Adolescent borderline symptoms in the community: prognosis for functioning over 20 years

Background:  The long-term prognosis associated with adolescent symptoms of borderline personality disorder (BPD) in the general population is virtually unknown. In this study, the relationship of early borderline symptoms to subsequent psychosocial functioning and attainment was investigated based on data from the Children in the Community cohort.
Method:  Using multilevel linear regression, symptoms of BPD at mean age 14 were employed as predictors of work/school/homemaker role function, social function (social support, relationship quality), and life satisfaction over the subsequent 20 years. Borderline symptoms were also employed as predictors of attainment at 20-year follow-up.
Results:  On average, those with higher levels of early adolescent borderline symptoms scored consistently lower in role function, social function, and life satisfaction from mid-adolescence through mid-adulthood. Borderline symptoms predicted lower academic and occupational attainment, less partner involvement, and fewer attained adult developmental milestones. Adolescent borderline symptoms were also associated with adult borderline symptoms, borderline diagnosis, general impairment, and need for services at mean age 33. These effects were evident despite symptom decline with age and were independent of adolescent Axis I disorders.
Conclusions:  Adverse prognosis associated with youth symptoms of BPD appeared early and persisted in important and interrelated life domains. These findings lend support to the utility of DSM-IV BPD symptoms assessed by self-report in early adolescence.     

Personality subtypes in adolescents with eating disorders: validation of a classification approach

Background:  Research has identified three personality subtypes in adults with eating disorders (EDs): a high-functioning, an undercontrolled, and an overcontrolled group. The current study investigated whether similar personality prototypes exist in adolescents with EDs, and whether these personality prototypes show relationships to external correlates indicative of diagnostic validity.
Methods:  Experienced clinicians from an adolescent practice-research network provided data on ED symptoms, DSM-IV comorbidity, personality pathology, and family and developmental history for 120 adolescent patients with EDs.
Results:  Consistent with the findings from the adult literature, three types of personality pathology emerged in adolescents: High-functioning/Perfectionistic, Emotionally Dysregulated, and Avoidant/Depressed. The High-functioning prototype showed negative associations with comorbidity and positive associations with treatment response. The Emotionally Dysregulated prototype was specifically associated with externalizing Axis I and Cluster B Axis II disorders, poor school functioning, and adverse events in childhood. The Avoidant/Depressed prototype showed specific associations with internalizing Axis I and Clusters A Axis II disorders, poor peer relationships, poor maternal relationships, and internalizing disorders in first-degree relatives.
Conclusions:  These data support the presence of at least three diagnostically meaningful personality prototypes in adolescents with EDs, similar to those found previously in adults. Diagnosis of adolescents with EDs may be usefully supplemented by the assessment of personality style.     

One factor or two parallel processes? Comorbidity and development of adolescent anxiety and depressive disorder symptoms

Background:  This study investigates whether anxiety and depressive disorder symptoms of adolescents from the general community are best described by a model that assumes they are indicative of one general factor or by a model that assumes they are two distinct disorders with parallel growth processes. Additional analyses were conducted to explore the comorbidity of adolescent anxiety and depressive disorder symptoms and the effects that adolescent anxiety and depressive disorder symptoms have on each other's symptom severity growth.
Methods:  Two cohorts of early ( N  = 923; Age range 10–15 years; Mean age = 12.4, SD = .59; Girls = 49%) and middle adolescent ( N  = 390; Age range 16–20 years; Mean age = 16.7, SD = .80; Girls = 57%) boys and girls from the general community were prospectively studied annually for five years. These two adolescent cohorts were divided into five groups: one group at-risk for developing a specific anxiety disorder and four additional groups of healthy adolescents that differed in age and sex. Self-reported anxiety and depressive disorder symptoms were analyzed with latent growth modeling.
Results:  Comparison of the fit statistics of the two models clearly demonstrates the superiority of the distinct disorders with parallel growth processes model above the one factor model. It was also demonstrated that the initial symptom severity of either anxiety or depression is predictive of the development of the other, though in different ways for the at-risk and healthy adolescent groups.
Conclusions:  The results of this study established that the development of anxiety and depressive disorder symptoms of adolescents from the general community occurs as two distinct disorders with parallel growth processes, each with their own unique growth characteristics.     

