Psychiatric comorbidity and the 16-month trajectory of substance-abusing and substance-dependent juvenile offenders.

OBJECTIVES: To examine the concurrent correlates of internalizing and externalizing disorders among substance-abusing and substance-dependent juvenile offenders and to determine the association between psychiatric comorbidity and psychosocial functioning of the youths 16 months later. METHOD: Participants were 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. A multisource measurement battery was used to assess drug use, criminal activity, family relations, peer relations, school functioning, and out-of-home placements. RESULTS: Comorbidity for externalizing disorders was associated with high rates of antisocial behavior and predicted worse 16-month outcomes than substance abuse alone or substance abuse with comorbid internalizing disorders. For criminal activity and drug use, the presence of internalizing disorders buffered the deleterious effect of externalizing disorders on substance-abusing and substance-dependent juvenile offenders. CONCLUSIONS: Even in substance-abusing delinquents, a population already extreme in antisocial behavior, the presence of externalizing disorders indicates high risk for deterioration.     

Childhood psychiatric disorders and young adult crime: a prospective, population-based study

OBJECTIVE: While psychopathology is common in criminal populations, knowing more about what kinds of psychiatric disorders precede criminal behavior could be helpful in delineating at-risk children. The authors determined rates of juvenile psychiatric disorders in a sample of young adult offenders and then tested which childhood disorders best predicted young adult criminal status. METHOD: A representative sample of 1,420 children ages 9, 11, and 13 at intake were followed annually through age 16 for psychiatric disorders. Criminal offense status in young adulthood (ages 16 to 21) was ascertained through court records. RESULTS: Thirty-one percent of the sample had one or more adult criminal charges. Overall, 51.4% of male young adult offenders and 43.6% of female offenders had a child psychiatric history. The population-attributable risk of criminality from childhood disorders was 20.6% for young adult female participants and 15.3% for male participants. Childhood psychiatric profiles predicted all levels of criminality. Severe/violent offenses were predicted by comorbid diagnostic groups that included both emotional and behavioral disorders. CONCLUSIONS: The authors found that children with specific patterns of psychopathology with and without conduct disorder were at risk of later criminality. Effective identification and treatment of children with such patterns may reduce later crime.     

Self-report measures in the study of comorbidity in children and adolescents with social phobia: research and clinical utility

We examined differences in self-reported anxiety and depression according to the number and pattern of DSM-IV comorbid diagnoses in 172 children and adolescents (mean age=11.87, S.D.=2.67; range=7-17) with a primary diagnosis of social phobia. Three hypotheses were tested: (1) children with comorbid anxiety disorders would show significantly higher scores than children with social phobia-only on self-report measures, (2) self-report measures would significantly differentiate between children with social phobia and comorbid internalizing versus externalizing disorders, and (3) self-report measures would significantly differentiate children according to the type of anxiety comorbidities present. Multinomial logistic regressions showed that children with three anxiety disorders scored significantly higher than children with one and two diagnoses on two of three self-report measures used. Logistic regressions revealed that children's scores on measures did not differ according to the nature of the comorbid diagnoses (internalizing vs. externalizing). Finally, ROC curves showed that the MASC and the SPAI-C accurately classified children with additional diagnoses of SAD and GAD, respectively. The potential of self-report measures to further our understanding of childhood anxiety comorbidity and the clinical implications of their use to screen for comorbidity are discussed along with suggestions for further study.     

Who Is at Greatest Risk of Adverse Long-Term Outcomes? The Finnish From a Boy to a Man Study

