The significance of at-risk symptoms for psychosis in children and adolescents.

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

Pharmacological prevention and treatment in clinical at-risk states for psychosis.

Over the last couple of decades, the treatment of psychoses has much advanced; yet, despite all progress, the individual and societal burden associated with psychosis and particularly schizophrenia has largely remained unchanged. Therefore, much hope is currently placed on indicated prevention as a mean to fight these burdens before they set in. Though the number of studies investigating pharmacological interventions is still limited, encouraging results have been reported from the pioneering trials, despite several methodological limitations. Furthermore, it has become clear that persons characterized by the at-risk criteria are already ill and do not only need preventive intervention, but also treatment. In consequence, outcome criteria have to be broadened to cover the current needs of the patients. As is indicated by a recent study successfully using Omega-3 fatty acids for both purposes, it may be promising to develop and investigate interventions especially for the at-risk state, independent of their effectiveness in manifest disease states. Treatment studies may become promoted by the proposed introduction of a new disorder category into DSM-V. Future prevention studies, however, need to solve the challenge of changing immediate transition rates, demanding for new risk enrichment strategies as a prerequisite for feasible trial designs.

Basic symptoms in the general population and in psychotic and non-psychotic psychiatric adolescents.

OBJECTIVE: Cognitive-perceptive 'basic symptoms' are used complementary to ultra-high-risk criteria in order to predict onset of psychosis in the pre-psychotic phase. The aim was to investigate the prevalence of a broad selection of 'basic symptoms' in a representative general adolescent population sample (GPS; N=96) and to compare it with adolescents first admitted for early onset psychosis (EOP; N=87) or non-psychotic psychiatric disorders (NP; N=137). METHODS: Subjects were assessed with the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Prevalence of at least one 'basic symptom' and mean numbers were compared across the three groups. Logistic regression was used to predict group membership by BSABS subscales; risk ratios were calculated to identify 'basic symptoms' which best discriminated between groups. RESULTS: The prevalence of at least any one 'basic symptom' was 30.2% in GPS compared to 81% in NP and 96.5% in EOP. Correct classification of EOP when compared to GPS was high (94.0%) and lower when compared to NP (78.6%). Cognitive symptoms discriminated best between EOP and NP. CONCLUSION: Alike other prodromal- and psychotic-like experiences, 'basic symptoms' are prevalent in the general adolescent population, yet at a lower rate compared to EOP and NP. The usage of 'at least one basic symptom' as a screening criterion for youth at risk of developing a psychotic disorder is not recommended in the general population or in unselected psychiatrically ill adolescents. However, particularly cognitive 'basic symptoms' may be a valuable criteria to be included in future 'at risk' studies in adolescents.

Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis.

OBJECTIVES: Studies investigating suicidal behaviour in psychosis rarely focus on incidence cohorts of first-episode patients. This is important, because patients who refuse study participation have higher rates of comorbid substance use disorders and longer duration of untreated psychosis as well as worse course illness, variables potentially linked to higher prevalence of suicidal behaviour. The aims of the present study were therefore to examine the prevalence and predictors of suicide and suicide attempt before and during the first 18-24 months of treatment. METHOD: A retrospective file audit of 661 patients was carried out. RESULTS: Six patients (0.9%) died by suicide, 93 (14.3%) attempted suicide prior to entry, and 57 (8.7%) did so during treatment. Predictors of suicide attempt were: previous attempt (odds ratio (OR)=45.54, 95% confidence interval (CI)=9.46-219.15), sexual abuse (OR=8.46, 95%CI=1.88-38.03), comorbid polysubstance (OR=13.63, 95%CI=2.58-71.99), greater insight (OR=0.17, 95%CI=0.06-0.49), lower baseline Global Assessment of Functioning Scale and Scale of Occupational and Functional Assessment score (OR=0.96, 95%CI=0.62-0.91; OR=0.98, 95%CI=0.95-0.99), and longer time in treatment (OR=1.05, 95%CI=1.03-1.08). CONCLUSIONS: The prevalence of suicidal behaviour was high, indicating that suicidal behaviour in incidence populations is higher than in non-epidemiological cohorts of first-episode patients. The rate of repetition of suicide attempt among the sample, however, was lower than expected, suggesting that specialist services can play a role in reducing suicide risk.

