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.

Heart rate variability as candidate endophenotype of social anxiety: A two-generation family study.

BACKGROUND: Social anxiety disorder (SAD) is the extreme fear and avoidance of one or more social situations. The goal of the current study was to investigate whether heart rate variability (HRV) during resting state and a social performance task (SPT) is a candidate endophenotype of SAD. METHODS: In this two-generation family study, patients with SAD with their partner and children, and their siblings with partner and children took part in a SPT (total n = 121, 9 families, 3-30 persons per family, age range: 8-61 years, 17 patients with SAD). In this task, participants had to watch and evaluate the speech of a female peer, and had to give a similar speech. HRV was measured during two resting state phases, and during anticipation, speech and recovery phases of the SPT. We tested two criteria for endophenotypes: co-segregation with SAD within families and heritability. RESULTS: HRV did not co-segregate with SAD within families. Root mean square of successive differences during the first resting phase and recovery, and high frequency power during all phases of the task were heritable. LIMITATIONS: It should be noted that few participants were diagnosed with SAD. Results during the speech should be interpreted with caution, because the duration was short and there was a lot of movement. CONCLUSIONS: HRV during resting state and the SPT is a possible endophenotype, but not of SAD. As other studies have shown that HRV is related to different internalizing disorders, HRV might reflect a transdiagnostic genetic vulnerability for internalizing disorders. Future research should investigate which factors influence the development of psychopathology in persons with decreased HRV.

Why don't you like me? Midfrontal theta power in response to unexpected peer rejection feedback.

Social connectedness theory posits that the brain processes social rejection as a threat to survival. Recent electrophysiological evidence suggests that midfrontal theta (4-8Hz) oscillations in the EEG provide a window on the processing of social rejection. Here we examined midfrontal theta dynamics (power and inter-trial phase synchrony) during the processing of social evaluative feedback. We employed the Social Judgment paradigm in which 56 undergraduate women (mean age=19.67 years) were asked to communicate their expectancies about being liked vs. disliked by unknown peers. Expectancies were followed by feedback indicating social acceptance vs. rejection. Results revealed a significant increase in EEG theta power to unexpected social rejection feedback. This EEG theta response could be source-localized to brain regions typically reported during activation of the saliency network (i.e., dorsal anterior cingulate cortex, insula, inferior frontal gyrus, frontal pole, and the supplementary motor area). Theta phase dynamics mimicked the behavior of the time-domain averaged feedback-related negativity (FRN) by showing stronger phase synchrony for feedback that was unexpected vs. expected. Theta phase, however, differed from the FRN by also displaying stronger phase synchrony in response to rejection vs. acceptance feedback. Together, this study highlights distinct roles for midfrontal theta power and phase synchrony in response to social evaluative feedback. Our findings contribute to the literature by showing that midfrontal theta oscillatory power is sensitive to social rejection but only when peer rejection is unexpected, and this theta response is governed by a widely distributed neural network implicated in saliency detection and conflict monitoring.

Putative EEG measures of social anxiety: Comparing frontal alpha asymmetry and delta-beta cross-frequency correlation.

The goal of the present study was to examine whether frontal alpha asymmetry and delta-beta cross-frequency correlation during resting state, anticipation, and recovery are electroencephalographic (EEG) measures of social anxiety. For the first time, we jointly examined frontal alpha asymmetry and delta-beta correlation during resting state and during a social performance task in high (HSA) versus low (LSA) socially anxious females. Participants performed a social performance task in which they first watched and evaluated a video of a peer, and then prepared their own speech. They believed that their speech would be videotaped and evaluated by a peer. We found that HSA participants showed significant negative delta-beta correlation as compared to LSA participants during both anticipation of and recovery from the stressful social situation. This negative delta-beta correlation might reflect increased activity in subcortical brain regions and decreased activity in cortical brain regions. As we hypothesized, no group differences in delta-beta correlation were found during the resting state. This could indicate that a certain level of stress is needed to find EEG measures of social anxiety. As for frontal alpha asymmetry, we did not find any group differences. The present frontal alpha asymmetry results are discussed in relation to the evident inconsistencies in the frontal alpha asymmetry literature. Together, our results suggest that delta-beta correlation is a putative EEG measure of social anxiety.

Trajectories of social anxiety during adolescence and relations with cognition, social competence, and temperament.