Dynamics of affective experience and behavior in depressed adolescents

Background:  Depression is often characterized as a disorder of affect regulation. However, research focused on delineating the key dimensions of affective experience (other than valence) that are abnormal in depressive disorder has been scarce, especially in child and adolescent samples. As definitions of affect regulation center around processes involved in initiating, maintaining, and modulating the occurrence , intensity , and duration of affective experiences, it is important to examine the extent to which affective experiences of depressed youth differ on these dimensions from those of healthy youth.
Methods:  The affective behavior and experience of adolescents with major depressive disorder (MDD; n  =   75) were compared to a demographically matched cohort of healthy adolescents ( n  =   77). Both samples were recruited from community high schools. A multi-source (parents and adolescent), multi-method (interviews, behavioral observations, questionnaires) assessment strategy was used to examine positive and negative affects.
Results:  Depressed youth had significantly longer durations, higher frequency, and greater intensity when experiencing angry and dysphoric affects and shorter durations and less frequency of happy affect when compared to healthy youth. The most consistent, cross-method results were evident for duration of affect.
Conclusions:  Clinically depressed adolescents experienced disturbances in affective functioning that were evident in the occurrence, intensity, and duration of affect. Notably, the disturbances were apparent in both positive and negative affects.     

The developmental course of anxiety symptoms during adolescence: the TRAILS study

Background:  Little is known about the development of anxiety symptoms from late childhood to late adolescence. The present study determined developmental trajectories of symptoms of separation anxiety disorder (SAD), social phobia (SoPh), generalized anxiety disorder (GAD), panic disorder (PD), and obsessive-compulsive disorder (OCD) in a large prospective community cohort.
Methods:  Anxiety symptoms were assessed in a community sample of 2220 boys and girls at three time-points across a 5-year interval. The Revised Child Anxiety and Depression Scale (RCADS) was used to assess anxiety symptoms, and multilevel growth-curve analyses were performed.
Results:  All subtypes of anxiety first showed a decrease in symptoms (beta for age ranged from –.05 to –.13, p  < .0001), followed by a leveling off of the decrease, and a subsequent slight increase in symptoms (beta for age-squared ranged from .006 to .01, p  < .0001) from middle adolescence (GAD, SoPh, SAD) or late adolescence (PD and OCD) onwards. This increase in anxiety symptoms could not be explained by a co-occurring increase in depression symptoms. Girls had more anxiety symptoms than boys, and this difference remained stable during adolescence ( p  < .0001). Gender differences were strongly attenuated by adjustment for symptoms of depression.
Conclusions:  The current study shows that, in the general population, anxiety symptoms first decrease during early adolescence, and subsequently increase from middle to late adolescence. These findings extend our knowledge on the developmental course of anxiety symptoms during adolescence. This is the first study to separate the development of anxiety symptoms from that of symptoms of depression.     

Different neurocognitive functions regulating physical aggression and hyperactivity in early childhood

Background:  There are strong parallels between early childhood and adolescent behavior problems. However, we do not know if behavioral symptoms associate with neurocognitive processes in very young children as they do in older children.
Methods:  We studied a population-based birth cohort of children ( N  =   1,950) whose developmental trajectories of physical aggression and hyperactivity were assessed between the ages of 17 and 41 months. We measured the following neurocognitive abilities at 41 months of age: Receptive vocabulary, visuospatial organization, and short-term memory.
Results:  After controlling for other neurocognitive abilities, frequent physical aggression was related specifically to receptive vocabulary deficits ( p  < .0001) while frequent hyperactivity was related specifically to deficits of visuospatial organization ( p  < .0001). The pattern of associations was robust despite controls for socioeconomic and perinatal status.
Conclusions:  The different neurocognitive correlates of physical aggression and hyperactivity problems observed during adolescence are apparent in early childhood. Whereas physical aggression problems are associated with language deficits, hyperactivity problems are related to non-verbal deficits.     

