR), and test the role of age throughout adolescence and young adulthood.

RESULTS

Three dimensions of antisociality were uncovered: 'callous-unemotional (CU)/manipulative traits', 'intentional aggression/conduct', and 'reactivity/impulsivity/irritability'. Shorter PEPs and higher testosterone were related to CU/manipulative traits, and a higher CAR is related to both CU/manipulative traits and intentional aggression/conduct. These effects were stable across age.

CONCLUSIONS

Across a heterogeneous sample and consistent across development, the CAR may be a valuable measure to link to CU/manipulative traits and intentional aggression, while sympathetic arousal and testosterone are additionally valuable to understand CU/manipulative traits. Together, these findings deepen our understanding of the fundamental mechanisms underlying different components of antisociality. Finally, we illustrate the potential of using current statistical techniques for combining multiple datasets to draw robust conclusions about biobehavioral associations.

Drop-out and ineffective treatment in youth with severe and enduring mental health problems: a systematic review

Youth with severe and enduring mental health problems (SEMHP) tend to drop out of treatment or insufficiently profit from treatment in child and adolescent psychiatry (CAP). Knowledge about factors related to treatment failure in this group is scarce. Therefore, the aim of this systematic review was to thematically explore factors associated with dropout and ineffective treatment among youth with SEMHP. After including 36 studies, a descriptive thematic analysis was conducted. Themes were divided into three main categories: client, treatment, and organizational factors. The strongest evidence was found for the association between treatment failure and the following subthemes: type of treatment, engagement, transparency and communication, goodness of fit and, perspective of practitioner. However, most other themes showed limited evidence and little research has been done on organizational factors. To prevent treatment failure, attention should be paid to a good match between youth and both the treatment and the practitioner. Practitioners need to be aware of their own perceptions of youth's perspectives, and transparent communication with youth contributes to regaining their trust.

Informative value of referral letters from general practice for child and adolescent mental healthcare

Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.

Integrative Multi-omics Analysis of Childhood Aggressive Behavior

This study introduces and illustrates the potential of an integrated multi-omics approach in investigating the underlying biology of complex traits such as childhood aggressive behavior. In 645 twins (cases = 42%), we trained single- and integrative multi-omics models to identify biomarkers for subclinical aggression and investigated the connections among these biomarkers. Our data comprised transmitted and two non-transmitted polygenic scores (PGSs) for 15 traits, 78,772 CpGs, and 90 metabolites. The single-omics models selected 31 PGSs, 1614 CpGs, and 90 metabolites, and the multi-omics model comprised 44 PGSs, 746 CpGs, and 90 metabolites. The predictive accuracy for these models in the test (N = 277, cases = 42%) and independent clinical data (N = 142, cases = 45%) ranged from 43 to 57%. We observed strong connections between DNA methylation, amino acids, and parental non-transmitted PGSs for ADHD, Autism Spectrum Disorder, intelligence, smoking initiation, and self-reported health. Aggression-related omics traits link to known and novel risk factors, including inflammation, carcinogens, and smoking.

[Linking mental healthcare- and Statistics Netherlands microdata to assess the effectiveness of care]

BACKGROUND

The effectiveness of mental health care is currently monitored through routine quantitative symptom-driven measurements in most clinical settings. These measurements seem inadequate, especially for target groups with complex, multi-faceted problems. There is as yet no alternative method.

AIM

1. To describe why quantitative symptom-driven measurements are inadequate for measuring healthcare effectiveness; and 2. to introduce a new data platform that adjusts for socioeconomic and environmental factors to monitor the effectiveness of healthcare.

METHOD

Overview of developments based on literature and introduction of a unique data platform.

RESULTS

In the case of complex, multi-faced problems, such as in children with mild intellectual disability and comorbid psychopathology, mental health problems cannot be quantified, isolated, and individualized, i.e., decontextualized. To evaluate care for external benchmarking and scientific research, a shift is advised from measuring clinical symptoms within the treatment period to measuring longer-term group-level social functioning across multiple life domains, with a focus on socio-demographic differences. The Extramuraal LUMC Academisch Netwerk Gezond & Gelukkig Den Haag (ELAN-GGDH ; in English: Extramural LUMC Academic Network Healthy & Happy The Hague) data platform accomplishes this by combining mental health data with Statistics Netherlands microdata.

CONCLUSION

The data platform could add value to external benchmarking and scientific research at group level.

General practitioners' everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands

BACKGROUND

Psychosocial problems in children and youth are common and may negatively impact their lives and the lives of their families. Since general practitioners (GPs) play a crucial role in detecting and intervening in such problems, it is clinically necessary to improve our insight into their clinical decision-making (CDM). The objective of this study was to explore which mechanisms underlie GPs' everyday CDM and their options for management or referral.

MATERIAL AND METHODS

This was a mixed methods study in which qualitative (interview substudy) and quantitative (online survey substudy) data were collected from GPs. Using a question framework and vignettes representative of clinical practice, GPs' CDM was explored. GPs were selected by means of an academic research network and purposive sampling. Data collection continued in constant comparison between both substudies. Using grounded theory, data from both substudies were triangulated into a flowchart consisting of mechanisms and management/referral options.

RESULTS

CDM-mechanisms were divided into three groups. GP-related mechanisms were GPs' primary approach of the problem (somatically or psychosocially) and their self-assessed competence to solve the problem based on interest in and knowledge about youth mental health care. Mechanisms related to the child and its social context included GPs' assessment whether there was psychiatric (co)morbidity, their sense of self-limitedness of the problem and assessed complexity of the problem. Whether GPs' had existing collaboration agreements with youth care providers and how they experienced their collaboration were collaboration-related mechanisms.