OBJECTIVE: To study associations between comorbid psychopathology and long-term outcomes in a large birth cohort sample from age 8 to early adulthood. METHOD: The sample included long-term outcome data on 2,556 Finnish boys born in 1981. The aim was to study the impact of early childhood psychopathology types (externalizing versus internalizing versus both) and informant sources (self-report versus parent/teacher reports) on young adult outcomes, based on data from a military registry of psychiatric diagnosis, a police registry on criminal and drug offenses, and self-reported problems in late adolescence and early adulthood. RESULTS: Children with combined conduct and internalizing problems at age 8 had the worst outcomes and highest risk of subsequent psychiatric disorders, criminal offenses, and self-reported problems at follow-up, with 62% of these boys manifesting psychiatric disorders, committing criminal offenses, or both at follow-up. Although these children included only 4% of the sample, they were responsible for 26% of all criminal offenses at follow-up. In contrast, children with conduct problems without internalizing problems and those with attention problems had much less severe but nonetheless elevated levels of risk of antisocial personality disorder and criminal offenses. Long-term outcomes for these two groups were substantially better than for children with combined conduct and internalizing problems. Children with "pure" emotional problems had an elevated risk only of similar emotional problems at follow-up. CONCLUSIONS: The subjective suffering and long-term burden to society is especially high among children with comorbid conduct and internalizing problems in childhood. A major challenge for child and adolescent psychiatric, education, and social services is to develop effective intervention strategies focusing on these children. Additional longitudinal epidemiological studies of this comorbidity group are needed, and, if replicated, such findings will have important implications for future diagnostic classification systems (DSM-V).     

Do young people with comorbid mental and alcohol disorders experience worse behavioural problems?

This article examines whether young individuals in the general population with comorbid alcohol use and mental health disorders experience worse internalizing and externalizing behaviour problems than those with single disorders. A large cohort of women at the Mater Misericordiae Hospital in Brisbane, Australia, was enroled during pregnancy in a longitudinal study. Mother/offspring dyads were followed over 21 years. At age 21, offspring behaviour problems were examined using the Young Adult Self Report, alcohol and mental health disorders with the Composite International Diagnostic Interview. Associations between comorbidity and behaviour problems were assessed using multinomial logistic regression, accounting for life-course factors. Twelve per cent of young adults had alcohol/mental health DSM-IV disorders with significant temporal overlap. A further 16% had alcohol disorders only and 23% mental health disorders only. The comorbid group scored significantly higher on total and externalizing behaviour problems but not internalizing behaviour problems. Stronger associations of aggression/delinquency with comorbidity were not fully accounted for by factors known to influence separate development of mental health and alcohol disorders. Young adults with comorbid alcohol/mental health disorders experience more, and more severe, behavioural problems than those with single disorder types, indicating an increased burden from comorbidity, with implications for treatment and public order.     

Community-Based Treatment for Youth with Co- and Multimorbid Disruptive Behavior Disorders

Little is known about the types of psychotherapeutic practices delivered to youth with comorbid and multimorbid diagnoses in community settings. The present study, based on therapists’ self-reported practices with 569 youth diagnosed with a disruptive behavior disorder (ODD or CD), examined whether specific therapeutic practice applications varied as a function of the number and type of comorbid disorders. While type of comorbid disorder (AD/HD or internalizing) did not predict therapists’ practices, youth with more than two diagnoses (multimorbid) received treatment characterized by a more diverse set and a higher dosage of practices.     

Beyond treatment effects: predicting emerging adult alcohol and marijuana use among substance-abusing delinquents

Secondary analyses of a randomized clinical trial examined the effects of 4 putative risk factors and 2 protective factors in predicting drug use among 80 emerging adults treated 5 years earlier for delinquency and alcohol and/or marijuana use disorders. Frequency of marijuana use and the number of comorbid psychiatric disorders in adolescence predicted cannabis use in emerging adulthood. Increasing academic competence at high levels of social competence predicted less marijuana use. At emerging adulthood, greater use of alcohol and marijuana were associated with both criminality and psychopathology.     

Effects of the First Step to Success Intervention on Preschoolers with Disruptive Behavior and Comorbid Anxiety Problems

Preschoolers with elevated anxiety symptoms are at high risk not only of developing more severe mental health disorders in later life but are also apt to respond more poorly to intervention if they present with comorbid disruptive behavior. Because early signs of anxiety disorders may not be recognized as such in preschool settings, many children selected for Tier 2 interventions that target externalizing problem behaviors may also have co-occurring anxiety symptoms and disorders. The First Step to Success intervention has recently been adapted for preschoolers with externalizing behaviors and was found to be efficacious in a randomized controlled trial. The current report examines effects of the First Step intervention on a subsample of 38 preschoolers with comorbid anxiety symptoms. Compared to usual-care controls, preschoolers who were assigned to the First Step intervention demonstrated medium-to-large effects in reducing externalizing behavior and improving social functioning outcomes, but had small effects for reductions in internalizing behaviors. Implications for intervening with preschoolers at risk of comorbid disruptive and anxiety behaviors are discussed.     