Interpersonal psychotherapy with pregnant adolescents: two pilot studies

Objective:  To test the feasibility, acceptability and helpfulness of group Interpersonal Psychotherapy (IPT-PA) for depression in pregnant adolescents.
Method:  Two open clinical trials were conducted of IPT-PA delivered in group format in a New York City public school for pregnant girls. Study 1 tests IPT-PA for management of depressive symptoms by delivery during health class to pregnant girls with varying levels of depressive symptoms ( N  =   14; 10 Hispanic, 3 African-American and 1 bi-racial). Study 2 tests IPT-PA for treatment of depression by delivery after school for self-nominating pregnant girls with DSM-IVR diagnoses of depressive disorder or an adjustment disorder ( N  =   11; 8 African-American, 1 girl Hispanic and 2 bi-racial). Depressive symptoms were assessed using the Beck Depression Inventory and the Edinburgh Depression Scale (for its sensitivity to severe symptoms, the Hamilton Depression Scale was added in Study 2). Clinical diagnosis was assessed using the Schedule for Affective Disorders and Schizophrenia for Children (K-SADS).
Study 1 Results:  At 12-week termination, level of depressive symptoms had decreased by 50%; 13/14 girls showed a decrease in level of symptoms.
Study 2 Results:  At 12-week termination, level of depressive symptoms had decreased by 40%; 10/11 girls showed decrease in level of symptoms and in DSM-IVR clinical diagnosis; treatment gains were maintained at 20-week post-partum follow-up.
Conclusion:  IPT-PA appears feasible and helpful in managing and treating depression in pregnant girls.     

Sleep problems are associated with poor outcomes in remedial teaching programmes: a preliminary study

Aim:   Problematic behaviour and deficient academic performance have been reported in children with sleep problems, but whether sleep problems are common among children presenting with primary behavioural and performance concerns in remedial programmes is not well studied. We studied this possibility in 80 Australian school children aged 6–15 years and then compared 15 of these children from mainstream schools to 15 demographically matched children in specialist behavioural programmes for problematic behaviour and academic difficulties.
Methods:   Parents completed the Child Behaviour Checklist and the Sleep Disorders Scale for Children. Questionnaires assessed behaviour, academic performance and symptoms of diverse sleep disorders, expressed as T-scores (mean (SD) = 50 (10)). Teachers rated students' academic performance (A, B, C, D, E).
Results:   When compared with the 15 controls, the 15 index children had significantly more sleep problems, in addition to parental concerns about school performance. In the total sample ( n  = 80), poor sleep including symptoms of daytime sleepiness, parasomnias, behavioural sleep problems and combined sleep problems was associated with poor academic performance and daytime behavioural issues.
Conclusions:   This preliminary study suggests that children in remedial school programmes may have poor sleep compared with those in mainstream schools. Sleep problems were associated with problematic behaviour and poor academic performance. If sleep disturbances worsen daytime behaviour, then diagnosis and treatment of underlying sleep disorders could offer a novel therapeutic opportunity.     

Is prenatal alcohol exposure related to inattention and hyperactivity symptoms in children? Disentangling the effects of social adversity