CONCLUSION

The current study contributes to a relatively unexplored research area by revealing GP's in-depth thought processes regarding their CDM. However, existing research in this area supports the identified CDM mechanisms. Future initiatives should focus on validating CDM mechanisms in a larger population. If confirmed, mechanisms could be integrated into GP training and may offer guidelines for regulating proper access to mental health care services.

A systematic review exploring youth peer support for young people with mental health problems

Youth peer support workers (YPSWs) are young adults with lived experience of mental illness during childhood or adolescence who support young people receiving treatment in mental health services. The contributions made by YPSWs are a promising development to facilitate consumer-centered and recovery-oriented care. Although the youth peer support workforce is expanding rapidly, structurally embedding YPSWs in practice is challenging. To overcome these challenges and thereby improve care for young people, insight into YPSW roles, barriers and facilitators for implementing and pursuing youth peer support (YPS) is a necessity. This systematic review examined the published literature to identify existing knowledge on YPSW roles in treatment settings, and the barriers and facilitators for implementing and pursuing YPS in practice. A total of 24 studies from a variety of youth serving contexts were included in this review. Thematic synthesis resulted in six YPSW roles and five themes with barriers and facilitators. The roles included the: engagement role, emotional support role, navigating and planning role, advocacy role, research role and the educational role. The themes explored the needs of YPSWs, experiences of YPSWs, relationships between service users and YPSWs, the collaboration process between YPSWs and non-peer staff, and organizational readiness. This review underlines that YPSWs likely are a valuable addition to numerous youth treatment contexts. Overall, the implementation of YPSWs is a multifaceted operation that requires careful planning. We recommend services to set clear and realistic expectations for YPSWs, to consider potential power imbalances between YPSWs and non-peer staff, to provide adequate resources to pursue YPS, and to approach the implementation of YPSWs with a growth mindset.

Offence type and neurodiversity: A comparison of 12-17-year-old boys charged with a criminal offence by diagnosis of autism spectrum disorder, attention deficit hyperactivity disorder or both

BACKGROUND

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) have been evidenced as common among adolescents with delinquent behaviour. Less is known, however, about the relationship between these disorders and type of alleged offence, when the adolescent is involved with the criminal justice system.

AIM

Our aim was to investigate whether the type of alleged index offences among 12-17-year-olds differ between those diagnosed with ASD, ADHD or ASD + ADHD.

METHOD

The sample was selected for ASD and/or ADHD diagnoses from a database of all pre-trial forensic psychiatric and psychological assessments of male adolescents of 12-17 years old in the Netherlands for the years 2013 and 2014. For each record, independent researchers scored a 76-item checklist encompassing health and offending characteristics. Sixty-nine of the 1799 pre-trial assessments of these male adolescents had a diagnosis of ASD, 90 of ADHD and 29 had been diagnosed with both; these 188 cases formed our sample.

RESULTS

The rate of sex offences was significantly higher among those with ASD (N = 20, 29%) than those with ADHD (N = 10, 11%) or both (N = 4, 14%; Fisher's exact test = 8.54; p = 0.014). By contrast, the rate of property offences without violence was significantly higher among those with ADHD (N = 22, 24%) than those with ASD (N = 4, 6%) or both (N = 5, 17%; Fisher's exact test = 10.50, p = 0.004), whereas violent offending rates did not differ between the three groups.

CONCLUSION

Specific offence types were not equally distributed among male adolescents with different psychiatric diagnoses. In our sample of male adolescents suspected of an offence nearly one-third of those diagnosed with ASD were convicted of a sex offence, suggesting highly specialised needs for further assessment and intervention. Among those diagnosed with ADHD, significantly more adolescents were charged with non-violent property offences. Such unequal distribution of alleged offence types among adolescents with different psychiatric diagnoses justifies tailor-made attention for offending adolescents with different psychiatric diagnoses.

Comparing Treatment Outcomes in Children and Adolescents With ADHD to Other Disorders Within an Australian and Dutch Outpatient Cohort

OBJECTIVE

Previous studies at child and youth mental health services (CYMHS) suggest that children with ADHD have poorer outcomes compared to those with other diagnoses. This study investigates this in more detail.

METHODS

Children with ADHD were compared to those with ASD and those with emotional disorders, on routinely collected outcomes at CYMHS in Australia (N = 2,513) and the Netherlands (N = 844).

RESULTS

Where the emotional disorders group reached a similar level of emotional symptoms at the end-of-treatment as the ADHD and ASD groups, the latter two groups still had higher scores on ADHD and ASD symptoms (attention and peer problems). The poorer outcomes were mainly explained by higher severity at baseline. In Australia, an ADHD and/or ASD diagnosis also independently contributed to worse outcomes.

CONCLUSION

Those with neurodevelopmental disorders within both countries had poorer outcomes than those with emotional disorders. Services should aim to optimize treatment to ensure best possible outcomes.

Clinical decision support methods for children and youths with mental health disorders in primary care

BACKGROUND

Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs).

OBJECTIVES

This review aimed to identify CDSMs in the literature and describe their functionalities and quality.

METHODS

In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols.

RESULTS

Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories.

