Lifetime psychiatric diagnoses among adolescents with severe conduct problems - A register-based follow-up study.

BACKGROUND: Both delinquency and out-of-home care (OOHC) are associated with a wide spectrum of psychiatric disorders. Reform schools (RS) are Finnish OOHC institutions for adolescents with severe conduct problems. OBJECTIVE: We investigated the prevalence of psychiatric diagnoses among individuals with a history of RS placement. PARTICIPANTS AND SETTING: The data consisted of individuals placed in a RS on the last day of the years 1991, 1996, 2001, 2006 or 2011 (N = 1074) and a matched comparison group (N = 5313). METHODS: Information on lifetime psychiatric diagnoses, grouped into eight categories, was collected from the nationwide health care registry. The follow-up time ranged from 17 to 44 years. RESULTS: Among RS population, 59.5 % had some psychiatric diagnosis, which was 12-fold compared to general population peers (hazard ratio HR = 12.4). The most prevalent categories were Conduct disorders and/or ADHD (30.7 %, HR = 41.5), Substance use disorders (29.3 %, HR = 16.8,), Other childhood disorders (8.6 %, HR = 11.9) and Personality disorders (10.9 %, HR = 11.6) followed by Mental retardation (6.4 %, HR = 8.4), Schizophrenia spectrum disorders (9.7 %, HR = 7.9), Affective disorders (17.9 %, HR = 7.3), and Disorders of psychological development (6.1 %, HR = 4.4). All differences were statistically significant (p < .001). CONCLUSIONS: RS background associates with an excess of psychiatric disorders, which adds to the burden of other known risk factors for adult age well-being. Effective screening and intervention for psychiatric problems should be available both during the RS placement and after-care.

Severe conduct problems in adolescence and risk of schizophrenia in early adulthood.

AIM: Reform school (RS) is a foster care institution for adolescents with severe conduct problems. Both instability of early rearing environment and severe conduct problems in adolescence may associate with later psychotic disorders. We studied whether the risk of schizophrenia in adulthood is elevated in RS adolescents, and whether it is related to the age at first foster care placement or placement instability. METHODS: Adult age schizophrenia spectrum disorder data from RS subjects (N = 1099) were compared to a comparison group matched by age, sex, and place of birth (N = 5437) in a register based follow-up study, with up to 23 years follow-up time. Schizophrenia was also predicted with chosen placement factors. Cox proportional regression model was used in the analysis. RESULTS: RS subjects had an 8-fold (HR = 7.82, 95% CI 5.63-10.87) risk of schizophrenia compared to the comparison group. RS subjects also had an earlier age of schizophrenia onset. RS cohort, gender, placement instability, or age during the first out-of-home placement did not predict later schizophrenia. CONCLUSIONS: Adolescents with severe conduct problems are a specific high-risk group for later schizophrenia. The risk manifests early, which compromises the pathway to the adult well-being. Specialized screening procedures for psychosis risk should be implemented in the standard clinical procedures when working with adolescents with severe behaviour problems, and early intervention programs should be available.

Adult criminality among former residential school adolescents.

BACKGROUND: There is evidence from around the world that disruptive behaviour during adolescence is associated with increased risk of later criminality. Outcomes for young people placed in the Finnish residential school because of severe conduct problems are not known. AIMS: Our aims were to investigate criminality after leaving a residential school placement during adolescence, and to compare trends in criminality between four successive graduate cohorts (1991, 1996, 2001 and 2006). METHODS: We used official records to study complete national cohort of all 861 people who had been resident in the Finnish residential school system on the last day of each of the years 1991, 1996, 2001 and 2006. They were compared with 4255 matched general population controls. The follow-up time was up to 20 years. RESULTS: Two-thirds (66%) of all residential school graduates (N = 566: 448/78% men, 118/41% women) had at least one criminal conviction in adulthood, a 13-fold elevation over the general population rate. The most prevalent crime categories were violence (N = 409, 48%: 331/58% men, 78/27% women) and property crimes (N = 405: 47%: 346/60% men, 51/21% women). The risk of violent crime was 18 times that among controls; 13 of residential school males (2.3%) had a homicide conviction. Once adult, the risk of offending decreased with age. There was a significant trend for improvement in offending rates between the earliest and latest residential school cohorts. CONCLUSIONS: The risk of committing crimes after a residential school placement is sufficiently elevated that alternative strategies, perhaps particularly longer-term post-release supervision and aftercare, should be considered. Indications of lower crime rates in later cohorts suggest that some positive changes to the school regime and/or aftercare may have been made already. Copyright © 2017 John Wiley & Sons, Ltd.

