Albert E. Boon

A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care

A large proportion (28% up to 75%) of the treatments in youth mental health care results in premature termination (dropout). It is important to gain knowledge of the determinants of dropout because it can have very severe consequences. The aim of our meta-analytic review was to provide an overview of findings from empirical studies on this subject. We structured the often contradicting results from two perspectives. First, we compared studies with efficacy and effectiveness designs. Second, we compared studies which used a dropout definition based on the opinion of therapists, with those that took the number of predetermined completed sessions as a criterion. Third, we studied three groups of predictors, i.e., pre-treatment child variables, pre-treatment family or parent variables, and treatment and therapist variables or treatment participation barriers. The meta-analytic review showed that dropout percentages were strongly influenced by study design: Percentages were lower in efficacy than in effectiveness studies. Within effectiveness studies, the dropout percentages were lower when the therapists opinion was used rather than when the number of sessions was used as a criterion. In efficacy studies on the contrary, the dropout percentages were similar for studies using the first or the second criterion. With respect to dropout predictors, results were less clear. Some of the dropout predictors were influenced by study design or dropout definition, but for most predictors this influence could not be analyzed because they were not studied in all groups of studies or because the effect sizes were small or non-significant. Treatment and therapist variables or experienced treatment participation barriers were overall stronger dropout predictors than the pre-treatment child variables and pre-treatment family or parent variables, although some strong predictive pre-treatment variables emerged as well.

Childhood Emotional Maltreatment Severity Is Associated with Dorsal Medial Prefrontal Cortex Responsivity to Social Exclusion in Young Adults

Children who have experienced chronic parental rejection and exclusion during childhood, as is the case in childhood emotional maltreatment, may become especially sensitive to social exclusion. This study investigated the neural and emotional responses to social exclusion (with the Cyberball task) in young adults reporting childhood emotional maltreatment. Using functional magnetic resonance imaging, we investigated brain responses and self-reported distress to social exclusion in 46 young adult patients and healthy controls (mean age = 19.2±2.16) reporting low to extreme childhood emotional maltreatment. Consistent with prior studies, social exclusion was associated with activity in the ventral medial prefrontal cortex and posterior cingulate cortex. In addition, severity of childhood emotional maltreatment was positively associated with increased dorsal medial prefrontal cortex responsivity to social exclusion. The dorsal medial prefrontal cortex plays a crucial role in self-and other-referential processing, suggesting that the more individuals have been rejected and maltreated in childhood, the more self- and other- processing is elicited by social exclusion in adulthood. Negative self-referential thinking, in itself, enhances cognitive vulnerability for the development of psychiatric disorders. Therefore, our findings may underlie the emotional and behavioural difficulties that have been reported in adults reporting childhood emotional maltreatment.

Ethnic differences in utilization of youth mental health care

Objectives. There is an overall underutilization of youth mental health care (YMHC). It is unknown whether underutilization differs per ethnic group. Therefore, this study is aimed at gaining insight into the effects of ethnicity, age and gender on this utilization. Design. The sample consisted of outpatient children (age 5–10) (n=1940) and adolescents (age 11–19) (n=2484) admitted to a Dutch YMHC centre. Ethnic background of the patients (patient registration system) was compared to that of the general population (municipality files). Relative risks (RRs) on utilization for non-native groups were calculated with natives as the reference group. Results. With regard to children, female children from Moroccan, Turkish and other non-native western descent were less likely to enter mental health care than native Dutch female children. The RR was 0.24 for Moroccan girls, 0.53 for Turkish girls, and 0.60 for girls from other non-native western countries. Male children from almost all non-native groups were also less likely to enter mental health care than native Dutch male children, with the RRs being between 0.43 and 0.65. With regard to adolescents, most non-native adolescents, were as likely as native adolescents to enter mental health care. An exception were males and females from Morocco and males from Turkey and non-native western countries, who were less likely than Dutch adolescents to enter mental health care (RRs between 0.61 and 0.80). Conclusion and discussion. Results imply that YMHC is less accessible for children from a minority background than for children from a native background. With adolescents, there is no difference in accessibility between natives and non-natives. Future research should focus on the reasons for this difference in accessibility. Potential mediators such as socioeconomic status, discrimination, acculturation processes, language barriers should be taken into account.

Disorganized Amygdala Networks in Conduct-Disordered Juvenile Offenders With Callous-Unemotional Traits.

BACKGROUND The developmental trajectory of psychopathy seemingly begins early in life and includes the presence of callous-unemotional (CU) traits (e.g., deficient emotional reactivity, callousness) in conduct-disordered (CD) youth. Though subregion-specific anomalies in amygdala function have been suggested in CU pathophysiology among antisocial populations, system-level studies of CU traits have typically examined the amygdala as a unitary structure. Hence, nothing is yet known of how amygdala subregional network function may contribute to callous-unemotionality in severely antisocial people. METHODS We addressed this important issue by uniquely examining the intrinsic functional connectivity of basolateral amygdala (BLA) and centromedial amygdala (CMA) networks across three matched groups of juveniles: CD offenders with CU traits (CD/CU+; n = 25), CD offenders without CU traits (CD/CU-; n = 25), and healthy control subjects (n = 24). We additionally examined whether perturbed amygdala subregional connectivity coincides with altered volume and shape of the amygdaloid complex. RESULTS Relative to CD/CU- and healthy control youths, CD/CU+ youths showed abnormally increased BLA connectivity with a cluster that included both dorsal and ventral portions of the anterior cingulate and medial prefrontal cortices, along with posterior cingulate, sensory associative, and striatal regions. In contrast, compared with CD/CU- and healthy control youths, CD/CU+ youths showed diminished CMA connectivity with ventromedial/orbitofrontal regions. Critically, these connectivity changes coincided with local hypotrophy of BLA and CMA subregions (without being statistically correlated) and were associated to more severe CU symptoms. CONCLUSIONS These findings provide unique insights into a putative mechanism for perturbed attention-emotion interactions, which could bias salience processing and associative learning in youth with CD/CU+.