CONCLUSION

Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

A comparison of methods to harmonize cortical thickness measurements across scanners and sites

Results of neuroimaging datasets aggregated from multiple sites may be biased by site-specific profiles in participants' demographic and clinical characteristics, as well as MRI acquisition protocols and scanning platforms. We compared the impact of four different harmonization methods on results obtained from analyses of cortical thickness data: (1) linear mixed-effects model (LME) that models site-specific random intercepts (LMEINT), (2) LME that models both site-specific random intercepts and age-related random slopes (LMEINT+SLP), (3) ComBat, and (4) ComBat with a generalized additive model (ComBat-GAM). Our test case for comparing harmonization methods was cortical thickness data aggregated from 29 sites, which included 1,340 cases with posttraumatic stress disorder (PTSD) (6.2-81.8 years old) and 2,057 trauma-exposed controls without PTSD (6.3-85.2 years old). We found that, compared to the other data harmonization methods, data processed with ComBat-GAM was more sensitive to the detection of significant case-control differences (Χ2(3) = 63.704, p < 0.001) as well as case-control differences in age-related cortical thinning (Χ2(3) = 12.082, p = 0.007). Both ComBat and ComBat-GAM outperformed LME methods in detecting sex differences (Χ2(3) = 9.114, p = 0.028) in regional cortical thickness. ComBat-GAM also led to stronger estimates of age-related declines in cortical thickness (corrected p-values < 0.001), stronger estimates of case-related cortical thickness reduction (corrected p-values < 0.001), weaker estimates of age-related declines in cortical thickness in cases than controls (corrected p-values < 0.001), stronger estimates of cortical thickness reduction in females than males (corrected p-values < 0.001), and stronger estimates of cortical thickness reduction in females relative to males in cases than controls (corrected p-values < 0.001). Our results support the use of ComBat-GAM to minimize confounds and increase statistical power when harmonizing data with non-linear effects, and the use of either ComBat or ComBat-GAM for harmonizing data with linear effects.

Structural brain alterations associated with suicidal thoughts and behaviors in young people: results from 21 international studies from the ENIGMA Suicidal Thoughts and Behaviours consortium

Identifying brain alterations associated with suicidal thoughts and behaviors (STBs) in young people is critical to understanding their development and improving early intervention and prevention. The ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium analyzed neuroimaging data harmonized across sites to examine brain morphology associated with STBs in youth. We performed analyses in three separate stages, in samples ranging from most to least homogeneous in terms of suicide assessment instrument and mental disorder. First, in a sample of 577 young people with mood disorders, in which STBs were assessed with the Columbia Suicide Severity Rating Scale (C-SSRS). Second, in a sample of young people with mood disorders, in which STB were assessed using different instruments, MRI metrics were compared among healthy controls without STBs (HC; N = 519), clinical controls with a mood disorder but without STBs (CC; N = 246) and young people with current suicidal ideation (N = 223). In separate analyses, MRI metrics were compared among HCs (N = 253), CCs (N = 217), and suicide attempters (N = 64). Third, in a larger transdiagnostic sample with various assessment instruments (HC = 606; CC = 419; Ideation = 289; HC = 253; CC = 432; Attempt=91). In the homogeneous C-SSRS sample, surface area of the frontal pole was lower in young people with mood disorders and a history of actual suicide attempts (N = 163) than those without a lifetime suicide attempt (N = 323; FDR-p = 0.035, Cohen's d = 0.34). No associations with suicidal ideation were found. When examining more heterogeneous samples, we did not observe significant associations. Lower frontal pole surface area may represent a vulnerability for a (non-interrupted and non-aborted) suicide attempt; however, more research is needed to understand the nature of its relationship to suicide risk.

Remodeling of the Cortical Structural Connectome in Posttraumatic Stress Disorder: Results From the ENIGMA-PGC Posttraumatic Stress Disorder Consortium

BACKGROUND

Posttraumatic stress disorder (PTSD) is accompanied by disrupted cortical neuroanatomy. We investigated alteration in covariance of structural networks associated with PTSD in regions that demonstrate the case-control differences in cortical thickness (CT) and surface area (SA).

METHODS

Neuroimaging and clinical data were aggregated from 29 research sites in >1300 PTSD cases and >2000 trauma-exposed control subjects (ages 6.2-85.2 years) by the ENIGMA-PGC (Enhancing Neuro Imaging Genetics through Meta Analysis-Psychiatric Genomics Consortium) PTSD working group. Cortical regions in the network were rank ordered by the effect size of PTSD-related cortical differences in CT and SA. The top-n (n = 2-148) regions with the largest effect size for PTSD > non-PTSD formed hypertrophic networks, the largest effect size for PTSD < non-PTSD formed atrophic networks, and the smallest effect size of between-group differences formed stable networks. The mean structural covariance (SC) of a given n-region network was the average of all positive pairwise correlations and was compared with the mean SC of 5000 randomly generated n-region networks.

RESULTS

Patients with PTSD, relative to non-PTSD control subjects, exhibited lower mean SC in CT-based and SA-based atrophic networks. Comorbid depression, sex, and age modulated covariance differences of PTSD-related structural networks.

CONCLUSIONS

Covariance of structural networks based on CT and cortical SA are affected by PTSD and further modulated by comorbid depression, sex, and age. The SC networks that are perturbed in PTSD comport with converging evidence from resting-state functional connectivity networks and networks affected by inflammatory processes and stress hormones in PTSD.

Exploring the course of adolescent anxiety and depression: associations with white matter tract microstructure

Cross-sectional Diffusion Tensor Imaging (DTI) studies have reported alterations in white matter (WM) microstructure in adolescents with internalizing psychopathology. Yet, longitudinal studies investigating the course of WM microstructure are lacking. This study explored WM alterations and its relation to clinical symptoms over time in adolescents with internalizing disorders. DTI scans were acquired at baseline and after three months in 22 adolescents with clinical depression and comorbid anxiety (INT), and 21 healthy peers (HC) (age: 12-18). Tract-based spatial statistics was used for three voxelwise analyses: i) changes in WM microstructure between and within the INT and HC group; ii) associations between changes in symptom severity and changes in WM microstructure within youths with INT; and iii) associations between baseline WM parameters with changes in symptom severity within youths with INT. Data did not reveal changes in WM microstructure between or within groups over three months' time nor associations between changes in WM microstructure and changes in self-reported symptoms (analyses corrected for age, gender and puberty stage). Lower baseline levels of fractional anisotropy (FA) in the right posterior corona radiata (PCR) and right cingulum were associated with a higher decrease of depressive symptoms within the INT group. Post hoc analysis of additional WM parameters in the significant FA clusters showed that higher levels of baseline mean diffusivity and radial diffusivity in the PCR were associated with a lower decrease in depressive symptoms. Baseline WM microstructure characteristics were associated with a higher decrease in depressive symptoms over time. These findings increase our understanding of neurobiological mechanisms underlying the course of internalizing disorders in adolescents.