Suicidality, self-harm and psychotic-like symptoms in a general adolescent psychiatric sample.

AIM: We investigated the associations between clinical high-risk for psychosis (CHR), psychotic-like symptoms and suicidality among adolescent psychiatric patients. METHODS: The sample consisted of 54 CHR and 107 non-CHR psychiatric patients aged 15-18 in Helsinki, Finland, who were assessed at the beginning of their psychiatric treatment with the Structured Interview for Prodromal Syndromes (SIPS). Current suicidality was measured with the Beck Depression Inventory (item 9), while lifetime suicidality was evaluated from all available data, including patient files. The participants were followed for 2.8-8.9 years via the national hospital discharge register, with the follow-up outcome being intentional self-harm. Data on suicides were also gathered from the Causes of Death statistics. RESULTS: Only 30.5% of the adolescents had no suicidal ideation at the beginning of their treatment. CHR risk state and SIPS-assessed delusions, suspiciousness, and hallucinations were associated with higher current suicidality. Of the 154 adolescents with register follow-up, there were five (3.2%) with intentional self-harm resulting in hospital treatment, all female. CHR status was not associated with self-harm. Current suicidality, familial risk of psychosis, and SIPS decreased expression of emotions were associated with self-harm during follow-up. In a Cox regression analysis model among girls, only decreased expression of emotions remained a significant predictor of intentional self-harm. Baseline suicidality measures were not associated with transitions to psychosis. CONCLUSIONS: CHR status was associated with higher current suicidality but did not predict follow-up intentional self-harm in treatment-seeking adolescents. Decreased expression of emotions may indicate higher risk of intentional self-harm in adolescent treatment-seeking girls.

Evaluation of verbal list learning as a predictor of psychosis.

AIM: We explored whether cognitive performance, and verbal learning in particular, predicts psychosis or psychiatric hospitalizations among unselected first-admission adolescent patients in general psychiatric care. METHODS: Up to 152 adolescents aged 15-18 were interviewed with the SIPS, tested with a cognitive test battery in the beginning of their psychiatric treatment, and followed for a maximum of 9 years (median 4.5 years). RESULTS: The composite factors of processing speed, verbal performance and visuospatial performance did not predict psychosis (n = 7) or all-cause psychiatric hospitalizations (n = 26) beyond psychosis risk symptoms. However, those who developed psychosis performed worse on California Verbal Learning Test (CVLT) compared to other adolescents. Lower scores of CVLT immediate recall predicted psychosis (P = .003, HR = 1.13 per CVLT point decrease). However, when general verbal ability was adjusted for, CVLT did not reach significance. CONCLUSIONS: Impaired verbal list learning may predict psychosis also among adolescent psychiatric patients not preselected for psychosis risk suspicion.

Adolescents in a residential school for behavior disorders have an elevated mortality risk in young adulthood.

BACKGROUND: Conduct problems during adolescence are associated with an elevated mortality risk. This study investigated the mortality rate, causes of death, and changes over time in a Finnish residential school (RS) population. METHODS: All adolescents (N = 885, M/F = 594/291, age mean 15.2 years at baseline) residing in the RS system in 1991, 1996, 2001, and 2006 and matched controls were included in a register-based study with a follow-up time of up to 22 years. RESULTS: The all-cause mortality rate for people with an RS background was 6.7 % compared to 1.0 % in the controls (Hazard Ratio HR = 6.95, 95 % 4.66-10.37, p < 0.001). 8.1 % of the RS boys had died compared to 2.2 % of the girls (HR = 2.2, p = 0.02). The HR for substance-related death was 24.31 (95 % CI 9.3-65.53, P < 0.001), for suicide 7.23 (95 % CI 3.24-16.11, P < 0.001) and for other external causes 5.45 (95 % CI 2.41-12.36, P < 0.001) compared to controls. Mortality peaked among RS boys at approximately 25 years, whereas for girls it peaked after 30 years. CONCLUSIONS: Adolescents with severe disruptive behavior problems have a seven-fold risk for premature adult-age death compared to matched controls. The most common causes for death were avoidable, substance-related followed by suicide. Effective treatment of mental and substance use related problems during and after the placement is needed to reduce mortality.

