The Mediational Effect of Affect Dysregulation on the Association Between Attachment to Parents and Oppositional Defiant Disorder Symptoms in Adolescents

Oppositional defiant disorder (ODD) is a childhood disorder, commonly occurring in early school aged children with some symptoms becoming normative in adolescence (e.g., irritability, disagreeing). Affect dysregulation is a risk factor in the development of ODD. Affect regulation is nurtured within parent–child relationships, thus disruptions to attachment may derail children’s capacity to develop adaptive affect regulation, increasing the risk for ODD. Using a high-risk sample of adolescents, we investigated the association between attachment anxiety and attachment avoidance with ODD through affect dysregulation. Attachment anxiety, but not avoidance, was associated with affect dysregulation and ODD. Affect dysregulation was found to fully mediate the relationship between attachment anxiety and ODD concurrently and prospectively. Similar findings have been demonstrated among children; results show that attachment anxiety, and its effects on affect dysregulation, are associated with ODD symptoms well into adolescence.

     

Oppositional defiant disorder with onset in preschool years: longitudinal stability and pathways to other disorders.

OBJECTIVE: To examine the stability and change in oppositional defiant disorder (ODD) with onset among preschool children in a pediatric sample. METHOD: A total of 510 children aged 2-5 years were enrolled initially in 1989-1990 (mean age 3.42 years); 280 participated in five waves of data collection over a period of 48 to 72 months (mean wave 5 age, 8.35 years). Test batteries varied by age, but they included the Child Behavior Checklist, developmental evaluation, Rochester Adaptive Behavior Inventory, and a play session (before age 7 years) and a structured interview (Diagnostic Interview for Children and Adolescents, parent and child versions) at ages 7+ years. Consensus diagnoses were assigned by using best-estimate procedures. RESULTS: Wave 1 single-diagnosis ODD showed a significant relationship with both single-diagnosis ODD and single-diagnosis attention-deficit hyperactivity disorder (ADHD) at subsequent waves, but not with single-diagnosis anxiety or mood disorders. Single-diagnosis ODD at wave 1 was associated with later comorbidity of ODD/ADHD, ODD/anxiety, and ODD/mood disorders. Stability across waves 2 through 5 was moderate to high for comorbid ODD/anxiety and ODD/ADHD; low to moderate stability for single-diagnosis ODD and single-diagnosis mood disorder; and low for mood disorder, single-diagnosis ADHD, and single-diagnosis anxiety disorder. CONCLUSIONS: Preschool children with ODD are likely to continue to exhibit disorder, with increasing comorbidity with ADHD, anxiety, or mood disorders.     

Clinical presentation and treatment outcome for children with comorbid externalizing and internalizing symptoms

This study examined the effects of comorbid separation anxiety disorder (SAD) on the expression of externalizing symptoms in children presenting with oppositional defiant disorder (ODD) as well as the treatment effects on anxiety and internalizing symptoms. Participants were 64 children with ODD seen in parent-child interaction therapy (PCIT), including 15 children with comorbid SAD. Children with ODD+SAD did not differ from children with ODD only in disruptive behavior severity at pre-treatment assessment, and children with ODD+SAD showed significant decreases in SAD symptoms at post-treatment. Additionally, children with clinical levels of internalizing behavior demonstrated significant reductions in these symptoms, along with reduction of externalizing symptoms targeted in treatment. We discuss the possibility that treatments focusing on parent-child interactions and certain parenting skills may generalize across specific child symptom constellations.     

Is oppositional defiant disorder a meaningful diagnosis in adults? Results from a large sample of adults with ADHD

We examined the prevalence and clinical characteristics of oppositional defiant disorder (ODD) in a sample of clinically referred adults with attention deficit hyperactivity disorder (ADHD). Subjects were consecutively referred adults with a DSM-III R/IV diagnosis of ADHD with or without ODD. Nearly half of subjects (43%) had a history of ODD. Subjects with a childhood history of ODD had increased risk for bipolar disorder, multiple anxiety disorders, and substance use disorders relative to the ADHD subjects without ODD. We concluded, as in children with ODD, adults with a childhood history of ODD have high rates of psychiatric comorbidity and more impaired psychosocial functioning than those without this condition. A better understanding of the course, phenomenology, and clinical significance of ODD in adults is needed to better understand therapeutic approaches for this disorder.     

