The association of developmental trajectories of adolescent mental health with early-adult functioning.

BACKGROUND: Mental health problems during adolescence may create a problematic start into adulthood for affected individuals. Usually, categorical indicators of adolescent mental health issues (yes/no psychiatric disorder) are used in studies into long-term functional outcomes. This however does not take into account the full spectrum of mental health, nor does it consider the trajectory of mental health problem development over time. The aim of this study was twofold: (1) to identify distinct developmental trajectories of (co-occurring) internalizing and externalizing mental health symptoms over the course of adolescence (ages 11-19), and (2) to document the associations between these adolescent trajectories and economic, social, and health outcomes in young adulthood (age 22), unadjusted and adjusted for childhood functioning, putative confounders and current mental health. METHODS: Data were used from the Dutch TRAILS cohort study (subsample n = 1524, 47.3% males). Self-reported INT and EXT symptoms using the Youth/Adult Self Report were assessed four times (ages 11y, 13y, 16y, 19y). Adolescent mental health trajectories were estimated using Parallel-Processes Latent Class Growth Analyses. Self-reported economic, social, and health outcomes and parent-reported current mental health (using Adult Behaviour Checklist) were assessed at age 22. Multiple logistic regression analyses were performed to test associations between trajectories and outcomes. RESULTS: Four distinct trajectory classes were identified: (1) a normative class with decreasing-low INT+EXT symptoms (n = 460), (2) continuous moderately-high INT+EXT (n = 298), (3) continuous moderate, INT>EXT (n = 414), and (4) decreasing moderate, EXT>INT (n = 352). Compared to the normative class, the other three trajectories generally predicted less optimal early-adult outcomes, with the strongest effects observed for individuals with continuous moderate-high levels of both INT and EXT symptoms throughout adolescence. The associations largely remained after adjustment for pre-adolescent functioning, selected confounders and current mental health. CONCLUSIONS: Both adolescent trajectories and current mental health had substantial independent effects on early-adult functioning.

Predicting Initial Specialist Mental Health Care Use in Adolescence Using Self-, Parent-, and Teacher-Reported Problem Behavior: A Prospective Community-Based Record-Linkage Study.

OBJECTIVE: The aim of this study was to determine the relative importance of self-, parent-, and teacher-reported problem behavior for initial specialist mental health care use in adolescence and the extent to which the relative importance of each informant changes over time. METHODS: Data from the Dutch community-based cohort study TRacking Adolescents' Individual Lives Survey (TRAILS) were linked to administrative records of specialist mental health care organizations. Self-, parent-, and teacher-reported internalizing and externalizing problems were assessed at ages 11, 13, and 16 years, with self-reported problems also assessed at age 19 years. The study included 1,478 adolescents, of whom 19.8% had administrative records between January 2000 (age 9 years) and December 2011 (age 21 years). RESULTS: After effects of internalizing and externalizing problems were adjusted for each other and for sociodemographic correlates, internalizing problems, but not externalizing problems, predicted initial specialist mental health care use. Teacher reports mainly predicted initial specialist care between the ages of 11 and 13 years (hazard ratio [HR] = 1.57; 95% confidence interval [CI], 1.22-2.02; P < .001), parent reports mainly predicted initial specialist care between the ages of 13 and 16 years (HR = 1.47; 95% CI, = 1.13-1.91; P = .004), and self-reports mainly predicted initial specialist care between the ages of 16 and 19 years (HR = 1.61; 95% CI, = 1.25-2.08; P < .001) and between the ages 19 and 21 years (HR = 1.50; 95% CI, 1.10-2.05; P = .011). CONCLUSIONS: Teachers, parents, and adolescents are the driving force behind initial specialist care at consecutive phases in adolescence. Future research should assess whether improving the problem recognition of teachers in secondary education and educating young adults about mental health problems are effective ways of reducing the treatment gap.

The predictive value of childhood subthreshold manic symptoms for adolescent and adult psychiatric outcomes.

BACKGROUND: Childhood subthreshold manic symptoms may represent a state of developmental vulnerability to Bipolar Disorder (BD) and may also be associated with other adverse psychiatric outcomes. To test this hypothesis we examined the structure and predictive value of childhood subthreshold manic symptoms for common psychiatric disorders presenting by early adulthood. METHODS: Subthreshold manic symptoms at age 11 years and lifetime clinical outcomes by age 19 years were ascertained in the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective Dutch community cohort. We used latent class analysis to identify subthreshold manic symptom profiles at baseline. The association between class membership and subsequent clinical diagnoses of BD (comprising BD-I, BD-II, mania and hypomania), depressive, anxiety and substance abuse disorders was determined using Cox proportional-hazard ratio (HR) models. RESULTS: At age 11 years, we identified a normative (n=916; 47%), a mildly symptomatic (n=843; 43%) and a highly symptomatic class (n=198; 10%). Referenced to the normative class, the sex- and age-adjusted risk of new-onset BD by the age of 19 years was significantly increased in the mildly (HR=2.01, 95%CI 1.13-3.59) and highly symptomatic classes (HR=5.02, 95%CI 2.48-10.16). These estimates remained significant after further adjustments for cognitive and family function, parental socioeconomic status, parental psychiatric morbidity, and comorbid disorders at baseline (p-value for linear trend across classes<0.01). Class membership did not show significant associations with incident depressive, anxiety and substance abuse disorders in the fully adjusted regression models. LIMITATIONS: The period of risk for adult-onset BD extends beyond the observational period of the study. CONCLUSIONS: Elevated childhood subthreshold manic symptoms are associated with increased risk of BD by early adulthood and are therefore a potentially useful phenotype for the early identification of at-risk individuals.