Background:  Studies concerning whether exposure to low levels of maternal alcohol consumption during fetal development is related to child inattention and hyperactivity symptoms have shown conflicting results. We examine the contribution of covariates related to social adversity to resolve some inconsistencies in the extant research by conducting parallel analyses of three cohorts with varying alcohol consumption and attitudes towards alcohol use.
Methods:  We compare three population-based pregnancy–offspring cohorts within the Nordic Network on ADHD from Denmark and Finland. Prenatal data were gathered via self-report during pregnancy and birth outcomes were abstracted from medical charts. A total of 21,678 reports concerning inattention and hyperactivity symptoms in children were available from the Strengths and Difficulties Questionnaire or the Rutter Scale completed by parents and/or teachers.
Results:  Drinking patterns differed cross-nationally. Women who had at least some social adversity (young, low education, or being single) were more likely to drink than those better off in the Finnish cohort, but the opposite was true for the Danish cohorts. Prenatal alcohol exposure was not related to risk for a high inattention-hyperactivity symptom score in children across cohorts after adjustment for covariates. In contrast, maternal smoking and social adversity during pregnancy were independently and consistently associated with an increase in risk of child symptoms.
Conclusions:  Low doses of alcohol consumption during pregnancy were not related to child inattention/hyperactivity symptoms once social adversity and smoking were taken into account.     

Sensory clusters of toddlers with autism spectrum disorders: differences in affective symptoms

Background:  Individuals with autism spectrum disorders (ASDs) show variability in their sensory behaviors. In this study we identified clusters of toddlers with ASDs who shared sensory profiles and examined differences in affective symptoms across these clusters.
Method:  Using cluster analysis 170 toddlers with ASDs were grouped based on parent rating of the Infant Toddler Sensory Profile ( Dunn, 2002 ) under-responsivity, over-responsivity, and seeking scales. Affective symptoms were evaluated with the Infant Toddler Social Emotional Assessment ( Carter & Briggs-Gowan, 2005 ).
Results:  Three clusters were identified: (1) low frequency of sensory symptoms ( n  =   44); (2) high frequency of symptoms ( n  =   49); and (3) mixed ( n  =   77); high frequency of under-and over-responsivity and low frequency of seeking). Relative to the low frequency cluster, parents rated toddlers in the high frequency and mixed clusters (both characterized by high frequencies of sensory under- and over-responsivity) as higher on negative emotionality, depression, and anxiety symptoms. Sensory and affective differences among clusters remained after co-varying severity of ASD symptoms.
Conclusions:  Interdisciplinary assessments are recommended for toddlers with ASDs in order to identify the interplay of sensory and affective symptoms.     

Impact of adolescent mental disorders and physical illnesses on quality of life 17 years later

OBJECTIVE: To investigate associations of mental disorders and physical illnesses during adolescence with quality of life (QOL) 17 years later. DESIGN: The Children in the Community Study, a prospective longitudinal investigation. SETTING: Upstate New York. PARTICIPANTS: A community-based sample of mothers and their offspring were interviewed. MAIN OUTCOME MEASURES: Axis I disorders and Axis II personality disorders and physical illnesses were assessed by self-report and mother report in 1985-1986. Outcome indicators of QOL were assessed in 2001-2004. RESULTS: Compared with participants without adolescent illness or disorder, those with a history of physical illness reported poorer physical health (mean difference [MD], -4.8); those with a history of an Axis I disorder reported poorer physical health (MD, -8.0) and more problematic social relationships (MD, -4.5); and those with a history of personality disorder reported poorer physical health (MD, -8.2), more problematic social relationships (MD, -5.0), lower psychological well-being (MD, -3.6), and more adversity within their environmental context (MD, -4.6) in adulthood. Comorbid physical illness and mental disorder were associated with all 5 QOL domains (MD, -3.1 to -11.9). After adjusting for all demographic variables and comorbidity, associations remained between physical illness and poor physical health (effect size [ES], -0.33); an Axis I disorder and problematic social relationships (ES, -0.37); and personality disorder and problematic social relationships (ES, -0.36), low psychological well-being (ES, -0.23), impaired role function (ES, -0.24), and an adverse environmental context (ES, -0.50). CONCLUSIONS: Mental disorders may have more adverse long-term associations with QOL than do physical illnesses. Adolescent personality disorders may have a more adverse impact on adult QOL than do adolescent Axis I disorders.     

