Baseline cortisol measures and developmental pathways of anxiety in early adolescence.

OBJECTIVE: This study investigated whether baseline cortisol measures predicted future anxiety, and compared cortisol values of groups with different developmental pathways of anxiety. METHOD: Cortisol levels were assessed in 1768 individuals (10-12 years). Anxiety levels were assessed at the same age and 2 years later. RESULTS: Cortisol measures did not predict future anxiety levels. Individuals with persistent anxiety problems did not show higher morning cortisol levels than those with persistently low, decreasing, or increasing anxiety levels. Instead, individuals with persistently high anxiety levels showed significantly lower evening cortisol levels than all other individuals. Further, participants with increasing anxiety levels showed higher morning cortisol levels (area under the curve; AUC) than individuals with persistently low anxiety levels. CONCLUSION: The extent to which the HPA-axis - by itself - plays a role in the aetiology of anxiety is questionable. Interactions of the HPA-axis with other biological or environmental factors may be more important.

The role of perceived parenting in familial aggregation of anxiety disorders in children.

This study was designed to explore the role of perceived parenting style in the familial aggregation of anxiety disorders. We examined the association between parental and child anxiety diagnoses, and tested whether this association was partly due to a perceived parenting style. The study was conducted in a clinical sample as well as in a control sample. Parental lifetime and current anxiety diagnoses were significantly associated with child anxiety diagnoses. When maternal and paternal lifetime and current anxiety diagnoses were entered as separate predictors, only maternal current anxiety diagnoses appeared to be significant. Perceived parenting style was assessed with the dimensions "overprotection," "emotional warmth," "rejection," and "anxious rearing." Results indicated that only maternal and paternal 'overprotection' was significantly but negatively associated with child anxiety. However, further analyses showed that 'overprotection' did not have a significant mediating role in the familial aggregation of anxiety disorders.

[Pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children and adolescents: an overview]. / Farmacotherapie bij sociale fobie, gegeneraliseerde angststoornis en separatieangststoornis bij kinderen en adolescenten: Een literatuuroverzicht.

BACKGROUND: Anxiety disorders are among the most prevalent psychiatric disorders during childhood. They are often persistent and are associated with a number of negative outcomes. Therefore, effective treatment is required. AIM: To present an overview of placebo-controlled studies of pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children an adolescents and to determine which medication is the most effective. METHOD: The literature was reviewed using Pubmed. RESULTS: Nine randomised double-blind studies on the efficacy of pharmacotherapy for generalised anxiety disorder, separation anxiety disorder and social phobia were found. Tricyclic antidepressants were not more effective than placebo. Studies on benzodiazepines showed that the effect of these drugs was not superior to that of placebo either. Studies of the efficacy of ssris, however, proved that they were superior to placebo. CONCLUSION: SSRIS are the drugs of first choice for the treatment of social phobias, separation anxiety disorder and generalised anxiety disorder in children and adolescents. There is strong evidence that ssris are effective for the treatment of these anxiety disorders; the standardised effect size varies between medium and large.

Associations between HPA axis functioning and level of anxiety in children and adolescents with an anxiety disorder.

The hypothalamus-pituitary-adrenal (HPA) axis becomes active in response to stress. Hence, increased levels of anxiety in children and adolescents may be associated with changes in HPA-axis functioning. The aim of this study was to test if level of anxiety or specific anxiety disorders were associated with basal HPA axis activity in children and adolescents with an anxiety disorder. In 99 8- to 16-year-olds with an anxiety disorder, basal cortisol levels were assessed. It was tested if (1) cortisol levels correlated with the level of self-reported anxiety and (2) if cortisol levels were different for individuals with different anxiety disorders. In girls, low levels of anxiety were associated with a stronger rise in early morning cortisol concentrations. In both boys and girls, harm avoidance predicted low cortisol concentrations after awakening. Separation anxiety and physical anxiety symptoms predicted cortisol concentrations at noon. Differences between individuals with different anxiety disorders were not found. More research is needed regarding mechanisms that explain the associations that were found, and to investigate if treatment may influence HPA axis functioning in children and adolescents with an anxiety disorder.