Predicting psychosis and psychiatric hospital care among adolescent psychiatric patients with the Prodromal Questionnaire.

The Prodromal Questionnaire (PQ) identifies psychiatric help-seekers in need of clinical interviews to diagnose psychosis risk. However, some providers use the PQ alone to identify risk. Therefore, we tested its predictive utility among 731 adolescent psychiatric help-seekers, with a 3-9-year register-based follow-up. Nine latent factors corresponded well with postulated subscales. Depersonalization predicted later hospitalization with a psychosis diagnosis (HR 1.6 per SD increase), and Role Functioning predicted any psychiatric hospitalization (HR 1.3). Published cut-off scores were poor predictors of psychosis; endorsement rates were very high for most symptoms. Therefore, we do not recommend using the PQ without second-stage clinical interviews.

Predicting psychosis in a general adolescent psychiatric sample.

INTRODUCTION: Current psychosis risk criteria have often been studied on a pre-selected population at specialized clinics. We investigated whether the Structured Interview for Prodromal Syndromes (SIPS) is a useful tool for psychosis risk screening among adolescents in general psychiatric care. METHODS: 161 adolescents aged 15-18 with first admission to adolescent psychiatric services in Helsinki were interviewed with the SIPS to ascertain Clinical High-Risk (CHR) state. The participants were followed via the national hospital discharge register, patient files, and follow-up interviews. DSM-IV Axis I diagnoses were made at baseline and 12 months. Register follow-up spanned 2.8-8.9 years, and hospital care for a primary psychotic disorder and any psychiatric disorder were used as outcomes. RESULTS: CHR criteria were met by 54 (33.5%) of the adolescents. Three conversions of psychosis as defined by SIPS emerged during follow-up, two of whom belonged to the CHR group. The positive predictive value of the CHR status was weak (1.9%) but its negative predictive value was 98.0%. Using the DSM-IV definition of psychosis, there were five conversions, three of which were in the CHR group. In regression analyses, hospital admissions for primary psychotic disorder were predicted by positive symptom intensity in the baseline SIPS. In addition, CHR status and SIPS positive and general symptoms predicted hospitalization for psychiatric disorder. DISCUSSION: Psychosis incidence was low in our unselected sample of adolescent psychiatric patients. CHR status failed to predict SIPS or DSM-IV psychoses significantly at 12 months. However, in a longer follow-up, CHR did predict psychiatric hospitalization.

Clinical high-risk state does not predict later psychosis in a delinquent adolescent population.

AIM: Adolescents with severe disruptive behaviour have an elevated risk for adult psychosis. We investigated whether the Structured Interview for Prodromal Syndromes (SIPS) is a useful psychosis risk-screening tool for adolescents with disruptive behaviour. METHOD: Fifty-three adolescents residing in a reform school due to severe behavioural problems were interviewed with SIPS to ascertain clinical high-risk (CHR) state. CHR status was compared to self-reported psychiatric problems, and to registry data on hospital treatments for mental health disorders during a 5-year follow-up time. RESULTS: CHR was associated with self-reported internalizing problems and thought problems. It failed to predict psychoses but was associated with hospital treatment for mood and conduct disorders. CONCLUSION: The SIPS interview has limited power for predicting psychosis among adolescents with severe behavioural problems. However, SIPS appears to be useful for screening and predicting other psychiatric problems.

Low verbal ability predicts later violence in adolescent boys with serious conduct problems.