Associations among the perceived parent-child relationship, eating behavior, and body weight in preadolescents: results from a community-based sample.

OBJECTIVE: Data on associations between the parent-child relationship, eating behavior, and body weight in a community-based sample of preadolescent children are presented. The aim of our study was to replicate the finding from clinical samples that families of overweight children demonstrate adverse characteristics of the parent-child relationship. METHODS: A community-based sample of 373 fourth-grade students was given self-report questionnaires on the perceived parent-child relationship and on eating behavior, and each child's height and weight was measured. RESULTS: No meaningful associations between children's body weight and the parent-child relationship were apparent. Deviant eating behavior was strongly linked to an adverse parent-child relationship irrespective of children's body weight. CONCLUSIONS: It is suggested that previous findings from clinical samples of overweight children cannot simply be generalized to the population of overweight children and that deviant eating behavior, not overweight itself, is linked to an adverse parent-child relationship in preadolescent children.

[The parent-child relationship inventory for children: background and first results]. / Der Fragebogen zur Eltern-Kind-Beziehung für Kinder: Grundlagen und erste Ergebnisse.

A questionnaire on representations of the parent-child relationship in preadolescent children is presented. At present, no standardised measure is available for this age group which assesses economically but still differentiated how younger children perceive the relationship with their parents. The original version of the Parent-Child Relationship Inventory for Children (PI-C, in German: FEB-K) was given to a sample of 371 fourth-grade students of different elementary schools in Hamburg. Factor- and item analysis led to a 22-item questionnaire with the dimensions Care, Control, Lack of Limitations, Confidence, and Conflict/Rejection. A total of 53.8 % of variance is explained by the 5-factor solution. Based on these factors, distinct groups of the perceived parent-child relationship emerged in cluster analysis which were associated with children's eating behaviour. The PI-C is proposed for research on the parent-child relationship in clinical as well as non-clinical samples and for the use as diagnostic instrument in clinical practice.

A prospective 12-week study of quetiapine in adolescents with schizophrenia spectrum disorders.

OBJECTIVE: The aim of this study was to investigate the effectiveness, tolerability, and safety of quetiapine in adolescents with schizophrenia, schizophreniform, and schizoaffective disorders in a prospective open-label study. METHOD: A total of 56 subjects (all-subjects-treated, AST), ages 12-17, received 200-800 mg of quetiapine per day (forced titration to 400 mg within week 1; median study dose 600 mg/day at week 6) in Germany, 2002 through 2004. Primary outcome measure was the change of Positive and Negative Syndrome Scale (PANSS) total score (based on the intent-to-treat (ITT) population, n = 52), secondary outcome measures were changes of PANSS subscales, severity of illness, subjective wellbeing, and safety/tolerability (the latter based on the AST population). Correlates of PANSS response (=50% reduction in PANSS total score) and discontinuation due to lack of effectiveness were analyzed by Cox regression analyses. RESULTS: Twenty-seven subjects (48%) completed the study; 17 subjects (30%) were discontinued due to lack of effectiveness. A significant reduction of PANSS total score (last observation carried forward, LOCF; p < 0.0001; effect size = 0.92) and of secondary effectiveness outcomes were detected. In all, 34.6% fulfilled the PANSS response criterion, correlated with the degree of PANSS total change within week 1. Somnolence (21.4%) and fatigue (17.9%) were the most frequent adverse events. A significant mean weight gain (6.2 kg) and mean decrease in total serum thyroxine (2.5 ng/dl) were detected. CONCLUSIONS: In this sample of mostly drug-naïve patients with early-onset schizophrenia spectrum disorders, significant reductions in PANSS total and positive scores were detected. Controlled studies are needed to confirm these findings. The significant weight gain with its potentially severe medical consequences must be weighed against quetiapine's effectiveness.

[Genetic findings in Attention-Deficit and Hyperactivity Disorder (ADHD)]. / Genetische Befunde bei der Aufmerksamkeitsdefizit- und Hyperaktivitätsstörung (ADHS).