[Child and adolescent psychiatry: a profession and its identity II]. / Kinder- en jeugdpsychiatrie: een vak en een identiteit II.

BACKGROUND: Up till the 1970s child and adolescent psychiatry had no distinctive diagnostic system of its own. From the 1980s onwards qualitative information-gathering (e.g. via discussion or play-situations) was no longer regarded as adequate and the standardised gathering of (quantitative) information became the cornerstone of the diagnostic process. This development fundamentally changed the child psychiatrist's profession and its identity. AIM: To investigate the specific features that are required in current child and adolescent psychiatry. METHOD: In this article we will clarify the change in the child psychiatrist's profession and identity by outlining how child an adolescent psychiatry evolved as from the early 1980s. We will do this by concentrating on the diagnostic process. The treatment aspect will be discussed only briefly. RESULTS: Over the last 25 years the role of the child psychiatrist has undoubtedly changed. From being mainly a diagnostician and/or being personally responsible for treating the child or adolescent the child psychiatrist has become increasingly the person who controls the diagnostic process and plans treatment. CONCLUSION: Over the last two decades the diagnostic technique of the child psychiatrist has developed in a new direction. The child psychiatrist has chosen instead to elucidate a patient's referral and to discuss the reasons for a request for assistance and/or care. The psychiatrist uses many types of information and a multitude of informants and methods. This development has led to a fundamental change in the child psychiatrist's profession and its identity.

Higher cortisol awakening response in young adolescents with persistent anxiety problems.

OBJECTIVE: The aims of the present study were to test the association between current anxiety problems and basal cortisol levels in a large population sample of young preadolescents, and to test if HPA-axis activity differs between individuals with no, only current, or persistent anxiety problems. METHOD: Cortisol levels of 10- to 12-year olds (n = 1,768) from the general population were measured on three time points during the day. A self-report questionnaire (RCADS) was used to assess current anxiety, a parent-report questionnaire (TPBQ) to assess anxiety problems at age 4. RESULTS: Associations between cortisol levels and current anxiety problems were not found. However, individuals with persistent anxiety problems had higher morning cortisol levels and a higher cortisol awakening response. CONCLUSION: Apparently, only persistent, and not current, anxiety problems are associated with higher HPA-axis activity. Alterations in HPA-axis activity might underlie persistent anxiety problems, or result from the stress accompanied by persistent anxiety problems.

Early attention processes and anxiety in children.

It has been hypothesized that anxiety in children is associated with attentional bias in the early stages of information processing. Bias towards threat indicates the tendency of an individual to direct attention towards threatening information. The aim of the present study was to investigate whether high test-anxiety in a sample of nonreferred children is associated with attentional bias towards threat pictures, and if low test-anxiety is associated with attentional bias away from threat pictures. A probe-detection task was used with 44 10- to 13-yr.-old children. The overall analyses indicated the presence of an attentional bias away from threatening pictures in these nonreferred children. However, in relation to anxiety, the study did not confirm that high anxious children show an attentional bias towards threatening pictures or that low anxious children show an attentional bias away from threatening pictures. Yet, higher anxiety did seem to be associated with longer mean response times. These longer response times might originate from the interpretation of the nature of a stimulus as too threatening, compared to the actual threatening content, in the first stage of information processing. This finding could be useful to improve treatment methods aimed at anxiety symptoms during childhood.

Parent-teacher disagreement regarding psychopathology in children: a risk factor for adverse outcome?

OBJECTIVE: To investigate if parent-teacher discrepancies in reports of behavioral/emotional problems in children predict poor outcome. METHOD: A total of 1154 4- to 12-year-old children from the general population were followed up. At the first assessment, parent and teacher ratings were obtained with the Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF). Fourteen years later, DSM-IV diagnoses were assessed, and ratings of self-reported and parent-rated behavioral and emotional problems were obtained. RESULTS: CBCL and TRF scores predicted most of the outcomes, but in general, discrepancies between CBCL and TRF scores did not. There were some exceptions. For instance, higher parental vs. teacher ratings of aggressive behaviors increased the risk of suicide attempts/self-mutilation. CONCLUSION: Risk factors for self-mutilating behaviors may be supplemented with parent-reported aggressive behaviors that are not observed by the teachers. In general, whereas CBCL and TRF scale scores were useful predictors of outcome, parent-teacher discrepancies were not.