[Mental impact of the COVID-19 pandemic: a consideration of the Dutch Health Council report]

In February 2022, the Dutch Health Council (DHC, Gezondheidsraad) issued a report on the mental health consequences of the COVID pandemic. In this commentary on this report, a critical analysis on the DHC report is given. First, as included articles had to be published by August 2021, only the mental health impact of the first year was covered. Second, since the focus was predominantly on quantitative studies, insight in how the impact targets different groups was lacking. For these reasons, the report is a very welcome start but at the same time an endeavor to be continued. Following the critical analysis, suggestions for the future are given. As mental health problems seem to have increased substantially in later phases of the pandemic, it is imperative to continue analyzing the situation.

The diagnostic process from primary care to child and adolescent mental healthcare services: the incremental value of information conveyed through referral letters, screening questionnaires and structured multi-informant assessment

BACKGROUND

A variety of information sources are used in the best-evidence diagnostic procedure in child and adolescent mental healthcare, including evaluation by referrers and structured assessment questionnaires for parents. However, the incremental value of these information sources is still poorly examined.

AIMS

To quantify the added and unique predictive value of referral letters, screening, multi-informant assessment and clinicians' remote evaluations in predicting mental health disorders.

METHOD

Routine medical record data on 1259 referred children and adolescents were retrospectively extracted. Their referral letters, responses to the Strengths and Difficulties Questionnaire (SDQ), results on closed-ended questions from the Development and Well-Being Assessment (DAWBA) and its clinician-rated version were linked to classifications made after face-to-face intake in psychiatry. Following multiple imputations of missing data, logistic regression analyses were performed with the above four nodes of assessment as predictors and the five childhood disorders common in mental healthcare (anxiety, depression, autism spectrum disorders, attention-deficit hyperactivity disorder, behavioural disorders) as outcomes. Likelihood ratio tests and diagnostic odds ratios were computed.

RESULTS

Each assessment tool significantly predicted the classified outcome. Successive addition of the assessment instruments improved the prediction models, with the exception of behavioural disorder prediction by the clinician-rated DAWBA. With the exception of the SDQ for depressive and behavioural disorders, all instruments showed unique predictive value.

CONCLUSIONS

Structured acquisition and integrated use of diverse sources of information supports evidence-based diagnosis in clinical practice. The clinical value of structured assessment at the primary-secondary care interface should now be quantified in prospective studies.

ENIGMA-anxiety working group: Rationale for and organization of large-scale neuroimaging studies of anxiety disorders

Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA-Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. This paper elaborates on the concepts and methods informing the work of the working group to date, and describes the initial approach of the four subgroups studying generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobia. At present, the ENIGMA-Anxiety database contains information about more than 100 unique samples, from 16 countries and 59 institutes. Future directions include examining additional imaging modalities, integrating imaging and genetic data, and collaborating with other ENIGMA working groups. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA-Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders.

Family group conferences for suicidal adolescents: Promising results from naturalistic case study research

Can thwarted belongingness and perceived burdensomeness, risk factors for suicidal adolescents, be turned around by family group conferences? In this case study on Nick, a 17-year-old who undertook six suicide attempts, we (including Nick) share insights and learning opportunities on how family group conferences can be used. The thematic analysis suggests that family group conferences might be a promising intervention for suicidal adolescents. For Nick, the conference was a turning point in his life, correcting perceptions of being a burden, pushing back passiveness, and boosting connection with and support from the broad social network.

Brain aging in major depressive disorder: results from the ENIGMA major depressive disorder working group

Major depressive disorder (MDD) is associated with an increased risk of brain atrophy, aging-related diseases, and mortality. We examined potential advanced brain aging in adult MDD patients, and whether this process is associated with clinical characteristics in a large multicenter international dataset. We performed a mega-analysis by pooling brain measures derived from T1-weighted MRI scans from 19 samples worldwide. Healthy brain aging was estimated by predicting chronological age (18-75 years) from 7 subcortical volumes, 34 cortical thickness and 34 surface area, lateral ventricles and total intracranial volume measures separately in 952 male and 1236 female controls from the ENIGMA MDD working group. The learned model coefficients were applied to 927 male controls and 986 depressed males, and 1199 female controls and 1689 depressed females to obtain independent unbiased brain-based age predictions. The difference between predicted "brain age" and chronological age was calculated to indicate brain-predicted age difference (brain-PAD). On average, MDD patients showed a higher brain-PAD of +1.08 (SE 0.22) years (Cohen's d = 0.14, 95% CI: 0.08-0.20) compared with controls. However, this difference did not seem to be driven by specific clinical characteristics (recurrent status, remission status, antidepressant medication use, age of onset, or symptom severity). This highly powered collaborative effort showed subtle patterns of age-related structural brain abnormalities in MDD. Substantial within-group variance and overlap between groups were observed. Longitudinal studies of MDD and somatic health outcomes are needed to further assess the clinical value of these brain-PAD estimates.