Attention-Deficit and Hyperactivity Disorder (ADHD) is a common child and adolescent psychiatric disorder with a prevalence rate of 3-7%. Formal genetic studies provided an estimated heritability of 0.6-0.8 and an approximately five-fold elevated risk for ADHD in first-degree relatives. Currently, four genome scans have led to the identification of chromosomal regions potentially relevant in ADHD; especially the evidence for linkage to chromosome 5p13 is convincing. Meta-analyses of a large number of candidate gene studies suggest association with gene variants of the dopaminergic receptors DRD4 and DRD5, the serotonergic receptor HTR1B, and the synaptosomal receptor protein (SNAP-25). Hyperactivity has been investigated particularly in animal models, focusing on knockout- and quantitative trait loci (QTL) designs, with promising results for the dopaminergic system. It is likely that several gene polymorphisms with moderate to small effect sizes contribute to the phenotype ADHD; different combinations of such predisposing variants presumably underlie ADHD in different individuals. Therefore, large samples for molecular genetic studies are mandatory to detect these polymorphisms. Accordingly, several of today's findings have to be regarded as preliminary. The understanding of ADHD's neurobiology may be advanced by new technologies, such as SNP-based genome scans performed with gene chips comprising 10,000-1,000,000 SNPs, as well as using more sophisticated animal model designs.

Eating Pattern Inventory for Children: a new self-rating questionnaire for preadolescents.

A questionnaire on psychological dimensions of eating behavior in children is presented. Existing questionnaires for children specifically focus on symptoms of eating disorders only, whereas for adults, questionnaires assessing general psychological dimensions of eating behavior are also available. The development of the Eating Pattern Inventory for Children (EPI-C) was based on a sample of 373 fourth-grade students. Factor and item analysis led to a psychometrically sound 20-item questionnaire with the dimensions dietary restraint, external eating, parental pressure to eat, and emotional eating. These factors explain 62% of the total item variance. Subscale scores and emerging eating patterns were associated with children's body weight suggesting initial evidence of its validity. The EPI-C is proposed for research on eating behavior in clinical and non-clinical preadolescent samples.

Predictors of service disengagement in first-admitted adolescents with psychosis.

OBJECTIVE: To assess the risk and predictors of service disengagement in adolescents with first-episode psychosis (FEP) receiving their first treatment in a long-standing early intervention and prevention centre. METHOD: The Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia admitted 157 adolescents, ages 15 to 18, with FEP from January 1998 to December 2000. Treatment at EPPIC spans an average of 18-months. Data were collected from patients' charts using a standardized questionnaire; 134 charts were available. Time to service disengagement was the outcome of interest. Baseline and treatment predictors of service disengagement were examined via Cox proportional hazards model. RESULTS: Kaplan-Meier 18-month risk of service disengagement was 0.28. A lower severity of illness at baseline (hazard ratio [HR] = 0.2; 95% confidence interval [CI] 0.1-0.4), living without family during treatment (HR = 4.8; 95% CI 2.1-11.2), and persistent substance use during treatment (HR = 2.6; 95% CI 1.1-5.9) contributed significantly to predicting service disengagement. Neither initial substance use nor insight at baseline was related to service disengagement. CONCLUSIONS: Clinicians should focus on treating substance use and establishing a social network if family support is missing in adolescents with FEP. In addition, clinicians should apply strategies to keep in touch with those adolescents who might not see the necessity of continuous treatment because of a moderate severity of illness.

Subjective distress related to side effects and subjective well-being in first admitted adolescents with early-onset psychosis treated with atypical antipsychotics.