Internalizing and externalizing problems in adolescence: general and dimension-specific effects of familial loadings and preadolescent temperament traits.

BACKGROUND: We investigated the links between familial loading, preadolescent temperament, and internalizing and externalizing problems in adolescence, hereby distinguishing effects on maladjustment in general versus dimension-specific effects on either internalizing or externalizing problems. METHOD: In a population-based sample of 2230 preadolescents (10-11 years) familial loading (parental lifetime psychopathology) and offspring temperament were assessed at baseline by parent report, and offspring psychopathology at 2.5-years follow-up by self-report, teacher report and parent report. We used purified measures of temperament and psychopathology and partialled out shared variance between internalizing and externalizing problems. RESULTS: Familial loading of internalizing psychopathology predicted offspring internalizing but not externalizing problems, whereas familial loading of externalizing psychopathology predicted offspring externalizing but not internalizing problems. Both familial loadings were associated with Frustration, low Effortful Control, and Fear. Frustration acted as a general risk factor predicting severity of maladjustment; low Effortful Control and Fear acted as dimension-specific risk factors that predicted a particular type of psychopathology; whereas Shyness, High-Intensity Pleasure, and Affiliation acted as direction markers that steered the conditional probability of internalizing versus externalizing problems, in the event of maladjustment. Temperament traits mediated one-third of the association between familial loading and psychopathology. Findings were robust across different composite measures of psychopathology, and applied to girls as well as boys. CONCLUSIONS: With regard to familial loading and temperament, it is important to distinguish general risk factors (Frustration) from dimension-specific risk factors (familial loadings, Effortful Control, Fear), and direction markers that act as pathoplastic factors (Shyness, High-Intensity Pleasure, Affiliation) from both types of risk factors. About one-third of familial loading effects on psychopathology in early adolescence are mediated by temperament.

Psychopathology in adolescence predicts substance use in young adulthood.

AIMS: To investigate prospective associations between psychopathology in adolescence and tobacco, alcohol and drug use in young adulthood. DESIGN: A sample of 787 10-14-year-olds from the Dutch general population was prospectively followed-up across an 8-year interval. The Child Behavior Checklist (CBCL) was administered at initial assessment, and at 2- and 4-year follow-ups. Substance abuse was assessed with the Young Adult Self-Report (YASR) at 8-year follow-up. FINDINGS: The Thought Problems scale of the CBCL was the strongest predictor of alcohol use, while smoking was predicted by the Thought Problems and Delinquent Behavior scales. The strongest association with drug use in young adulthood was for the CBCL Delinquent Behavior scale. Predictive value of predictors in early adolescence was as important as in late adolescence. CONCLUSION: To investigate pathways towards substance use in young adulthood, studies assessing a broad range of possible predictors, including Thought Problems, at different developmental stages of adolescence, are needed.

Associations between behavioural and emotional problems in adolescence and maladjustment in young adulthood.

This study was designed to investigate associations between emotional and behavioural problems in adolescence and psychopathology in young adulthood. Seven hundred and six 11- to 16-year-olds from the Dutch general population were followed across a period of 8 years and 8 months. Subjects were initially assessed using the Child Behaviour Checklist (CBCL). At follow-up, a subsample of 131 subjects were assessed for DSM-III-R Axis 1 diagnoses with the SCAN (a semi-structured interview), while the Global Assessment of Functioning scale and the Groningen Social Disabilities Schedule were used to assess functioning in daily life. Scores on the CBCL scales Withdrawn, Anxious/Depressed, Somatic Complaints, Social Problems and Thought Problems in adolescence were associated with DSM-III-R symptomatology or dysfunctioning in young adulthood.

Associations between different diagnostic approaches for child and adolescent psychopathology.