The prevalence of mitral valve prolapse in children with anxiety disorders.

Studies in adults have suggested a comorbidity of mitral valve prolapse and anxiety disorders, especially panic disorder. The nature of the association between these disorders is yet unclear. In the last years, case studies have appeared, reporting on the comorbidity of anxiety disorders and mitral valve prolapse in children. The present study evaluated the prevalence of mitral valve prolapse in children with anxiety disorders as compared to normal controls. The study group consisted of 52 children, 6-18 years old, with a diagnosis of panic disorder (9.6%), separation anxiety disorder (65.4%) and/or overanxious disorder (61.5%). Fifty-one normal age- and gender-matched healthy children served as controls. All participants were evaluated for the presence of mitral valve prolapse by cardiac auscultation and echocardiography. None of the 52 children with anxiety disorder and one of the 51 control children (1.96%) had mitral valve prolapse. There appears to be no association between childhood anxiety disorders and mitral valve prolapse. Whether children with panic disorder proper show a greater prevalence of mitral valve prolapse remains an open question. Implications to the association of mitral valve prolapse and panic disorder are discussed.     

A multiwave multi-informant study of the specificity of the association between parental and offspring psychiatric disorders

The present study was conducted to investigate the specificity of the association between parental and offspring psychiatric disorders using epidemiological data from a series of parent and offspring interviews. A community-based sample of 593 mothers and their offspring from upstate New York were interviewed during the adolescence and early adulthood of the offspring. The children of parents with generalized anxiety disorder were at specifically elevated risk for anxiety disorders when co-occurring psychiatric disorders were controlled. The associations between parental and offspring antisocial, conduct, depressive, and substance use disorders were characterized by modest specificity. Children of parents with externalizing disorders were nearly as likely to develop internalizing disorders as they were to develop externalizing disorders. Children of parents with internalizing disorders were somewhat, but not significantly, more likely to develop internalizing disorders. These findings support the inference that children of parents with generalized anxiety disorder may be more likely to develop anxiety disorders than they are to develop other psychiatric disorders. However, when co-occurring psychiatric disorders are accounted for, the children of parents with depressive, disruptive, and substance use disorders may be as likely to develop other disorders as they are to develop the same type of disorder that their parents have had.     

Developmental and clinical predictors of comorbidity for youth with obsessive compulsive disorder

ObjectiveTo date, few studies of childhood obsessive compulsive disorder (OCD) have been adequately powered to examine patterns and predictors of comorbidity, despite the frequency with which it occurs. We address this gap, drawing on a large sample of youth with OCD who were systematically assessed through research and clinical programs in a university-based specialty program for children and adolescents with OCD. We examine patterns of comorbidity across different epochs of development and predict specific classes of OCD (comorbidity internalizing/externalizing/both) from key demographic and clinical variables that may be useful in guiding individualized treatment.MethodA total of 322 youths (mean age = 12.28, 53% male) were assessed using the Anxiety Disorders Interview Schedule (ADIS; Silverman and Albano, 1996), the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) and other standardized measures.ResultsConsistent with prior research, 50% of youth met criteria for a co-occurring anxiety or depressive disorder. Rates of externalizing disorders were lower (16%). Developmental differences emerged such that older youth met criteria for a higher number of co-occurring disorders. As expected, adolescents in particular were more likely to have a co-occurring internalizing disorder compared to early or pre-adolescent peers. Surprisingly, they were also more likely to have a comorbid externalizing disorder. Developmental trends were particularly striking with respect to depression, with adolescents with OCD demonstrating a six-fold greater likelihood of co-occurring depressive disorder compared to younger counterparts.DiscussionClinical implications are discussed with eye toward tailoring interventions, particularly during the transition to adolescence when youth are at heightened risk for depression.     