OBJECTIVE: Side effects (SE) of antipsychotics are considered a major source of subjective discomfort. The aim of this pilot study was to evaluate the subjective distress-related to different SE and its association with subjective well-being in a sample of adolescents treated with atypical antipsychotics. METHODS: Subjects enrolled were first hospitalized adolescent inpatients with diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) schizophrenia, schizophreniform, or schizoaffective disorder. Subjects' Clinical Global Impression-Severity (CGI-S) and subjective well-being (SWN-K, BfS) were evaluated at baseline, week 2, and week 6. Side effects (UKU) and subjective distress under SE (Subjective Distress Scale, SDS) were evaluated at weeks 2 and 6. RESULTS: Twenty adolescents were included. Almost all subjects suffered from at least one distressing SE at both follow-up time points. The mean number of distressing SE decreased from weeks 2 to 6. The most prevalent distressing SE were psychic SE and weight gain. There was an association between distress related to psychic and neurological SE and negative subjective wellbeing (r = 0.60-0.70). Subjective distress with these SE, especially neurological SE at both time points and sedation-increased sleep at week 6, did not correspond to clinician's severity ratings. CONCLUSIONS: Clinicians may overlook distress by only judging the severity of SE objectively in the treatment with atypical antipsychotics, leading to negative subjective well-being and a high rate of nonadherence to treatment. Therefore, it is recommended to discuss the severity of, and distress with, SE independently with patients. Future studies should focus on distress related to neurological SE, sedation, and weight gain.

Olanzapine in subjects with a first-episode psychosis non-responsive, intolerant or non-compliant to a first-line trial of risperidone.

Objective. Investigation of the efficacy and tolerability of olanzapine (OLZ) as second-line treatment in subjects with a first-episode psychosis (FEP) who had been non-responsive, intolerant or non-compliant to Risperidone (RIS). Methods. The Early Psychosis Prevention and Intervention Centre in Melbourne admitted 786 FEP subjects between 1998 and 2000. Data were collected from subjects' medical records (MR). The objective was to evaluate the efficacy of OLZ as measured by CGI-S, GAF, SOFAS and remission rates as well as tolerability. Results. A total of 104 subjects were switched because of non-response (38%), non-compliance (15%), or intolerance (47%). Independent of reasons for switch, significant symptomatic and functional improvements were detected. Overall, 46 subjects (44%) achieved full remission. Regression analysis indicated that reason for switch did not predict full remission. Significantly more extrapyramidal side effects (P<0.001) were related to previous RIS and significantly more weight gain to the subsequent OLZ treatment (P<0.001). Conclusions. OLZ may be an effective alternative for FEP patients who are non-responsive, intolerant or non-compliant to RIS. The decision to switch to OLZ must be weighted against the greater risk of weight gain with its risks for medical complications and its psychosocial consequences.

Huntington disease: a case study of early onset presenting as depression.

Huntington disease is a dominantly inherited, neurodegenerative disease characterized by choreiform movement disturbances and dementia, usually with adult onset. The rare juvenile-onset Huntington disease differs from the adult phenotype. A case presenting twice, at age 10 with all the signs of a major depression and age 14 with mutism and rigidity, is reported. Meanwhile, the father developed the adult variant of Huntington disease. The boy's diagnosis was confirmed by molecular genetic analysis and magnetic resonance imaging. It is important to be aware of hereditary conditions such as Huntington disease and to provide family counseling before genetic testing and after the diagnosis is confirmed.

[Questionnaire on parental attitudes and rearing practices (FEPS)]. / Fragebogen zu Erziehungseinstellungen und Erziehungspraktiken (FEPS). Eine erweiterte Version des Parental Bonding Instruments (PBI).

A positive parent-child relationship is one of the most important determinants of a healthy cognitive, emotional and social development. The relationship from parent to child is determined by parenting styles. Parenting styles are characterised by the two dimensions parental attitudes and rearing practices. The development and the psychometric properties of a questionnaire on parental attitudes and rearing practices (FEPS), which contains an extended version of the Parental Bonding Instrument by Parker et al. (PBI, 1979) and two scales on parental reinforcement and punishment behaviour, is presented. In a sample of 457 women and 159 men factorial and item analysis revealed four scales (care, autonomy, low punishment and low material reinforcement). The care dimension contained items of immaterial reinforcement on the positive pole and items of coldness and ignorance as means of punishment on the negative pole. Based on findings from its first application in a clinical study it can be assumed that the FEPS differentiates between clinical and non-clinical populations. Additionally, varying patterns of the four scales may emerge as risk factors for the development of certain psychiatric/psychological problems.