OBJECTIVE: To test the convergence between the empirical-quantitative approach of the Child Behavior Checklist (CBCL) and the clinical-diagnostic approach of the DSM. METHOD: The parent version of the NIMH Diagnostic Interview Schedule for Children (DISC), version 2.3, was administered after completion of the CBCL for 231 children and adolescents consecutively referred to an outpatient mental health clinic. RESULTS: Of the subjects with a DSM-III-R diagnosis, 60% scored in the clinical range of the CBCL total problem score. The Withdrawn scale predicted affective and anxiety disorders. The Somatic Complaints scale predicted anxiety and mood disorders and Attention Deficit Hyperactivity Disorder. The Anxious/Depressed scale predicted anxiety and mood disorders and, to a lesser extent, disruptive behavior disorders. The Social Problems scale predicted Oppositional Defiant Disorder. The Attention Problems scale was the only significant predictor of "pure" Attention Deficit Hyperactivity Disorder (ADHD). The Aggressive Behavior scale predicted several disruptive behavior disorders, and Major Depression. The Delinquent Behavior scale was strongly associated with Conduct Disorder. CONCLUSIONS: Empirically based CBCL scale scores and DISC-P based DSM-III-R diagnoses converged. However, both approaches do not converge to a degree that one approach can replace the other. Instead, combining both approaches may be valuable by adding information from one approach that is not captured by the other.

The prevalence of DSM-III-R diagnoses in a national sample of Dutch adolescents.

BACKGROUND: We estimated the 6-month prevalence of psychiatric disorders among Dutch adolescents, using standardized, internationally available, and replicable assessment procedures, and assessed sex differences and comorbidity of diagnoses. METHODS: In phase 1, the parent, self-report, and teacher versions of the Child Behavior Checklist screened a sample representative of 13- to 18-year-olds from the Dutch general population. In phase 2, the parent (P) and child (C) versions of the Diagnostic Interview Schedule for Children (DISC) provided DSM-III-R diagnoses for a selected subsample of 780 subjects. RESULTS: The prevalence of any disorder was 21.5% for the DISC-C and 21.8% for the DISC-P. There was little overlap between subjects identified as having a disorder by the DISC-P and the DISC-C; only 4% met the criteria for any disorder on both. The most common disorders were simple phobia, social phobia, and conduct disorder. The most frequent comorbid diagnoses were anxiety and mood disorders. CONCLUSIONS: Although prevalences of more than 21% for DISC-C- and DISC-P-derived diagnoses seem high, many adolescents with DSM-III-R diagnoses functioned quite well. The prevalence of any DSM-III-R diagnosis based on the DISC-C or DISC-P, in combination with the criterion for a definite case, was 7.9%.

The prevalence of self-reported problems in young adults from the general population.

This study assessed the prevalence of a wide range of behavioral and emotional problems in 706 19- to 24-year-olds from the Dutch general population using the Young Adult Self-Report (YASR). The prevalence rates found can be used to make comparisons with data from individuals or other samples. Large or medium (variance > 5.9%) sex effects were found for alcohol use, for the items 'Brags' and 'Swears' (males > females), and for the items 'Cries a lot' and 'Fears' (females > males). With respect to socially desirable items, females more often reported attitudes or behaviors pertaining to helping other people, while males more often reported competitive behaviors or attitudes. For YASR syndromes, higher mean scores for females than males were found for the Withdrawn, Somatic Complaints, and Anxious/Depressed syndromes, while mean scores on the Delinquent Behavior syndrome were higher for males than females. No age effects were found, indicating that normative data were similar across the 19- to 24-year age span. Compared to other problem areas, thought problems and delinquent behavior in males, and social problems and delinquent behavior in females were least likely to be associated with other types of problems. Hence, instruments for the assessment of psychopathology in young adults should include these areas to provide a comprehensive picture of behavioral and emotional problems.

Psychopathology from adolescence into young adulthood: an 8-year follow-up study.