Measurement and description of underlying dimensions of comorbid mental disorders using Factor Mixture Models: results of the ESEMeD project

Epidemiological studies on mental health and mental comorbidity are usually based on prevalences and correlations between disorders, or some other form of bivariate clustering of disorders. In this paper, we propose a Factor Mixture Model (FMM) methodology based on conceptual models aiming to measure and summarize distinctive disorder information in the internalizing and externalizing dimensions. This methodology includes explicit modelling of subpopulations with and without 12 month disorders ("ill" and "healthy") by means of latent classes, as well as assessment of model invariance and estimation of dimensional scores. We applied this methodology with an internalizing/externalizing two-factor model, to a representative sample gathered in the European Study of the Epidemiology of Mental Disorders (ESEMeD) study -- which includes 8796 individuals from six countries, and used the CIDI 3.0 instrument for disorder assessment. Results revealed that southern European countries have significantly higher mental health levels concerning internalizing/externalizing disorders than central countries; males suffered more externalizing disorders than women did, and conversely, internalizing disorders were more frequent in women. Differences in mental-health level between socio-demographic groups were due to different proportions of healthy and ill individuals and, noticeably, to the ameliorating influence of marital status on severity. An advantage of latent model-based scores is that the inclusion of additional mental-health dimensional information -- other than diagnostic data -- allows for greater precision within a target range of scores.     

Disruptive behavior in young children: what does it mean?

OBJECTIVE: To examine how the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) primary diagnoses, Parent-Infant Relationship Global Assessment Scale, and Child Behavior Checklist/2-3 (CBCL/2-3) externalizing and internalizing symptoms augment the DSM-III-R/IV and guide treatment. METHOD: 82 children aged 18 to 47 months, who presented with disruptive behavior to an early childhood psychiatry clinic, were diagnosed using DSM-III-R/IV, DC 0-3, and the CBCL/2-3. RESULTS: Children with DSM-III-R/IV disruptive disorders or attention-deficit/hyperactivity disorder were diagnosed with DC 0-3 regulatory disorders, disorders of affect, and traumatic stress disorder. Clinically significant externalizing and internalizing symptoms co-presented in 45.1% of the children. Of children with disorders of affect, 41.2% had relationships categorized as disordered, contrasting with 21.1% of those with traumatic stress disorder and 10.3% of those with regulatory disorders. Increasingly disordered relationships were significantly correlated with externalizing and internalizing symptoms, and children with disordered relationships were 3.6 times more likely to have clinically significant levels of internalizing symptoms. CONCLUSION: In these children with disruptive behaviors, co-presentation of externalizing and internalizing symptoms is most common. Those with increased relational risk had more externalizing and internalizing symptoms and more disorders of affect.     

Early childhood internalizing problems,externalizing problems and their co-occurrence and (mal)adaptive functioning in emerging adulthood: a 16-year follow-up study

Purpose

A vast amount of studies suggest that internalizing or externalizing problems are related to individual functioning, and often co-occur. Yet, a focus on their additive and interactive effects is scarce. Furthermore, most research has focused on a limited number of developmental domains and mostly on maladaptive functioning. Therefore, the current prospective study examined whether early childhood (ages 4–8) internalizing and externalizing problems and their interaction were related to a broad range of (mal)adaptive functioning outcomes in emerging adulthood (ages 20–24).

Methods

Data from the Flemish Study on Parenting, Personality and Development were used. At Time 1 (1999) mothers of 374 children (45% boys) and fathers of 357 children (46% boys) rated internalizing and externalizing problems through the Child Behavior Checklist. Outcomes in emerging adulthood were measured through self-reports 16 years later across the following domains: psychological functioning, social functioning, work, physical health, and self-concept.