BACKGROUND: Delinquent adolescents are a known high-risk group for later criminality. Cognitive deficits correlate with adult criminality, and specific cognitive deficits might predict later criminality in the high-risk adolescents. AIMS: This study aimed to explore the neuropsychological performance and predictors of adult criminal offending in adolescents with severe behavioural problems. METHODS: Fifty-three adolescents (33 boys and 20 girls), aged 15-18 years, residing in a reform school due to serious conduct problems, were examined for neuropsychological profile and psychiatric symptoms. Results were compared with a same-age general population control sample, and used for predicting criminality 5 years after the baseline testing. RESULTS: The reform school adolescents' neuropsychological performance was weak on many tasks, and especially on the verbal domain. Five years after the baseline testing, half of the reform school adolescents had obtained a criminal record. Males were overrepresented in both any criminality (75% vs. 10%) and in violent crime (50% vs. 5%). When cognitive variables, psychiatric symptoms and background factors were used as predictors for later offending, low verbal intellectual ability turned out to be the most significant predictor of a criminal record and especially a record of violent crime. CONCLUSIONS: Neurocognitive deficits, especially in the verbal and attention domains, are common among delinquent adolescents. Among males, verbal deficits are the best predictors for later criminal offending and violence. CLINICAL IMPLICATIONS: Assessing verbal abilities among adolescent population with conduct problems might prove useful as a screening method for inclusion in specific therapies for aggression management.

Prodromal psychosis screening in adolescent psychiatry clinics.

BACKGROUND: Research has identified a syndrome conferring ultra-high risk (UHR) for psychosis, although UHR interviews require intensive staff training, time and patient burden. Previously, we developed the Prodromal Questionnaire (PQ) to screen more efficiently for UHR syndromes. AIMS: This study examined the concurrent validity of the PQ against UHR status and preliminary predictive validity for later psychotic disorder. METHOD: We assessed a consecutive patient sample of 408 adolescents who presented to psychiatry clinics in Helsinki, Finland, seeking mental health treatment, including 80 participants who completed the Structured Interview for Prodromal Syndromes (SIPS). RESULTS: A cut-off score of 18 or more positive symptoms on the PQ predicted UHR diagnoses on the SIPS with 82% sensitivity and 49% specificity. Three of 14 (21%) participants with high PQ scores and SIPS UHR diagnoses developed full psychotic disorders within 1 year. CONCLUSIONS: Using the PQ and SIPS together can be an efficient two-stage screening process for prodromal psychosis in mental health clinics.

Alexithymia is common among adolescents with severe disruptive behavior.

This study aimed to examine alexithymic features and associations between alexithymia and psychiatric symptoms among adolescents living in a closed institution because of severe behavioral problems. Forty-seven adolescents (29 boys and 18 girls) aged 15 to 18 years completed the 20-item Toronto Alexithymia Scale (TAS-20) Questionnaire and the Youth Self-Report, whereas their foster parents completed the Child Behavior Checklist. The TAS-20 scores of the participants were compared with those of an extensive population sample (N = 6000) matched by age and birth year. Reform school adolescents are significantly more alexithymic than the control group, and the TAS-20 scores are correlated with numerous psychiatric problems, mainly in the internalizing spectrum, but also with thought problems and self-reported aggression. Promoting abilities in identifying and describing feelings is important when treating delinquent adolescents.

[Risk symptoms of psychosis in the young]. / Psykoosin riskioireet nuorilla.

Early intervention may postpone or even prevent the onset of psychosis and relieve symptom-related anxiety. Support and follow-up observation requires up-to-date knowledge of the nature of the risk symptoms of psychosis and of the therapy of the person having symptoms within the healthcare system. Healthcare professionals should be aware of the limitations of present research information in order to assess the correct magnitude of the risk of psychosis. Although a person assigned by current methods to the risk group presents a higher than tenfold risk compared with the rest of the population, improvement of prognostic accuracy remains as the central research issue.

The relationship between psychotic-like symptoms and neurocognitive performance in a general adolescent psychiatric sample.