Altered white matter microstructural organization in posttraumatic stress disorder across 3047 adults: results from the PGC-ENIGMA PTSD consortium

A growing number of studies have examined alterations in white matter organization in people with posttraumatic stress disorder (PTSD) using diffusion MRI (dMRI), but the results have been mixed which may be partially due to relatively small sample sizes among studies. Altered structural connectivity may be both a neurobiological vulnerability for, and a result of, PTSD. In an effort to find reliable effects, we present a multi-cohort analysis of dMRI metrics across 3047 individuals from 28 cohorts currently participating in the PGC-ENIGMA PTSD working group (a joint partnership between the Psychiatric Genomics Consortium and the Enhancing NeuroImaging Genetics through Meta-Analysis consortium). Comparing regional white matter metrics across the full brain in 1426 individuals with PTSD and 1621 controls (2174 males/873 females) between ages 18-83, 92% of whom were trauma-exposed, we report associations between PTSD and disrupted white matter organization measured by lower fractional anisotropy (FA) in the tapetum region of the corpus callosum (Cohen's d = -0.11, p = 0.0055). The tapetum connects the left and right hippocampus, for which structure and function have been consistently implicated in PTSD. Results were consistent even after accounting for the effects of multiple potentially confounding variables: childhood trauma exposure, comorbid depression, history of traumatic brain injury, current alcohol abuse or dependence, and current use of psychotropic medications. Our results show that PTSD may be associated with alterations in the broader hippocampal network.

Cortical volume abnormalities in posttraumatic stress disorder: an ENIGMA-psychiatric genomics consortium PTSD workgroup mega-analysis

Studies of posttraumatic stress disorder (PTSD) report volume abnormalities in multiple regions of the cerebral cortex. However, findings for many regions, particularly regions outside commonly studied emotion-related prefrontal, insular, and limbic regions, are inconsistent and tentative. Also, few studies address the possibility that PTSD abnormalities may be confounded by comorbid depression. A mega-analysis investigating all cortical regions in a large sample of PTSD and control subjects can potentially provide new insight into these issues. Given this perspective, our group aggregated regional volumes data of 68 cortical regions across both hemispheres from 1379 PTSD patients to 2192 controls without PTSD after data were processed by 32 international laboratories using ENIGMA standardized procedures. We examined whether regional cortical volumes were different in PTSD vs. controls, were associated with posttraumatic stress symptom (PTSS) severity, or were affected by comorbid depression. Volumes of left and right lateral orbitofrontal gyri (LOFG), left superior temporal gyrus, and right insular, lingual and superior parietal gyri were significantly smaller, on average, in PTSD patients than controls (standardized coefficients = -0.111 to -0.068, FDR corrected P values < 0.039) and were significantly negatively correlated with PTSS severity. After adjusting for depression symptoms, the PTSD findings in left and right LOFG remained significant. These findings indicate that cortical volumes in PTSD patients are smaller in prefrontal regulatory regions, as well as in broader emotion and sensory processing cortical regions.

Improvement of group climate in a residential setting for juveniles with mild intellectual disability through training of staff in Non-Violent Resistance

BACKGROUND

An open group climate is essential in successful residential care for juveniles with mild intellectual disability (MID). This study examined whether non-violent resistance, adapted for MID (NVR-MID), stimulates an open group climate in time.

METHOD

NVR-MID was implemented in three residential settings in The Netherlands, in a quasi-experimental stepped wedge design. In total, 124 clients with MID (M_age  = 16.39 [SD = 4.95], 49.9% male) participated. Group climate was assessed seven times with the Group Climate Inventory for Children or the Group Climate Inventory-Revisited (GCI-R), during a total of 20 months.

RESULTS

Open group climate scores increased in all three institutions; effect size was medium. Clients with lower IQs experienced group climate as more positive compared to clients with higher IQs. Effects were similar for both groups.

CONCLUSIONS

As NVR-MID appeared to contribute to a positive experienced group climate, it might be advisable to implement NVR-MID on larger scale.

Associations between Neonatal Magnetic Resonance Imaging and Short- and Long-Term Neurodevelopmental Outcomes in a Longitudinal Cohort of Very Preterm Children

OBJECTIVE

To assess associations between neonatal brain injury assessed by magnetic resonance imaging and cognitive, motor, and behavioral outcomes at 2 and 10 years of age, in a longitudinal cohort of children born very preterm.

STUDY DESIGN

There were 112 children born at <32 weeks of gestation who participated in a longitudinal prospective study on brain injury and neurodevelopmental outcome. Using the Kidokoro score, neonatal brain injury and altered brain growth in white matter, cortical and deep gray matter, and the cerebellum were assessed. Cognitive, motor, and behavioral outcomes were assessed during follow-up visits at both 2 (corrected) and 10 years of age.

RESULTS

After adjusting for perinatal factors and level of maternal education, the global brain abnormality score was associated with cognition (B = -1.306; P = .005), motor skills (B = -3.176; P < .001), and behavior (B = 0.666; P = .005) at 2 years of age, but was not associated with cognition at 10 years of age. In the subgroup of children with a moderate-severe global brain abnormality score, magnetic resonance imaging was independently associated with cognitive impairment at 10 years of age. For children with milder forms of brain injury, only birth weight and level of maternal education were associated with cognitive outcomes.

CONCLUSIONS

Neonatal brain injury, assessed by a standardized scoring system, was associated with short-term neurodevelopmental outcomes, but only with motor skills and behavior in childhood. Environmental factors, such as level of maternal education, become more important for cognitive development as children grow older, especially for children with relatively mild neonatal brain injury.

Classes of Oppositional Defiant Disorder Behavior in Clinic-referred Children and Adolescents: Concurrent Features and Outcomes: Classification Des Comportements Dans le Trouble Oppositionnel Avec Provocation Chez Des Enfants et des Adolescents Aiguillés à Une Clinique: Caractéristiques Co-occurrentes et Résultats

OBJECTIVE

Oppositional defiant disorder (ODD) consists of irritable and oppositional behaviors, both of which are associated with different problems. However, it is unclear whether irritability and oppositionality enable classification of clinic-referred children and adolescents into mutually exclusive groups (e.g., high in oppositionality, low in irritability), and whether this classification is clinically meaningful.