Comparison between Japanese and Swedish schoolchildren in regards to physical symptoms and psychiatric complaints

BACKGROUND: Physical symptoms are an increasing problem among Japanese children and adolescents, and the symptoms seem to be related to their school situation. These symptoms are prevalent in Sweden, and a comparison with Japan is of interest due to the differences in the educational system and school climate. OBJECTIVE AND METHODS: To compare physical symptoms and psychiatric complaints in school pupils from Japan and Sweden, using a questionnaire that also addressed life satisfaction and stressful life events. The study population comprised 742 Japanese children and 1,120 Swedish children attending public compulsory schools, grades 4-9 (10-15 y). Physical symptom and psychiatric complaint scores were calculated for each pupil. RESULTS: The Japanese children had significantly higher physical symptom and psychiatric complaint scores than did the Swedish children. Both the physical symptom and psychiatric complaint scores were significantly higher in adolescents than in preadolescents in Japan; this trend was less apparent in Swedish children. In addition, Japanese children were found to have considerably lower life satisfaction. Loss of appetite was the only physical symptom more prevalent in the Swedish population compared to the Japanese population.CONCLUSION: We conclude that Japanese schoolchildren have more physical symptoms and psychiatric complaints and less life satisfaction than Swedish schoolchildren of corresponding ages.     

The developmental course of illicit substance use from age 12 to 22: links with depressive, anxiety, and behavior disorders at age 18

Background:  Previous theory and research suggest links between substance use and externalizing behavior problems, but links between substance use and internalizing problems are less clear. The present study sought to understand concurrent links among diagnoses of substance use disorders, internalizing disorders, and behavior disorders at age 18 as well as developmental trajectories of illicit substance use prior to and after this point.
Methods:  Using data from 585 participants in the Child Development Project, this study examined comorbidity among substance use, behavior, and internalizing disorders at age 18 and trajectories of growth in illicit substance use from age 12 to age 22.
Results:  In this community sample, meeting diagnostic criteria for comorbid internalizing disorders, a behavioral disorder (conduct disorder or oppositional defiant disorder) alone, or both internalizing and behavioral disorders predicted higher concurrent substance use disorders (abuse, dependence, or withdrawal). Meeting diagnostic criteria for an anxiety disorder alone or depression alone did not predict higher concurrent substance use diagnoses. Over time, youths with behavioral disorders at age 18 showed a pattern of increasing substance use across early adolescence and higher levels of substance use than those with no diagnosis at age 18. Substance use declines from late adolescence to early adulthood were observed for all groups.
Conclusions:  Substance use disorders were more highly comorbid with behavior disorders than with internalizing disorders at age 18, and behavior disorder and comorbid behavior-internalizing disorders at age 18 were related to trajectories characterized by steep increases in illicit substance use during adolescence and high rates of illicit substance use over time.     

Poor utility of the age of onset criterion for DSM-IV attention deficit/hyperactivity disorder: recommendations for DSM-V and ICD-11

Background:  To test whether the retrospective reporting of the age of onset impairment criterion for attention deficit/hyperactivity disorder (ADHD) required in the Diagnostic and Statistical Manual of Mental Disorders – IV (DSM-IV) complicates identification of new and known child and adolescent cases later in life.
Methods:  A birth-records-based cohort of twins assessed at ages 7 to 19 years were blindly reassessed five years later using the MAGIC interview. Study outcome measures were differences in reported ages of onset for attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD) and major depressive disorder (MDD).
Results:  For all age groups and respondents (parent on youth or youth self-report), later ages of ADHD onset were reported five years later. The same phenomenon was also present for the other diagnostic groups. Of the initial ADHD individuals who continued to meet all other ADHD criteria at follow-up, 46% failed the age of onset criterion five years later. When ignoring the age of onset criterion, late onsets of ages 7–16 years accounted for about 10% of all ADHD.
Conclusions:  Use of the DSM-IV age of onset criterion for attention deficit/hyperactivity disorder in the assessment of adolescents and young adults results in under-identification of affected individuals. Consideration should be given to revising the current nomenclatures to reflect the reality of retrospective reporting errors in age of onset as well as the presence of late onset cases.     