INTRODUCTION: The current criteria for detecting a Clinical High-Risk (CHR) state for psychosis do not address cognitive impairment. A first step for identifying cognitive markers of psychosis risk would be to determine which aspects of neurocognitive performance are related with more severe psychotic-like symptoms. This study assessed cognitive impairment associated with prodromal symptoms in adolescents receiving public psychiatric treatment. METHODS: 189 adolescents were recruited from consecutive new patients aged 15-18 attending mainly outpatient adolescent psychiatric units in Helsinki. They had been screened for prodromal symptoms using the Prodromal Questionnaire, and all screen-positives as well as a random sample of screen-negatives were interviewed using the Structured Interview for Prodromal Symptoms (SIPS) and underwent testing using a large, standardized neurocognitive test battery. The sample included 62 adolescents who met the CHR criteria (CHR) and 112 who did not (non-CHR). A healthy control sample (n=72) was also included to provide age- and gender-matched norms. RESULTS: The CHR group performed worse on visuospatial tasks than the non-CHR group. Among CHR adolescents, negative symptoms were associated with slower processing speed and poorer performance on verbal tasks. Among non-CHR adolescents, positive symptoms were associated with poorer performance on visuospatial tasks, and negative symptoms with poorer performance on verbal tasks. CONCLUSION: Clinical high-risk status is associated with impaired visuospatial task performance. However, both positive, psychotic-like symptoms and negative symptoms are associated with lower levels of neurocognitive functioning among adolescents in psychiatric treatment regardless of whether CHR criteria are met. Thus, even mild positive and negative symptoms may have clinical relevance in adolescents in psychiatric care. Adolescents with both psychotic-like symptoms and neurocognitive deficits constitute a group requiring special attention.

Efficiency of working memory encoding in twins discordant for schizophrenia.

It has been proposed that patients with schizophrenia and some of their relatives suffer from reduced neurocognitive efficiency, increasing their sensitivity to experimental task demands. The present study evaluated such a possibility during performance of a working memory task by schizophrenia patients and their co-twins along with a healthy control sample. Electrophysiological data were obtained from sets of nine twin pairs (monozygotic and dizygotic pairs collapsed) discordant for a diagnosis of schizophrenia and from nine matched healthy control twin pairs, during administration of a variable-load spatial working memory task. Event-related potentials (ERPs) were measured immediately after memory set onset and during a delay period. For correctly performed trials, slow-wave ERP activity measured during the late stimulus encoding and delay periods exhibited a significant Diagnostic Group-by-Memory Load interaction, with schizophrenia patients showing a differentially strong load effect. Patients' co-twins displayed an intermediate level of load sensitivity while healthy controls showed no significant load effect. These results support an inefficiency model of neurocognitive dysfunction in schizophrenia, a pattern that appears to be related to the pathogenesis and inheritance of the disorder. Furthermore, this inefficiency appeared during the late stimulus encoding stage of working memory functioning, possibly reflecting disruptions in stimulus representation consolidation.

Lack of association between neuropsychological performance and level of psychosis-proneness in an adolescent psychiatric sample.

Studies of the prodromal stage of schizophrenia show that the late prepsychotic phase is associated with mild neuropsychological deficits that parallel those of schizophrenia. However, it is still unclear whether this association is present across the whole range of symptoms of psychosis-proneness, or specific to the extreme groups. In this study, the linear associations between dimensions of psychosis-proneness (as measured by the 92-item Prodromal Questionnaire) and performance on 20 neuropsychological measures were assessed in a group of 71 nonpsychotic adolescent psychiatric patients. A structure of positive, negative and disorganized prodromal symptom dimensions was found, replicating earlier findings. No symptom dimension was significantly associated with neuropsychological performance, even when corrected for nonspecific psychological distress. These findings suggest that the association between symptoms and neuropsychological performance is specific to high levels of symptoms or to the truly prodromal subpopulation. The results also highlight the importance of simultaneous assessment of affective state.

Abnormally high EEG alpha synchrony during working memory maintenance in twins discordant for schizophrenia.