METHOD

As part of a clinical protocol, ODD behaviors were assessed at referral through a comprehensive diagnostic interview and questionnaire. Parent- and teacher-reported ODD of 2,185 clinic-referred 5- to 18-year-olds (36.9% females) were used in latent class analysis. Resulting ODD classes were compared, concurrently at referral, and, longitudinally at the end of the diagnostic and treatment process, on various clinically relevant measures that were completed by various informants, including mental health problems, global functioning, and Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications.

RESULTS

Three classes emerged with high, moderate, and low levels of both irritability and oppositionality. At referral, the high class experienced the highest levels of mental health problems and DSM classifications. Importantly, all ODD classes defined at intake were predictive of diagnostic and treatment outcomes months later. Notably, the high class had higher rates of clinician-based classifications of ODD and conduct disorder, and the lowest levels of pre- and posttreatment global functioning. Additionally, the low class exhibited higher rates of generalized anxiety disorder and fear disorders.

CONCLUSIONS

Irritability and oppositionality co-occur in clinic-referred youths to such an extent that classification based on these behaviors does not add to clinical inference. Instead, findings suggest that the overall ODD severity at referral should be used as a guidance for treatment.

Using the biopsychosocial model for identifying subgroups of detained juveniles at different risk of re-offending in practice: a latent class regression analysis approach

BACKGROUND

Juvenile delinquents constitute a heterogeneous group, which complicates decision-making based on risk assessment. Various psychosocial factors have been used to define clinically relevant subgroups of juvenile offenders, while neurobiological variables have not yet been integrated in this context. Moreover, translation of neurobiological group differences to individual risk assessment has proven difficult. We aimed to identify clinically relevant subgroups associated with differential youth offending outcomes, based on psychosocial and neurobiological characteristics, and to test whether the resulting model can be used for risk assessment of individual cases.

METHODS

A group of 223 detained juveniles from juvenile justice institutions was studied. Latent class regression analysis was used to detect subgroups associated with differential offending outcome (recidivism at 12 month follow-up). As a proof of principle, it was tested in a separate group of 76 participants whether individual cases could be assigned to the identified subgroups, using a prototype 'tool' for calculating class membership.

RESULTS

Three subgroups were identified: a 'high risk-externalizing' subgroup, a 'medium risk-adverse environment' subgroup, and a 'low risk-psychopathic traits' subgroup. Within these subgroups, both autonomic nervous system and neuroendocrinological measures added differentially to the prediction of subtypes of reoffending (no, non-violent, violent). The 'tool' for calculating class membership correctly assigned 92.1% of participants to a class and reoffending risk.

CONCLUSIONS

The LCRA approach appears to be a useful approach to integrate neurobiological and psychosocial risk factors to identify subgroups with different re-offending risk within juvenile justice institutions. This approach may be useful in the development of a biopsychosocial assessment tool and may eventually help clinicians to assign individuals to those subgroups and subsequently tailor intervention based on their re-offending risk.

Neural processing of socioemotional content in conduct-disordered juvenile offenders with limited prosocial emotions

BACKGROUND

Reflecting evidence on Callous-Unemotional (CU) traits (e.g., lack of empathy and guilt, shallow affect), the DSM-5 added a categorical CU-based specifier for Conduct Disorder (CD), labeled 'with Limited Prosocial Emotions' (LPE). Theory and prior work suggest that CD youths with and without LPE will likely differ in neural processing of negative socioemotional content. This proposition, however, is mainly derived from studies employing related, yet distinct, operationalizations of CU traits (e.g., dimensional measure/median split/top quartile), thus precluding direct examination of LPE-specific neurocognitive deficits.

METHODS

Employing a DSM-5 informed LPE proxy, neural processing of recognizing and resonating negative socioemotional content (angry and fearful faces) was therefore examined here among CD offenders with LPE (CD/LPE+; N = 19), relative to CD offenders without LPE (CD/LPE-; N = 31) and healthy controls (HC; N = 31).

RESULTS

Relative to HC and CD/LPE- youths and according to a linearly increasing trend (CD/LPE- < HC < CD/LPE+), CD/LPE+ youths exhibited hyperactivity within dorsolateral, dorsomedial, and ventromedial prefrontal regions during both emotion recognition and resonance. During emotion resonance, CD/LPE+ youths additionally showed increased activity within the posterior cingulate and precuneal cortices in comparison to HC and CD/LPE- youths, which again followed a linearly increasing trend (CD/LPE- < HC < CD/LPE+). These effects moreover seemed specific to the LPE specifier, when compared to a commonly employed method for CU-based grouping in CD (i.e., median split on CU scores).

CONCLUSIONS

These data cautiously suggest that CD/LPE+ youths may exhibit an over-reliance on cortical neurocognitive systems when explicitly processing negative socioemotional information, which could have adverse downstream effects on relevant socioemotional functions. The findings thus seem to provide novel, yet preliminary, clues on the neurocognitive profile of CD/LPE+, and additionally highlight the potential scientific utility of the LPE specifier.

Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth

As hospital beds are scarce, and emergency admissions to a psychiatric ward are major life-events for children and adolescents, it is essential to have insight into the decision-making process that leads to them. To identify potentially modifiable factors, we, therefore, studied the contextual and clinical characteristics associated with the voluntary and compulsory emergency admission of minors. We used registry data (2008-2017) on 1194 outpatient emergencies involving children aged 6-18 who had been referred to the mobile psychiatric emergency service in two city areas in The Netherlands. Demographic and contextual factors were collected, as well as clinical characteristics including diagnoses, psychiatric history, Global Assessment of Functioning (GAF), and the Severity of Psychiatric Illness (SPI) scale. Logistic regression analyses were used to identify factors that predict voluntary or compulsory admission. Of 1194 consultations, 227 (19.0%) resulted in an admission, with 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) compulsorily. Independently of legal status, the following characteristics were associated with admission: severity of psychiatric symptoms, consultation outside the patient's home, and high levels of family disruption. Relative to voluntary admission, compulsory admission was associated with more severe psychiatric problems, higher suicide risk, and prior emergency compulsory admission. Two potentially modifiable factors were associated with psychiatric emergency admission: the place where patients were seen for consultation, and the presence of family problems. Psychiatric emergency admissions may be reduced if, whenever possible, minors are seen in their homes and if a system-oriented approach is used.