Results

Early externalizing problems were related to maladaptive outcomes on the psychological and social domains. With regard to adaptive functioning, externalizing problems were associated with lower satisfaction regarding general health on the physical domain. Early internalizing problems were not associated with any emerging adulthood outcomes. The interaction of (father reported) internalizing and externalizing problems was related to aggressive behavior.

Conclusion

Early childhood externalizing problems were associated with maladaptive and adaptive functioning over a time span of 16 years. The results add to studies on the implementation of prevention and intervention programs in early childhood and to the value for developing personalized interventions.

     

Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14-year follow-up during childhood, adolescence, and young adulthood

OBJECTIVE: The goal of this study was to predict the onset of mood and anxiety disorders from parent-reported emotional and behavioral problems in childhood across a 14-year period from childhood into young adulthood. METHOD: In 1983, parent reports of behavioral and emotional problems were obtained with the Child Behavior Checklist for children and adolescents 4-16 years of age from the Dutch general population. At follow-up 14 years later, lifetime mood and anxiety diagnoses were obtained by a standardized DSM-IV interview for 1,580 subjects. Cox proportional hazards models were used to predict the incidence of mood and anxiety disorders from childhood problems and demographic covariates. RESULTS: Mood disorders were significantly predicted by high scores on the anxious/depressed scale and on the internalizing composite (withdrawn, somatic complaints, and anxious/depressed). Anxiety disorders were significantly predicted by the social problems scale and the externalizing composite (delinquent behavior and aggressive behavior). Anxiety disorders predominantly started in childhood and early adolescence, whereas the incidence of mood disorders increased sharply in adolescence and young adulthood. CONCLUSIONS: These results suggest different developmental pathways for mood and anxiety disorders. The predictions based on problem behavior remained stable during the 14-year period across adolescence and young adulthood. The results therefore underline the importance of early intervention and prevention of behavioral and emotional problems in childhood.     

Criminality in men with major mental disorder with and without comorbid substance abuse

Violent and criminal behavior in the mentally ill remains an issue of major importance and in this context the role of comorbid substance abuse must be addressed. Data on criminal behavior in 282 men with schizophrenia and 261 men with affective disorder were studied. Samples of patients with and without additional substance abuse were compared. Also, non-abusing patients from both diagnostic groups were compared with matched controls from the general population. Substance abuse was found in half of all men in both groups of major mental disorders, and substance abusers had twice as high a probability of having a criminal record. However, compared with the matched sample from the general population, violent criminality was increased in schizophrenic patients without comorbid substance abuse, and patients with affective disorders without substance abuse had a higher probability of committing crimes against property. Men with major mental disorder have an increased probability of becoming criminal even when there is no comorbid substance abuse.     

Tourette syndrome in youth with and without obsessive compulsive disorder and attention deficit hyperactivity disorder

Chronic tic disorders (TD) are consistently found to have high rates of comorbidity with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). The purpose of this study is to compare the severity of TD only to TD with comorbid OCD or ADHD based on severity of tics, measures of psychopathology and additional comorbid diagnoses. Baseline data from 158 youth with a chronic TD who participated in two longitudinal studies were examined. Fifty-three percent (N = 85) of the youth also met criteria for a diagnosis of OCD, 38.6 % (n = 61) met criteria for ADHD and 24.1 % (N = 38) met criteria for both. Measures of interest addressed severity of tics, symptoms of anxiety, depression, ADHD, psychosocial stress, global functioning and the presence of comorbid diagnoses. Youth with comorbid TD and OCD were characterized by more severe tics, increased levels of depressive and anxious symptoms, heightened psychosocial stress and poorer global functioning. Youth with comorbid TD and ADHD did not differ from those with TD alone on measures of tic severity, but experienced greater psychosocial stress and poorer global functioning. Subjects with comorbid TD and OCD had more internalizing disorders than those without OCD, while those with comorbid ADHD were more likely to meet criteria for oppositional defiant disorder. TD with OCD is a more severe subtype of TD than TD without OCD. TD with ADHD is associated with higher psychosocial stress and more externalizing behaviors. Further research is needed into the underlying relationships between these closely associated conditions.     