This cohort-sequential study examined developmental trajectories of social anxiety in a nonclinical sample (N = 331, 161 girls) aged 9 to 17 years at initial and 12 to 21 years at final assessment. We tested whether variables assessing cognition, social competence, and temperament discriminated between the trajectories. Variables were collected from different sources: participants, independent observers, parents, and teachers. Using Latent Class Growth Modeling (LCGM) we identified three distinct social anxiety trajectory groups: i) high and changing; ii) moderate and decreasing; and iii) low and decreasing. Multinomial regression analyses showed that the cognition variables, negative interpretations of ambiguous social situations and self-focused attention, differentiated between all three trajectories. A lack of social skills and having social problems at school were specifically related to the chance of following the high trajectory versus the moderate trajectory. Neuroticism differentiated between the low and moderate trajectories. Findings indicate that adolescents at risk of belonging to a high social anxiety trajectory can be discriminated from peers belonging to a less anxious trajectory using both cognition and social competence variables.

Children's sense of coherence and trait emotional intelligence: a longitudinal study exploring the development of somatic complaints.

The objective of this study was to investigate the prospective relationships between sense of coherence, trait emotional intelligence and children's somatic complaints. The study included four waves of data collection with six months in between each wave. Participants were 324 girls and 393 boys (mean age = 10 years and 3 months, SD = 8.5 months) at the first time of data collection. The children filled out self-report questionnaires concerning their somatic complaints, sense of coherence and trait emotional intelligence. Multilevel model analyses were carried out that included cross-sectional and longitudinal effects of sense of coherence and trait emotional intelligence on children's somatic complaints. The results showed that higher levels of trait emotional intelligence and a stronger sense of coherence were associated with fewer somatic complaints in children. These relationships seemed to be bidirectional.

Age and puberty differences in stress responses during a public speaking task: do adolescents grow more sensitive to social evaluation?

During adolescence pubertal development is said to lead to an increase in general stress sensitivity which might create a vulnerability for the emergence of psychopathology during this period. However, the empirical evidence for increasing stress sensitivity is scarce and mixed. Biological responses (salivary cortisol and alpha-amylase) were investigated during a social-evaluative stressor, the Leiden Public Speaking Task, in 295 nine to 17-year olds. Specific attention was paid to different elements of the task, that is anticipation to and delivery of the speech. Biological reactivity to the speech task increased with age and puberty, particularly during anticipation. Current findings support the idea that biological stress sensitivity increases during adolescence, at least in response to a social-evaluative situation. The increasing stress sensitivity appears related to both age and pubertal maturation, but unique contribution could not be distinguished. The importance of measuring anticipation is discussed.

Social fears during adolescence: is there an increase in distress and avoidance?

Mid-adolescence is considered as the time of onset for social phobia and is assumed to be related to a normative increase of social fears. People diagnosed with social phobia, however, do not only experience high levels of fear or distress, but also report avoidance behavior. Little attention has been paid to the development of avoidance behavior during adolescence. In the current study, a community sample with 9-17 year olds (n=260) completed a questionnaire derived from the Anxiety Disorders Interview Schedule for Children (ADIS-C) [Silverman, W. K., & Albano, A. M. (1996). Anxiety disorders interview schedule for DSM-IV child version, child interview schedule. San Antonio: The Psychological Corporation]. They rated their levels of distress and avoidance in a variety of social situations. The results showed an age related increase for formal speaking and interaction situations in both avoidance and distress, with a stronger increase in avoidance than in distress. The same pattern was found for girls for situations regarding observation by others. No effects were observed for informal speaking and interaction situations.

The impact of modified instructions on ego-level scores: a psychometric hazard or indication of optimal ego level?

Various modified instructions have different effects on the Washington University Sentence Completion Test for Ego Development (Loevinger, 1985). These effects were reviewed and 2 alternative explanations were explored: The "measurement unreliability explanation" versus the "optimal level explanation." Both explanations were systematically studied in 2 test-retest experiments with the Sentence Completion Test for Children and Youths (Westenberg, Treffers, & Drewes, 1998). The modified instructions were to make a favorable impression on the tester ("fake good" condition) or to complete the sentences in as adult and mature a manner as one can ("be mature" condition). Both experiments were conducted with 9- to 15-year-old children and adolescents (N = 127, 128). As was anticipated, neither the fake good nor the be mature condition yielded higher (or lower) reliability indexes as compared to the standard instructions, hence discounting the measurement unreliability explanation. Also as expected, the fake good condition did not yield significantly higher ego-level scores, whereas the be mature condition did yield significantly higher ego-level scores. The former instructions did not convey information relevant to the construct or measure of ego development, whereas the latter instructions did convey information relevant for raising ego-level scores. It is argued that the higher scores under the be mature instructions might reflect the respondents' "optimal" ego level (best functioning), whereas the ego-level score under the standard instructions might reflect their "functional" level (normal functioning).