Clinical precursors of adolescent conduct disorder in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To examine precursors of adolescent conduct disorder (CD) in children with attention-deficit/hyperactivity disorder (ADHD), investigating the significance of childhood oppositional defiant disorder (ODD) and ADHD. METHOD: A total of 151 children with ADHD recruited from child psychiatric and pediatric clinics were assessed through standardized diagnostic interviews at ages 6 to 13 years and in adolescence 5 years later. Using multiple regression analysis, we assessed baseline ODD diagnosis and ODD, CD, and ADHD symptom scores as clinical predictors of adolescent CD diagnosis and symptom scores. RESULTS: Childhood ODD (diagnosis and severity) was significantly associated with adolescent CD (diagnosis and severity), independent of childhood ADHD severity and childhood CD. Children with a diagnosis of ODD were almost three times more likely to develop CD in adolescence (odds ratio = 2.79, 95% CI 1.16-6.70, p = .02). Childhood ADHD severity predicted adolescent CD scores but not diagnosis of CD (although there was a trend toward association). The presence of at least one CD symptom in childhood predicted adolescent CD severity. CONCLUSIONS: ODD is a significant precursor of adolescent CD in children with ADHD independent of ADHD severity. Considering the negative prognosis of ADHD with comorbid CD, it is imperative that clinicians pay specific attention to the presence of childhood ODD behaviors.     

Examining the relationships between error-related brain activity (the ERN) and anxiety disorders versus externalizing disorders in young children: Focusing on cognitive control,fear, and shyness

ObjectiveWe examine the relationship between individual differences in temperament (cognitive control, fear, and shyness) and the error-related negativity (i.e., the ERN) in a large sample of young children. Furthermore, we explore to what extent variation in temperament may underlie the associations between the ERN and anxiety disorders versus externalizing disorders.MethodUsing the Children's Behavior Questionnaire (CBQ), we focus on scales related to cognitive control (attentional focusing, attentional shifting, and inhibitory control) and a fearful/anxious temperament (fearfulness and shyness). We use diagnostic interviews to assess anxiety (specific phobia, separation anxiety disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and agoraphobia) and externalizing disorders (attention deficit hyperactivity disorder; ADHD, and oppositional defiant disorder; ODD). A go/no-go task was used to measure the ERN.ResultsResults suggest that while shyness was related to an increased ERN, fearfulness was associated with a decreased ERN. Moreover, increased cognitive control was related to an increased ERN, and an exploratory model suggested that while shyness displayed an independent relationship with the ERN, the relationship between fear and the ERN was accounted for by deficits in cognitive control. Additionally, we found that the ERN was increased in children with anxiety disorders, and that this association was explained by shyness, but not fear or cognitive control. In contrast, the ERN was blunted in children with externalizing disorders (ADHD or ODD), and this association was accounted for by lower levels of both shyness and cognitive control.ConclusionsOverall, these results are novel insofar as they suggest that the temperamental factors of shyness and cognitive control may underlie the associations between the ERN and internalizing versus externalizing disorders.     

Child and adolescent anxiety as a risk factor for bipolar disorder: A systematic review of longitudinal studies

Objectives

Several studies have suggested that anxiety disorders in childhood and adolescence often precede the onset of bipolar disorder. We therefore systematically reviewed the relationship between child and adolescent anxiety and later bipolar disorder.

Methods

Online databases (Medline [for Ovid], EMBASE and PsychINFO) were searched for original, peer-reviewed studies examining the relationship between child and adolescent anxiety and later bipolar disorder. Studies in both community samples and bipolar offspring samples were included.

Results

A total of 16 studies were included in the review. The results were broadly consistent and revealed that child and adolescent anxiety disorders are associated with later bipolar disorder in community samples. In bipolar offspring, child and adolescent anxiety disorders are a marker of increased risk and predict the onset of bipolar disorder and other major mood disorders.

Conclusions

There is evidence that anxiety disorders in childhood and adolescence increase the risk of later bipolar disorder. Anxiety disorders may be a useful target for early intervention in those at high-risk of bipolar disorder.     