Longitudinal Follow-Up of Children Born Preterm: Neurodevelopment From 2 to 10 Years of Age

Objective: To investigate the rate and stability of impairments in children born preterm by assessing (1) early and school-age outcome in four developmental domains and (2) individual changes in outcome at both timepoints. Design: Prospective, longitudinal cohort study in children born in 2006-2007, <32 weeks' gestation. Follow-up at 2 and 10 years of age included standardized neurological, motor, cognitive and behavioral assessments. Children were categorized as having no, mild or moderate-severe impairment in these four domains. A composite impairment score was composed and the number of domains with impairments counted. For each child, individual outcomes at both timepoints were compared. Results: Follow-up at both time-points was available in 71/113(63%) children. At group level, there were no significant changes in the severity of impairments per domain. However, at individual level, there were less children with a mild abnormal composite score at 10 years of age (44 vs. 20%; p = 0.006), and more with a moderate-severe abnormal composite score (12 vs. 35%; p = 0.001). Especially children with normal/mild outcome at 2 years were likely to shift to other outcome categories over time. Conclusions: Children with early severe impairment are likely experiencing impairments later on, but early normal/mild abnormal outcomes should be interpreted with care, considering the large individual shifts over time. Long-term follow-up in all children born very preterm should therefore be continued to at least school-age.

[The therapeutic alliance as predictor in the treatment of young people]

BACKGROUND

The quality of the therapeutic alliance is an important factor in the treatment of both adult and adolescent patients in psychiatry. Little is known about the importance of the therapeutic alliance among youths who seek help for their substance abuse problems in addiction treatment.

AIM

We investigated the importance of first treatment session therapeutic alliance for outcome in youth mental health and addiction treatment, considering both the youths' and therapists' perspective.

METHOD

127 adolescents participated in a prospective clinical cohort study, with favorable or unfavorable treatment outcome after 4 months as primary outcome measure. At the end of the first treatment session, youths and their therapists were asked to rate the therapeutic alliance.

RESULTS

Youths' and therapists' perceptions about the therapeutic alliance at the start of treatment were predictive of treatment outcome at four months follow-up. In particular, the combined perspective on first-session alliance by both youths and therapists appeared a strong predictor for treatment outcome. If both youths and therapists rated the therapeutic alliance as weak, the percentage of youths showing a favorable treatment outcome was much lower (23%), than if youths and therapists rated the alliance as strong (70%).

CONCLUSION

The present study confirms the importance of a combined perspective on the therapeutic alliance for predicting treatment outcome among patients in youth mental health and addiction treatment.

Investigating microstructure of white matter tracts as candidate endophenotypes of Social Anxiety Disorder - Findings from the Leiden Family Lab study on Social Anxiety Disorder (LFLSAD)

BACKGROUND

Social anxiety disorder (SAD) is a mental illness with a complex, partially genetic background. Differences in characteristics of white matter (WM) microstructure have been reported in patients with SAD compared to healthy controls. Also, WM characteristics are moderately to highly heritable. Endophenotypes are measurable characteristics on the road from genotype to phenotype, putatively reflective of genetically based disease mechanisms. In search of candidate endophenotypes of SAD we used a unique sample of SAD patients and their family members of two generations to explore microstructure of WM tracts as candidate endophenotypes. We focused on two endophenotype criteria: co-segregation with social anxiety within the families, and heritability.

METHODS

Participants (n = 94 from 8 families genetically vulnerable for SAD) took part in the Leiden Family Lab Study on Social Anxiety Disorder (LFLSAD). We employed tract-based spatial statistics to examine structural WM characteristics, being fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD) and radial diffusivity (RD), in three a-priori defined tracts of interest: uncinate fasciculus (UF), superior longitudinal fasciculus (SLF) and inferior longitudinal fasciculus (ILF). Associations with social anxiety symptoms and heritability were estimated.

RESULTS

Increased FA in the left and right SLF co-segregated with symptoms of social anxiety. These findings were coupled with decreased RD and MD. All characteristics of WM microstructure were estimated to be at least moderately heritable.

CONCLUSION

These findings suggest that alterations in WM microstructure in the SLF could be candidate endophenotypes of SAD, as they co-segregated within families genetically vulnerable for SAD and are heritable. These findings further elucidate the genetic susceptibility to SAD and improve our understanding of the overall etiology.

Towards Integrated Youth Care: A Systematic Review of Facilitators and Barriers for Professionals

To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: ‘Child’s environment’, ‘Preconditions’, ‘Care process’, ‘Expertise’, ‘Interprofessional collaboration’, ‘Information exchange’, and ‘Professional identity’. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered.

Registration PROSPERO, registration number CRD42018084527.

Recognition of anxiety disorders in children: a cross-sectional vignette-based survey among general practitioners

OBJECTIVE

To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.

DESIGN AND SETTING

In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.

PARTICIPANTS

A sample of 229 GPs, resulting in a total of 1128 vignette evaluations.

MAIN OUTCOME MEASURE

GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).

RESULTS

Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.

CONCLUSION

A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition.