BACKGROUND: The present analyses aimed to test the prediction that schizophrenia patients and their non-schizophrenic co-twins would display reduced efficiency of the neurocognitive mechanisms subserving active maintenance of spatial information in working memory. METHODS: Upper alpha frequency band EEG event-related desynchronization and synchronization (ERD/ERS) were calculated as percent changes in power relative to an inter-trial baseline across 4 memory loads in a spatial delayed-response task. RESULTS: During the delay, the diagnostic groups showed equivalent ERD/ERS activity over posterior scalp regions at the lowest memory load; however, as memory load increased, patients, and to an intermediate degree, their non-schizophrenic co-twins (monozygotic and dizygotic pairs collapsed together), showed significantly greater increases in ERD/ERS amplitude as compared with controls. CONCLUSIONS: These findings demonstrate abnormally increased ERD/ERS amplitudes with increasing memory load in patients with schizophrenia and their co-twins, consistent with inefficiency of the neurocognitive mechanisms supporting active maintenance of information across a delay.

The relationship between performance and fMRI signal during working memory in patients with schizophrenia, unaffected co-twins, and control subjects.

While behavioral research shows working memory impairments in schizophrenics and their relatives, functional neuroimaging studies of patients and healthy controls show conflicting findings of hypo- and hyperactivation, possibly indicating different relationships between physiological activity and performance. In a between-subjects regression analysis of fMRI activation and performance, low performance was associated with relatively lower activation in patients than controls, while higher performance was associated with higher activation in patients than controls in DLPFC and parietal cortex, but not occipital cortex, with unaffected twins of schizophrenics being intermediate between the groups. Accordingly, this supports the idea that both hyper and hypoactivation may be possible along a continuum of behavioral performance in a way consistent with a neural inefficiency model. Further, this study offers preliminary evidence that the relationship between behavior and physiology in schizophrenia may be heritable.

Inherited auditory-cortical dysfunction in twin pairs discordant for schizophrenia.

BACKGROUND: Information on the inheritance of neurophysiological abnormalities might help elucidate the molecular genetic basis of schizophrenia. We used magnetoencephalography (MEG) and electroencephalography (EEG) to investigate the inheritance of auditory-cortical deficiencies in twin pairs discordant for schizophrenia. METHODS: Auditory EEG/MEG responses to frequent standard and occasional deviant tones were measured in mono- and dizygotic (MZ and DZ) twin pairs discordant for schizophrenia and demographically matched healthy twin pairs, recruited from a total population cohort. The MEG/EEG results were regressed against the genetic resemblance to patients with schizophrenia across the patients' unaffected MZ/DZ co-twins and control subjects (with genetic correlations of 1, .5, and 0 to schizophrenia patients, respectively). RESULTS: The EEG responses P50, N100, and mismatch negativity (MMN), as well as the MEG response P50m, were reduced in the schizophrenic patients. P50 and N100 were significantly decreased also in their unaffected co-twins, as compared with the control subjects. Importantly, the P50 and N100 decrease correlated with the unaffected subjects' genetic resemblance to schizophrenia patients. CONCLUSIONS: Our results suggest inherited abnormalities in cortical auditory processing in schizophrenia, reflected by the decreased P50/P50m and N100 amplitudes, whereas the MMN abnormalities might reflect predominantly state-dependent neurodegeneration.

Spatial working memory as an endophenotype for schizophrenia.

BACKGROUND: Spatial working memory impairments are among the neurocognitive deficits that may mark genetic predisposition toward schizophrenia. We previously reported that impairment on the spatial span subtask of the Wechsler Adult Intelligence Scale-Revised increased in a dose-dependent manner with increasing genetic predisposition toward schizophrenia in a sample of discordant twins; however, it remains to be determined whether these deficits reflect difficulties with encoding, maintenance, manipulation, time-tagging of visual spatial information, storage capacity, or complex motor response. METHODS: We developed a spatial delayed response task in which memory set size was parametrically varied, holding constant manipulation and decision processes. We then reassessed 80 of the previously studied twins (17 probands with 8 monozygotic co-twins and 13 dizygotic co-twins, and 42 healthy twins). RESULTS: The spatial delayed response task was sensitive to genetic loading for schizophrenia but did not provide evidence for capacity limitations in probands or their co-twins. CONCLUSIONS: The findings suggest that deficits in the encoding or storage aspects of short-term spatial mnemonic processing may be an effective endophenotypic marker for schizophrenia.