Anxiety disorders of childhood and adolescence: a critical review

The 1980s were a decade of advancement in the knowledge of anxiety disorders in children and adolescents; this sets the stage for research achievements in the 1990s. This review examines the anxiety disorders of childhood and adolescence (separation anxiety disorder, overanxious disorder, and avoidant disorder), including prevalence rates, demographic profiles, comparisons of clinical presentations in different developmental age groups, and comorbidity patterns. Fears and simple phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder in children and adolescents are also evaluated. The controversy of whether panic attacks occur in prepubertal children is addressed. A brief review of behavioral and pharmacological treatment studies is included. Future directions for research are suggested.     

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.     

Psychiatric comorbidity in patients with pediatric bipolar disorder – A systematic review

Background

A growing body of evidence suggests that pediatric bipolar disorder (PBD) frequently co-occurs with comorbid psychiatric disorders that may impact functioning.

Objective

To review existing literature on the prevalence of psychiatric comorbidity and general functioning in patients with a primary diagnosis of PBD.

Methods

We performed a systematic literature search on the PubMed, Embase and PsycInfo databases on November 16th, 2022. We included original papers on patients ≤18 years with primary PBD and any comorbid psychiatric disorder, diagnosed according to a validated diagnostic tool. Risk of bias of the individual studies was assessed using the STROBE checklist. We calculated weighted means to assess the comorbidity prevalence. The review complied with PRISMA statement guidelines.

Results

Twenty studies with a total study population of 2722 patients with PBD were included (mean age = 12.2 years). We found an overall high prevalence of comorbidity in patients with PBD. The most common comorbidities were attention-deficit-hyperactivity disorder (ADHD) (60%) and oppositional defiant disorder (ODD) (47%). Anxiety disorders, obsessive–compulsive disorder, conduct disorder, tic disorders and substance-related disorders affected between 13.2% and 29% of patients, while one in 10 had comorbid mental retardation or autism spectrum disorder (ASD). The prevalence of comorbid disorders was lower in studies that assessed the current prevalence in patients in full or partial remission. General functioning was overall not specifically decreased in patients with comorbidity.

Conclusions

Comorbidity across a broad range of disorders was high in children diagnosed with PBD, especially regarding ADHD, ASD, behavioral and anxiety disorders including OCD. Future original studies should assess current prevalence of comorbidities in patients with PBD who are in remission to obtain more reliable estimates of psychiatric comorbidity in this patient group. The review highlights the clinical and scientific importance of comorbidity in PBD.     

Considering Comorbidity in Adolescents with Social Anxiety Disorder

Social anxiety disorder is a highly prevalent psychiatric disorder, with elevated comorbidity rates with other mental health disorders and may cause severe negative consequences. In adolescence, there is a lack of research on how comorbid disorders to social anxiety tends to form particular associations. With a large sample of adolescents with a clinical diagnosis of social anxiety disorder, data have revealed that certain disorders are more frequent and tend to dwell on concrete aggregates. Thus, it may be particularly useful and efficient for mental health providers, pediatricians and school counselors to screen for generalized anxiety disorder and specific phobia when assessing SAD in youth. Overall, findings stress the presence of comorbidity being the rule rather than the exception in adolescents with social anxiety disorder, and the need for further examination of its impact on assessment and differential diagnosis on this psychiatric disorder.     

Childhood and adulthood psychological ill health as predictors of midlife affective and anxiety disorders: the 1958 British Birth Cohort