Characteristics of internalizing and externalizing disorders in medication-naive, clinically referred children with attention deficit hyperactivity disorder, combined type and dysthymic disorder

OBJECTIVE: Internalizing and externalizing disorders are frequently comorbid with attention deficit hyperactivity disorder, combined type (ADHD-CT) and dysthymic disorder (DD) in referred primary school-age children, yet there has been relatively little systematic research of the nature of these comorbid disorders. We describe the characteristics of parent- and child-reported internalizing and externalizing disorders in primary school-age children with ADHD-CT and DD. METHOD: A cross-sectional study of 45 clinically referred medication naive children with ADHD-CT and DD, examining parent and child reports of internalizing and externalizing disorders, defined categorically and dimensionally. RESULTS: Generalized anxiety disorder and separation anxiety disorder were increased in the DD groups, whether ADHD-CT was present or not. Major depressive disorder was increased in the ADHD-CT and DD group compared to the ADHD-CT alone and the DD alone groups. Conduct disorder was increased in the ADHD-CT alone group compared to the DD with and without ADHD-CT groups. Verbal and fullscale IQ were increased in the DD groups, whether ADHD-CT was present or not, compared to the ADHD-CT alone group. CONCLUSIONS: There is emerging evidence that DD and anxiety may represent a different phenotypic expression of a common underlying aetiological process, while the co-occurrence of ADHD-CT and anxiety disorders remains unclear. Only the ADHD-CT and DD group is significantly associated with major depressive disorder, which suggests an additive effect. In contrast, conduct disorder and decreased verbal and fullscale IQ are only associated with the ADHD-CT group, which may suggest a protective effect of DD when comorbid with ADHD-CT. From a research perspective, it is important to confirm these found associations in larger samples derived from epidemiological populations.     

Suicide attempts associated with externalizing psychopathology in an epidemiological sample

OBJECTIVE: Borrowing from recent dimensional models of psychopathology, the authors conducted analyses that optimized the common variance shared by internalizing (depression, anxiety) and externalizing (antisocial personality, substance dependence) disorders in statistically predicting suicidal behaviors. These relationships were analyzed in a large epidemiological sample, thus allowing for the examination of gender differences in risk for suicide attempts associated with psychopathology. METHOD: The data were obtained from the Colorado Social Health Survey. Participants (N=4,745) were a community sample recruited by household address. Structured clinical interviews were used to obtain lifetime diagnostic and symptom count information. Symptom counts were included in a factor analysis that yielded two main dimensions of psychopathology: internalizing and externalizing. These factors were used in hierarchical logistic regression analyses to predict history of suicide attempts associated with the presence of internalizing symptoms, externalizing symptoms, and comorbid internalizing and externalizing symptoms. RESULTS: After the investigators controlled for the presence of internalizing symptoms and the comorbidity of internalizing and externalizing symptoms, externalizing symptoms were related to suicidal behavior in both men and women, although comorbidity was most predictive of suicide attempts among women, compared to men. CONCLUSIONS: Suicidal behavior among individuals with externalizing symptoms is not necessarily a result of comorbid depressive or other internalizing disorder. Thus, persons exhibiting antisocial behaviors should receive rigorous assessment for suicidal ideation and behavior.     

Depression and anxiety among mothers who bring their children to a pediatric mental health clinic

OBJECTIVE: Maternal psychiatric illness is a potent risk factor for child psychiatric disorders, but little is known about rates of psychiatric diagnoses among mothers who bring their children to pediatric mental health clinics. This study investigated rates of psychiatric disorders among mothers of children presenting for psychiatric evaluation and examined the relationship between maternal diagnosis and child psychopathology. METHODS: Interviewers conducted structured diagnostic interviews with nonpsychotic, school-age children and their mothers (N=222) and collected self-report measures of symptoms, functioning, and social support. RESULTS: One-hundred-thirty-five participating mothers (61 percent) met DSM-IV criteria for a current axis I disorder, most commonly depression (35 percent) and anxiety (42 percent). Children of mothers with a diagnosis met criteria for significantly more diagnoses on the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime version and had significantly higher scores on measures of internalizing and externalizing symptoms than children of mothers without a diagnosis. Two-thirds of mothers with a diagnosis were not receiving psychiatric treatment. CONCLUSIONS: More than half the mothers who brought their children for psychiatric treatment were themselves suffering from a psychiatric disorder. Maternal psychiatric illness was, in turn, associated with greater occurrence of psychopathology among offspring, underscoring the importance of developing interventions that address the needs of both children with psychiatric disorders and their at-risk mothers.     