Cohort Profile Update: the TRacking Adolescents' Individual Lives Survey (TRAILS).

TRAILS consists of a population cohort (N=2230) and a clinical cohort (N=543), both of which were followed from about age 11 years onwards. To date, the population cohort has been assessed five times over a period of 11 years, with retention rates ranging between 80% and 96%. The clinical cohort has been assessed four times over a period of 8 years, with retention rates ranging between 77% and 85%. Since the IJE published a cohort profile on the TRAILS in 2008, the participants have matured from adolescents into young adults. The focus shifted from parents and school to entry into the labour market and family formation, including offspring. Furthermore, psychiatric diagnostic interviews were administered, the database was linked to a Psychiatric Case Registry, and the availability of genome-wide SNP variations opened the door to genome-wide association studies regarding a wide range of (endo)phenotypes. With some delay, TRAILS data are available to researchers outside the TRAILS consortium without costs; access can be obtained by submitting a publication proposal (see www.trails.nl).

The TRacking Adolescents' Individual Lives Survey (TRAILS): design, current status, and selected findings.

OBJECTIVES: The objectives of this study were as follows: to present a concise overview of the sample, outcomes, determinants, non-response and attrition of the ongoing TRacking Adolescents' Individual Lives Survey (TRAILS), which started in 2001; to summarize a selection of recent findings on continuity, discontinuity, risk, and protective factors of mental health problems; and to document the development of psychopathology during adolescence, focusing on whether the increase of problem behavior often seen in adolescence is a general phenomenon or more prevalent in vulnerable teens, thereby giving rise to diverging developmental pathways. METHOD: The first and second objectives were achieved using descriptive statistics and selective review of previous TRAILS publications; and the third objective by analyzing longitudinal data on internalizing and externalizing problems using Linear Mixed Models (LMM). RESULTS: The LMM analyses supported the notion of diverging pathways for rule-breaking behaviors but not for anxiety, depression, or aggression. Overall, rule-breaking (in both genders) and withdrawn/depressed behavior (in girls) increased, whereas aggression and anxious/depressed behavior decreased during adolescence. CONCLUSIONS: TRAILS has produced a wealth of data and has contributed substantially to our understanding of mental health problems and social development during adolescence. Future waves will expand this database into adulthood. The typical development of problem behaviors in adolescence differs considerably across both problem dimensions and gender. Developmental pathways during adolescence suggest accumulation of risk (i.e., diverging pathways) for rule-breaking behavior. However, those of anxiety, depression and aggression slightly converge, suggesting the influence of counter-forces and changes in risk unrelated to initial problem levels and underlying vulnerability.

Benefits of extensive recruitment effort persist during follow-ups and are consistent across age group and survey method. The TRAILS study.

BACKGROUND: Extensive recruitment effort at baseline increases representativeness of study populations by decreasing non-response and associated bias. First, it is not known to what extent increased attrition occurs during subsequent measurement waves among subjects who were hard-to-recruit at baseline and what characteristics the hard-to-recruit dropouts have compared to the hard-to-recruit retainers. Second, it is unknown whether characteristics of hard-to-recruit responders in a prospective population based cohort study are similar across age group and survey method. METHODS: First, we compared first wave (T1) easy-to-recruit with hard-to-recruit responders of the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective population based cohort study of Dutch (pre)adolescents (at first wave: n = 2230, mean age = 11.09 (SD 0.56), 50.8% girls), with regard to response rates at subsequent measurement waves. Second, easy-to-recruit and hard-to-recruit participants at the fourth TRAILS measurement wave (n = 1881, mean age = 19.1 (SD 0.60), 52.3% girls) were compared with fourth wave non-responders and earlier stage drop-outs on family composition, socioeconomic position (SEP), intelligence (IQ), education, sociometric status, substance use, and psychopathology. RESULTS: First, over 60% of the hard-to-recruit responders at the first wave were retained in the sample eight years later at the fourth measurement wave. Hard-to-recruit dropouts did not differ from hard-to-recruit retainers. Second, extensive recruitment efforts for the web based survey convinced a population of nineteen year olds with similar characteristics as the hard-to-recruit eleven year olds that were persuaded to participate in a school-based survey. Some characteristics associated with being hard-to-recruit (as compared to being easy-to-recruit) were more pronounced among non-responders, resembling the baseline situation (De Winter et al.2005). CONCLUSIONS: First, extensive recruitment effort at the first assessment wave of a prospective population based cohort study has long lasting positive effects. Second, characteristics of hard-to-recruit responders are largely consistent across age groups and survey methods.