Detained adolescent females’ multiple mental health and adjustment problem outcomes in young adulthood

Background: Although prior studies have shown that detained females are marked by significant adverse circumstances, little is known about their adult outcomes. Method: Prospective follow‐up study of 184 (80.4% of original sample of 229) detained adolescent females who were reassessed 4.5 (SD = 0.6) years later in young adulthood (mean age = 20.0, SD = 1.4) on mental health and adjustment outcomes. Associations between these outcomes and detained females’ behavior problems and offense history were examined. Results: In the total sample, 59.0% had one or more mental health problems at follow‐up, whereas 96.2% were facing at least one adjustment problem. Subjects with a personality disorder (PD) reported more adjustment problems compared to subjects without PD. Mental health and adjustment problems in young adulthood were predicted by detained adolescent females’ behavior problems and offense history. Conclusion: Detained adolescent females suffered from multiple mental health and adjustment problems in young adulthood. Females who developed PD were most impaired. Results of this study underline the compelling need for continued and gender‐specific interventions. The identification of predictors during detention for poor adult outcomes can serve as targets for intervention.     

Persistence of literacy problems: spelling in adolescence and at mid-life

Background:  Developmental reading problems show strong persistence across the school years; less is known about poor readers' later progress in literacy skills .
Method:  Poor ( n  =   42) and normally developing readers ( n  =   86) tested in adolescence (ages 14/15 years) in the Isle of Wight epidemiological studies were re-contacted at mid-life (ages 44/45 years). Participants completed a spelling test, and reported on educational qualifications, perceived adult spelling competence, and problems in day-to-day literacy tasks.
Results:  Individual differences in spelling were highly persistent across this 30-year follow-up, with correlations between spelling at ages 14 and 44 years of r  = .91 ( p  < .001) for poor readers and r  = .89 ( p  < .001) for normally developing readers. Poor readers' spelling remained markedly impaired at mid-life, with some evidence that they had fallen further behind over the follow-up period. Taking account of adolescent spelling levels, continued exposure to reading and literacy demands in adolescence and early adulthood was independently predictive of adult spelling in both samples; family social background added further to prediction among normally developing readers only.
Conclusions:  By adolescence, individual differences in spelling and its related sub-skills are highly stable. Encouraging young people with reading disabilities to maintain their exposure to reading and writing may be advantageous in the longer term.     

School‐based prevention of depression: a randomised controlled study of the beyondblue schools research initiative

Background: Depressive disorders are experienced by 3–5% of the adolescent population at any point of time. They adversely affect adolescent development in a range of areas and greatly increase risk for suicide. The present study investigated the effectiveness of a universal intervention designed to reduce depressive symptoms among students commencing high school. Methods: Twenty‐five pairs of secondary schools matched on socio‐economic status were randomly assigned to either an intervention or a comparison group (n = 5,634 Year 8 students). The intervention extended over a 3‐year period and utilised a comprehensive classroom curriculum programme, enhancements to the school climate, improvements in care pathways, and community forums. A range of measures completed by students, average age at baseline = 13.1 years (SD = .5), and teachers was used to assess changes in depressive symptoms, risk and protective factors relevant to depression, and the quality of the school environment. Results: Changes in the level of depressive symptoms and in the levels of risk and protective factors experienced by students in the two groups did not differ significantly over the 3 years of the study. Furthermore, statistically significant differences in the ratings of school climate across this time period were found only for staff‐rated assessments. Conclusions: Despite using an extensive, structured programme, based on best evidence to increase protective factors and reduce risk factors at the individual and school levels, the intervention did not reduce levels of depressive symptoms among participating adolescents. The results draw attention to the difficulties faced when implementing large‐scale, school‐based, universal preventive interventions. These include the need to develop methods to effectively train teachers across large geographical regions to deliver new interventions with fidelity, the difficulty of engaging young adolescents with prevention programmes, and the long period of time required to implement policy and practice changes at ‘whole‐school’ levels.