Diagnostic predictors of treatment patterns in a cohort of adolescents.

Data on 776 American adolescents studied longitudinally were used to show treatment patterns related to psychiatric disorders. When DSM-III-R diagnoses based on mother and youth Diagnostic Interview Schedule for Children interviews were used prospectively to determine subsequent treatment seeking, it was found that consultation with mental health specialists, but not with pediatricians or general practitioners, was elevated in those with disorders. The specific diagnoses most associated with treatment seeking were conduct disorder and oppositional/defiant disorder. No compensation for differences in mental health service usage between children with internalizing disorders and those with externalizing disorders in the form of help from informal or other professional sources was present.     

Gender differences in ADHD subtype comorbidity

OBJECTIVE: To examine gender differences in attention-deficit/hyperactivity disorder ("ADHD") symptom comorbidity with "oppositional defiant disorder", "conduct disorder", "separation anxiety disorder", "generalized anxiety disorder", speech therapy, and remedial reading in children. METHOD: From 1994 to 1995, data from a large sample (N = 4,371) of twins and siblings studied in the Australian Twin ADHD Project were obtained by mailed DSM-IV-based questionnaires, investigating patterns of comorbidity in the three subtypes of "ADHD": "inattentive", "hyperactive/impulsive", and "combined". A total of 1,550 questionnaires were returned (87%) over the next 12 to 18 months. RESULTS: Analysis of variance showed significant between-group differences in males and females for inattention and hyperactive/impulsive symptom counts with higher rates of "oppositional defiant disorder" and "conduct disorder" in males, and higher rates of "separation anxiety disorder" in females indicating internalizing disorders are more common in females and externalizing disorders are occurring more often in males. Differences were found between the "ADHD" subtypes and the no ADHD category for all comorbid conditions, for both males and females. Children without ADHD consistently had fewer symptoms, while children with the combined subtype showed consistently more comorbid symptoms indicating a strong relationship between high rates of externalizing symptoms and high rates of internalizing symptoms. Gender differences in speech therapy were significant only for the children without ADHD. The rates of "separation anxiety disorder" were higher in females with the "inattention" subtype and the rate of "generalized anxiety disorder" higher for females with the "combined" subtype, indicating that the subtypes of ADHD were associated with these internalizing disorders in different ways. CONCLUSIONS: Although comorbidity differs among ADHD subtypes, there were no significant gender differences in comorbidity for externalizing disorders. Inattentive girls may present with anxiety. Clinical approaches for both males and females should be sensitive to possible language and reading problems.     

Major depression and drug disorders in adolescence: general and specific impairments in early adulthood.

OBJECTIVE: To identify adulthood impairments associated with major depression and drug disorders in adolescence, distinguishing between general impairments for both disorders and specific impairments for each disorder. METHOD: Within a longitudinal community study (N= 365), the Diagnostic Interview Schedule provided 1-year diagnoses of major depression and drug abuse/dependence at age 18. At age 21, current functioning was assessed. RESULTS: Adolescents with either depression or drug disorders had substantial deficits in later functioning, with few impairments shared in common. General areas of impairment included lower global functioning, externalizing behavior problems, and suicidal behaviors. Difficulties specific to depression encompassed multiple internalizing problems: interpersonal difficulties, decreased psychological well-being, career dissatisfaction, and active major depression at age 21. For males only, overall poor health was also a specific depression outcome. Age 21 problems unique to drug disorders included lower likelihood of post-high school education, being fired, and active drug disorders. Males, but not females, were also more likely to report antisocial behaviors in adulthood. CONCLUSIONS: Despite several significant commonalities, including suicide attempts, deficits associated with depression and drug disorders were primarily specific, suggesting distinct trajectories. Results highlight the need for specific follow-up services to alleviate continuing problems associated with these disorders.