OBJECTIVE: This study investigated the stability of behavioral and emotional problems from adolescence into young adulthood. METHOD: Subjects from the general population (N = 459), aged 13-16 years, were evaluated initially with the Child Behavior Checklist (completed by parents) and 8 years later with the Young Adult Self-Report. The scoring format and factor structure of the two assessment instruments are similar; syndromes constructed from the two instruments are based on parents', teachers', and self-report information derived from large clinical samples. Signs of maladjustment also were assessed at follow-up through interviews. RESULTS: Of the individuals with total problem scores in the deviant range on the Child Behavior Checklist, 27.3% had total problem scores in the deviant range on the Young Adult Self-Report at follow-up. The probability of having a total problem score in the deviant range at follow-up was raised 7.4-fold by having deviant-range scores on the Child Behavior Checklist somatic complaints and anxious/depressed syndromes (simultaneously) at the initial assessment. Referral to mental health services was predicted by deviant-range scores on the anxious/depressed syndrome, while suicide attempts were predicted by deviance on the withdrawn syndrome. CONCLUSIONS: Adolescent problems tended to persist into young adulthood to a moderate degree. High rates of withdrawal from social contacts, anxiety or depression, somatic complaints without known medical origin, social problems, attention problems, delinquent behavior, and aggressive behavior during adolescence were risk factors for specific types of psychopathology and maladjustment at 8-year follow-up. The presence of psychopathology in adolescence should not be regarded as normative.

Continuity and change of self-reported problem behaviors from adolescence into young adulthood.

OBJECTIVE: To investigate the 4-year course of behavioral and emotional problems from adolescence into young adulthood in a general population sample. METHOD: The population consisted of 364 individuals, aged 15 to 18 years at the beginning of the study. Subjects filled out the Youth Self-Report at the first time of assessment. At follow-up, 2 and 4 years later, subjects aged 19 or older completed the Young Adult Self-Report, which was derived from the Youth Self-Report. RESULTS: Almost 40% of the adolescents who were classified as deviant initially were still deviant 4 years later. There was no significant difference in the continuity of internalizing problems versus externalizing problems in this sample. CONCLUSIONS: All types of problems tended to persist to a similar degree. This holds also for problems that are often regarded as typical childhood problems, such as attention problems and hyperactivity. Because adolescent problems are likely to continue, we need more knowledge on the efficacy of interventions.

Assessment of the prevalence of psychiatric disorder in young adults.

BACKGROUND: The effectiveness of different assessment procedures for determining prevalence rates of psychiatric disorder in young adults was investigated. METHOD: In a two-stage multi-method procedure, the Young Adult Self-Report, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the Structured Interview for Personality Disorders (Revised), and the Global Assessment of Functioning (GAF) Scale were used to assess prevalence rates in 706 19-24-year-olds from the general population. Furthermore, individuals' subjective perception of distress and referral to mental health services were assessed. RESULTS: The prevalence of any SCAN/DSM-III-R disorder was 19.3% (95% confidence interval: 11.2-27.4%). Most subjects who received a SCAN/DSM-III-R diagnosis were only mildly impaired. The highest prevalence rates of dysfunctioning (GAF score below 61) without referral to mental health services were for dissociative disorder (2.3%), sleep disorder (2.1%), alcohol dependence (1.3%) and affective disorder (1.8%). CONCLUSION: Instruments that assess functional impairment in addition to DSM-III-R diagnoses are indispensable in prevalence studies.

Psychopathology in Dutch young adults: enduring or changeable?

This study reports on stability and change in emotional and behavioral problems in young adults over a 2-year time span. A sample of 528 18- to 22-year-olds from the general population was assessed using the Young Adult Self-Report (YASR) on two occasions. Stability coefficients for the total problem score of the YASR were 0.63 for males and 0.75 for females. Forty-nine percent of the subjects who were initially classified as deviant were still deviant at follow-up. Of all YASR syndromes, the highest stability was for the Anxious/Depressed scale.

The prediction of poor outcome in young adults: comparison of the Young Adult Self-Report, the General Health Questionnaire and the Symptom Checklist.

The ability of the Young Adult Self-Report (YASR), the Symptom Checklist (SCL-90) and the General Health Questionnaire (GHQ-28) to predict maladjustment across a 2-year time-span was assessed in a general population sample of 528 18- to 22-year-olds. Referral for mental health services and need for professional help were predicted by total problem scores of the YASR, the GHQ-28 and the SCL-90 and by the internalizing scale of the YASR. Furthermore, the internalizing scale predicted suicide attempts or suicidal ideation, whereas the externalizing scale predicted police contacts. The YASR delinquent behavior syndrome was the only significant predictor of alcohol abuse. The findings supported the validity of the YASR as an instrument for the assessment of psychopathology in young adults.