Separation anxiety and overanxious disorders: relations to age and level of psychosocial maturity.

OBJECTIVE: To study the developmental underpinnings of age trends in the prevalence of separation anxiety disorder (SAD) and overanxious disorder (OAD) in children and adolescents. METHOD: The sample consisted of 118 children and adolescents (aged 8-18 years) with SAD or OAD, who were referred to an outpatient psychiatric clinic. Anxiety disorders were assessed with Silverman and Nelles' Anxiety Disorders Interview Schedule for Children; level of psychosocial development was conceptualized and assessed by means of Jane Loevinger's model and measure of ego development. Logistic regression analyses were applied to study the extent to which age and level of ego development were related to the presence of SAD or OAD. RESULTS: Level of ego development was the strongest predictor of group membership (SAD versus OAD). Although age was a strong predictor as well, the age effect became insignificant after ego level had been entered into the regression equation. As predicted, SAD was related primarily to the Impulsive ego level, whereas OAD was related mostly to the Conformist ego level. The comorbid condition (SAD and OAD) fell squarely in between the 2 "pure" groups, both in terms of age and ego level. The results were controlled for possibly confounding variables, such as gender, IQ, and socioeconomic status. CONCLUSIONS: The presence of SAD and OAD appears to be related to specific levels of psychosocial maturity, irrespective of age.

Personality prototypes and ego development: conceptual similarities and relations in adult women.

Three studies investigated how three personality prototypes (K. York & O.P. John, 1992) relate to J. Loevinger's (1976) stages of ego development (ED). Study 1 examined their conceptual similarities, and Study 2 their relations in a sample of adult women. In both studies, the personality prototypes mapped onto regions defined by multiple ED stages: The Individuated prototype was most likely to reach the high region of ED (Individualistic, Autonomous, and Integrated); the Traditional prototype was most likely to function in the middle region (Conformist, Self-aware, and Conscientious); and the Conflicted prototype was more likely to remain in the low region (Impulsive and Self-protective). In addition to these between-prototype differences, Study 3 explored whether differences in life outcomes within the prototypes are also related to ED; findings suggest that personality prototype and ego development may interact in shaping the life course.

The factor structure of the Buss and Plomin EAS Temperament Survey (parental ratings) in a Dutch sample of elementary school children.

The psychometric properties of the Buss and Plomin (1984) EAS Temperament Survey for Children (Parental Ratings) were examined in a sample of Dutch children between 4 and 13 years of age. Ratings were obtained from 230 mothers and 172 fathers. The findings presented here provide the lacking cross-validation of the original analyses by Rowe and Plomin (1977): Emotionality, activity, and shyness were independent temperaments, regardless of age and gender. The factorial position of the yet experimental Sociability scale is more ambiguous: Sociability was significantly related to both shyness and activity but was more strongly associated with shyness in the youngest age cohort and most strongly with activity in the oldest cohort. This age trend, combined with a positive association with activity, supports the premise that sociability cannot be equated to nonshyness and justifies the inclusion of a separate Sociability scale in the EAS. All four EAS scales are reliable in terms of internal consistency and interrater agreement, but one modification of the Sociability scale is needed.

Ego development and individual differences in personality.

The relation between individual differences in personality and differences in developmental maturity was studied by relating observations of personality by multiple, independent judges to level of ego development. The personality characteristics of longitudinally followed Ss (104 at age 14; 98 at age 23) were evaluated by the California Adult Q-Set (CAQ); ego level was evaluated by the Washington University Sentence Completion Test of Ego Development (SCT). A priori personality dimensions--consisting of CAQ items for which a common developmental pathway was expected--were constructed and related to the SCT: (a) Ego-resiliency and interpersonal integrity were associated with increasing ego development, (b) conformity was associated with the Conformist level and, unexpectedly, to the Conscientious level, (c) need regulation was associated with the Conscientious level, and (d) self-ease and expressiveness-playfulness were not associated with ego level.