CONTEXT: Affective and anxiety disorders in early adulthood are associated with internalizing and externalizing disorders in childhood. Previous studies have not examined whether the risk associated with childhood psychological ill health persists for midlife psychological health. OBJECTIVES: To examine whether childhood and adulthood psychological health are associated with midlife affective and anxiety disorders and to examine sex differences in these associations. DESIGN: Data were gathered during a biomedical survey of the 1958 British Birth Cohort, a 45-year longitudinal study of 98% of births in 1 week in 1958. SETTING: General population sample in England, Scotland, and Wales. PARTICIPANTS: Analyses were based on 9297 participants, 54% of the surviving sample. MAIN OUTCOME MEASURE: Diagnoses according to the International Statistical Classification of Diseases, 10th Revision (ICD-10) at age 45 years for depressive episode and generalized anxiety disorder. RESULTS: Internalizing and externalizing disorders at ages 7, 11, and 16 years were associated with a 1.5- to 2-fold increase in risk for midlife anxiety and affective disorder (P<.05), whereas psychological ill health at ages 23, 33, and 42 years was associated with a 2- to 7-fold increase in risk for midlife disorder (P<.05). Early-adulthood associations were significantly stronger for men (P<.05). Type and age at onset of childhood problems did not contribute to variations in the associations with midlife disorder. Risk for midlife disorder increased significantly with the cumulative number of adulthood reports of psychological ill health (P<.001). CONCLUSIONS: Childhood psychological health is an important independent distal factor in adulthood psychological health. Adulthood psychological health shows stronger associations with midlife disorders, indicating a poorer prognosis for adulthood than childhood psychological ill health. Men may be more susceptible than women to the effects of psychological ill health in early adulthood on midlife disorders. Targeting prevention, recognition, and treatment efforts in early adulthood, as well as in childhood and adolescence, may significantly reduce the burden of disease.     

Oppositional Defiant Disorder in Children With Intellectual Disabilities

The study examines the epidemiology of oppositional defiant disorder (ODD) for children with intellectual disabilities (ID; n = 49), children with borderline intellectual functioning (BIF; n = 20), and typically developing children (TD; n = 115). The Diagnostic Interview Schedule for Children was administered to mothers at child ages 5, 6, 7, 8, and 9 years. Children with ID had consistently higher rates of ODD than TD children, whereas children with BIF had intermediate prevalence rates. The comorbidity of ODD with other disorders, especially attention-deficit hyperactivity disorder, was elevated for children with ID. There were no group differences in gender, age of onset, or stability of ODD and all of the groups endorsed symptoms of ODD with the same relative frequency. Accordingly, the study findings generally support the assertion that ODD is the same disorder for children with and without ID.     

Obsessive-compulsive and spectrum disorders in children and adolescents.

The available literature indicates that OCD affecting children and adolescents is highly prevalent. Pediatric-onset OCD seems to share important similarities with the adult disorder but also shows important differences.For example, the clinical phenotype of OCD is remarkably consistent at all ages with some allowances for developmental expression. Pediatric patients frequently demonstrate poor insight into the nature of their obsessions, which in association with their limited verbal expression may make the diagnosis more difficult. Obsessions involving fear of harm and separation, compulsions without obsessions, and rituals involving family members are more common in younger patients. Treatment response,including serotonergic specificity and the need for robust dosing, is another feature shared by early- and adult-onset OCD. Imporfant differences across the life span can also be identified. Perhaps the clearest difference pertains to age of onset. Age-at-onset data have shown a bimodal distribution of age of onset of OCD, with one peak in preadolescent childhood and another peak in adulthood. Another distinction between child and adult OCD is gender representation. Whereas adult studies report equal gender representation or a slight female preponderance, pediatric clinical samples are clearly male predominant. Patterns of psychiatric comorbidity in pediatric OCD show high rates of tic and mood and anxiety disorders, similar to the patterns in adults, but also show a distinct association with disruptive behavior disorders (ADHD and oppositional defiant disorder) and other specific and pervasive developmental disorders. Family studies indicate that the disorder is highly familial and that a childhood onset of the disorder seems to be associated with a markedly increased risk for familial transmission of OCD, tic disorders, and ADHD.Both scientifically and clinically, the recognition of developmentally specific OCD phenotypes may be valuable. For example, research efforts aimed at identifying OCD-associated genes are likely to be more successful if developmentally homogeneous samples are studied instead of combining data from children, adolescents, and adults, as has been common in OCD studies.Clinical management is also informed by an appreciation of the unique cor-relates of OCD affecting youth, especially comorbidity with chronic tic dis-orders and ADHD and their impact on treatment.The so-called "spectrum disorders" related to OCD are less prominent in children and adolescents than in adults. Although sharing some features with typical OCD, these symptoms are less clearly ego-dystonic and less anxiety producing, frequently provide a measure of gratification, and are less responsive in general to SSRIs. Often cognitive antecedents to these behaviors are less well developed than in more typical OCD, and behavioral interventions are the mainstay of treatment but with more variable success.     