Urinary Amine and Organic Acid Metabolites Evaluated as Markers for Childhood Aggression: The ACTION Biomarker Study

Biomarkers are of interest as potential diagnostic and predictive instruments in personalized medicine. We present the first urinary metabolomics biomarker study of childhood aggression. We aim to examine the association of urinary metabolites and neurotransmitter ratios involved in key metabolic and neurotransmitter pathways in a large cohort of twins (N = 1,347) and clinic-referred children (N = 183) with an average age of 9.7 years. This study is part of ACTION (Aggression in Children: Unraveling gene-environment interplay to inform Treatment and InterventiON strategies), in which we developed a standardized protocol for large-scale collection of urine samples in children. Our analytical design consisted of three phases: a discovery phase in twins scoring low or high on aggression (N = 783); a replication phase in twin pairs discordant for aggression (N = 378); and a validation phase in clinical cases and matched twin controls (N = 367). In the discovery phase, 6 biomarkers were significantly associated with childhood aggression, of which the association of O-phosphoserine (β = 0.36; SE = 0.09; p = 0.004), and gamma-L-glutamyl-L-alanine (β = 0.32; SE = 0.09; p = 0.01) remained significant after multiple testing. Although non-significant, the directions of effect were congruent between the discovery and replication analyses for six biomarkers and two neurotransmitter ratios and the concentrations of 6 amines differed between low and high aggressive twins. In the validation analyses, the top biomarkers and neurotransmitter ratios, with congruent directions of effect, showed no significant associations with childhood aggression. We find suggestive evidence for associations of childhood aggression with metabolic dysregulation of neurotransmission, oxidative stress, and energy metabolism. Although replication is required, our findings provide starting points to investigate causal and pleiotropic effects of these dysregulations on childhood aggression.

A dual perspective on first-session therapeutic alliance: strong predictor of youth mental health and addiction treatment outcome

We investigated the potential role of first-session therapeutic alliance ratings to serve as an early marker of treatment outcome in youth mental health and addiction treatment. The present study is among the first to incorporate both a youths' and a therapists' perspective of the therapeutic alliance in order to maximize predictive value of the alliance for treatment outcome. One hundred and twenty-seven adolescents participated in a multi-site prospective naturalistic clinical cohort study, with assessments at baseline and at 4 months post-baseline. Main outcome measure was favorable or unfavorable treatment outcome status at 4-month follow-up. Early therapeutic alliance had a medium and robust association with treatment outcome for youth' (b = 1.29) and therapist' (b = 1.12) perspectives and treatment setting. Based on the two alliance perspectives four subgroups were distinguished. Incorporating the alliance-ratings from both perspectives provided a stronger predictor of treatment outcome than using one perspective. Youth with a strong alliance according to both perspectives had an eightfold odds of favorable treatment outcome compared with youth with a weak alliance according to both perspectives. The association between therapeutic alliance and treatment outcome in youth mental health and addiction treatment may be substantially stronger than earlier assumed when both a youths' and therapists' perspective on alliance is considered.

[The development of an mHealth app with young people in mental health care using Agile; a practical experiment]

In recent years, many mobile health (mHealth) apps have been developed to support diagnostics and treatment, among other purposes. It is likely that involving patients closely in the development process will lead to more relevant apps. In theory, the Agile style of software development can make this possible. However, whether this is feasible in mental healthcare practice has never been investigated.<br/> AIM: To investigate whether it is possible in practice to develop an mHealth app together with young people in a highly specialized mental healthcare context, by using Agile.<br/> METHOD: A proof-of-concept study that seeks to develop an mHealth app by implementing Agile together with clinically admitted, young psychiatric patients. Patients would directly influence the development goals and priorities.<br/> RESULTS: In the period from May to July 2019 the app 'Constant Circles' has been developed using Agile together with patients. The main focus of this app is social support. The patients supplied 18 concrete user stories and also provided feedback with general principles for developing an mHealth app.<br/> CONCLUSION: This study has demonstrated that it is possible to closely involve patients in highly specialized mental health care in the development process of an mHealth app by using Agile.

Common elements of evidence-based systemic treatments for adolescents with disruptive behaviour problems

A growing number of evidence-based systemic treatments for adolescents with disruptive behaviour problems exist. However, it is not clear to what extent these treatments have unique and common elements. Identification of common elements in the different treatments would be beneficial for the further understanding and development of family-based interventions, training of therapists, and research. Therefore, the aim of this Review was to identify common elements of evidence-based systemic treatments for adolescents with disruptive behaviour. Several common elements of systemic treatments were identified, showing a strong overlap between the interventions. Investigation of these common mechanisms and techniques could potentially build strong universal systemic treatment and training modules for a broad spectrum of adolescents with problem behaviours.

Factors associated with the identification of child mental health problems in primary care-a systematic review

Background: Although common and often with long-lasting effects, child mental health problems (MHPs) are still under-recognized and under-treated. A better understanding of the factors associated with the identification of MHPs in primary care may improve the recognition of MHPs.

Objectives: To review studies on factors associated with the identification of child MHPs in primary care.

Methods: Six leading databases were systematically searched until 1 October 2018. Two independent researchers selected articles and extracted data on study characteristics and factors associated with MHP identification. Inclusion criteria were the investigation of factors associated with MHP identification by primary care professionals (PCPs) in children aged 0–18 years.

Results: Of the 6215 articles identified, 26 were included. Prevalence rates of PCP-identified MHPs varied between 7 and 30%. PCPs identified 26–60% of children with an increased risk of MHPs as indicated by MHP assessment tools, but associated factors were investigated in relatively few studies. MHPs were more often identified in children with a family composition other than married parents, with worse mental health symptoms, prior MHPs, among boys in elementary school, when contact with PCPs was related to parental psychosocial concerns or routine health check-ups, when PCPs were recently trained in MHPs or when PCPs felt less burdened treating MHPs.

Conclusion: MHP identification varied substantially between studies and PCPs and was related to several child, family and practice factors. Future studies should systematically investigate factors associated with MHP identification by PCPs and specifically in children with an increased risk of MHPs according to mental health assessment tools.