Internalizing and externalizing disorders in childhood and adolescence: A latent transition analysis using ALSPAC data

BackgroundResearch examining the association between internalizing and externalizing dimensions of psychopathology has relied heavily on variable-centered analytical techniques. Person-centered methodologies complement the variable-centered approach, and may help explain the medium-to-large correlations that exist between higher order dimensions of psychopathology. What little person-centered research exists has been cross-sectional and utilized adult samples. The present study sought to take a person-centered approach to the modeling of psychiatric comorbidity during a key developmental phase; middle childhood through adolescence.MethodsAnalysis was conducted on data from the Avon Longitudinal Study of Parents and Children (ALSPAC, N = 9282). Latent transition analysis (LTA) was conducted using eight DSM-IV disorders assessed at ages 7.5 and 14 years as measured indicators.ResultsAt both time points, a four class solution provided the best fit, with classes labeled as (i) normative, (ii) primarily internalizing, (iii) primarily externalizing, and (iv) high-risk/multimorbid. There was considerable individual-level stability across time, with approximately 80% of children remaining in the same class at both time points. Those in the internalizing class at baseline were more likely to transition to a less severe class (i.e., the normative class).ConclusionsPerson-centered methodologies demonstrate that the association between internalizing and externalizing is accounted for by a sub-population at high risk for experiencing psychiatric comorbidity, and ‘cross-class’ disorders which link the internalizing and externalizing spectra.     

Oppositional defiant and conduct disorders: issues to be resolved for DSM-IV.

Oppositional defiant disorder (ODD) and conduct disorder (CD) are reasonably distinct both in terms of statistical covariation among symptoms and ages of onset. The two disorders are related in similar ways to impairment and family history of antisocial behavior, but the association is stronger for CD than ODD. Virtually all clinic-referred youths with prepubertal onset of CD have retained the symptoms of ODD that emerged at earlier ages. Furthermore, a set of serious antisocial behaviors characteristically emerges at later ages in some youths with CD, suggesting further developmental progression within CD. These findings are consistent with a conceptualization of ODD and CD as developmentally staged, hierarchically organized levels of severity of the same disorder, but two findings argue for distinguishing separate disorders in DSM-IV: (1) many youths with ODD never develop CD, and (2) CD that emerges for the first time in adolescence appears to be independent of ODD.     

Forty-year psychiatric outcomes following assessment for internalizing disorder in adolescence

OBJECTIVE: The aim of this study was to define the long-term psychiatric outcomes of adolescent internalizing disorder in the general population, using data collected over 40 years from a national birth cohort. METHOD: A total of 3,279 members of the Medical Research Council National Survey of Health and Development (the 1946 British birth cohort) underwent assessments of psychiatric symptoms, primarily anxiety and depression, at ages 13 and 15. Adolescents who had internalizing disorder at both ages 13 and 15 and those who had internalizing disorder at one of the two ages were compared with mentally healthy adolescents on various psychiatric outcomes in adulthood (ages 26-53), including the prevalence of mental disorders, self-reported trouble with "nerves," suicidal ideation, and treatment for psychiatric disorders. RESULTS: About 70% of adolescents who had internalizing disorder at both ages 13 and 15 had mental disorder at age 36, 43, or 53, compared with about 25% of the mentally healthy adolescents. They were also more likely than healthy adolescents to have self-reported "nervous trouble" and to have been treated for psychiatric disorder during adulthood. None of these effects was apparent among subjects who had internalizing disorder at only one of the two adolescent assessments. CONCLUSIONS: The long-term psychiatric outcome for adolescents with persistent or recurrent internalizing disorder was poor, whereas the outcome for those who had a single episode was better than expected. The association between adolescent internalizing disorder and poor psychiatric outcomes in adulthood may be mediated by persistence or severity of symptoms in adolescence.