Childhood Characteristics of Adolescent Inpatients with Early-Onset and Adolescent-Onset Disruptive Behavior.

Childhood characteristics are associated with life-course-persistent antisocial behavior in epidemiological studies in general population samples. The present study examines this association in an inpatient sample. The purpose is to identify easily measurable childhood characteristics that may guide choice of treatment for adolescent psychiatric inpatients with severe disruptive behavior. Patients (N = 203) were divided into two groups with either early-onset (EO) or adolescent-onset (AO) disruptive behavior, based on ages at which professional care was used for disruptive behavior, referral to special education, and criminal offences. Both groups differed on several childhood characteristics. No gender differences in these characteristics were found. Logistic regression analysis indicated that individuals with grade retention in primary school, childhood impulsive behavior, and a history of physical abuse, had the highest probability of being member of the EO group. These characteristics are reasonably easy to identify, likely apply to other clinical samples as well, and may help clinicians to target their treatment.

The neural correlates of childhood maltreatment and the ability to understand mental states of others

ABSTRACT Background: Emotional abuse and emotional neglect are related to impaired interpersonal functioning. One underlying mechanism could be a developmental delay in mentalizing, the ability to understand other people’s thoughts and emotions. Objective: This study investigates the neural correlates of mentalizing and the specific relationship with emotional abuse and neglect whilst taking into account the level of sexual abuse, physical abuse and physical neglect. Method: The RMET was performed in an fMRI scanner by 46 adolescents (Age: M = 18.70, SD = 1.46) who reported a large range of emotional abuse and/or emotional neglect. CM was measured using a self-report questionnaire (CTQ). Results: Neither severity of emotional abuse nor neglect related to RMET accuracy or reaction time. The severity of sexual abuse was related to an increased activation of the left IFG during mentalization even when controlled for psychopathology and other important covariates. This increased activation was only found in a group reporting both sexual abuse and emotional maltreatment and not when reporting isolated emotional abuse or neglect or no maltreatment. Functional connectivity analysis showed that activation in the left IFG was associated with increased activation in the right insula and right STG, indicating that the IFG activation occurs in a network relevant for mentalizing. Conclusions: Being sexually abused in the context of emotional abuse and neglect is related to an increase in activation of the left IFG, which may indicate a delayed development of mirroring other people’s thoughts and emotions. Even though thoughts and emotions were correctly decoded from faces, the heightened activity of the left IFG could be an underlying mechanism for impaired interpersonal functioning when social situations are more complex or more related to maltreatment experiences.

Fairness decisions in response to emotions: a functional MRI study among criminal justice-involved boys with conduct disorder

Research suggests that individuals with conduct disorder (CD) are marked by social impairments, such as difficulties in processing the affective reactions of others. Little is known, though, about how they make decisions during social interactions in response to emotional expressions of others. In this study, we therefore investigated the neural mechanisms underlying fairness decisions in response to communicated emotions of others in aggressive, criminal justice-involved boys with CD (N = 32) compared with typically developing (TD) boys (N = 33), aged 15-19 years. Participants received written emotional responses (angry, disappointed or happy) from peers in response to a previous offer and then had to make fairness decisions in a version of the Dictator Game. Behavioral results showed that CD boys did not make differential fairness decisions in response to the emotions, whereas the TD boys did show a differentiation and also responded more unfair to happy reactions than the CD boys. Neuroimaging results revealed that when receiving happy vs disappointed and angry reactions, the CD boys showed less activation than the TD boys in the temporoparietal junction and supramarginal gyrus, regions involved in perspective taking and attention. These results suggest that boys with CD have difficulties with processing explicit emotional cues from others on behavioral and neural levels.

Characteristics of Adolescent Psychiatric Inpatients with Early-Onset and Adolescent-Onset Disruptive Behavior

The main aim of this study was to identify factors that diagnosticians in clinical practice can use to differentiate between adolescents on the life-course-persistent and adolescence-limited pathways of antisocial behavior. In epidemiological research these subtypes could not be distinguished based on their disruptive behavior. Because this differentiation is important for choice of treatment for adolescent psychiatric inpatients with severe disruptive behavior, the purpose of the present study was to identify easily measurable characteristics present in adolescence that are associated with the pathways. Male and female adolescent psychiatric inpatients were divided into either early-onset (EO) (n = 134) or adolescent-onset (AO) (n = 69) disruptive behavior, based on the age at which professional care was required for disruptive behavior, referral to special education occurred, or criminal offences were first committed. The groups differed on several characteristics. No gender differences were found in these characteristics. Logistic regression analysis indicated that males with a history of physical abuse, who were referred by a youth care facility had the highest probability of being member of the EO group. These characteristics are reasonably easy to identify, may apply to other clinical samples as well, and may help clinicians to target their treatment.

Drug usage as a treat to the stability of treatment outcome: a one-year follow-up study of adolescent psychiatric patients.

ObjectiveTo examine the stability of treatment outcome one year after discharge from an inpatient treatment programme for adolescents with severe behavioural problems combined with psychiatric disorders.MethodSymptom Check List-90 Revised (SCL-90 R) ratings were obtained at admission, discharge and one-year follow-up for 75 patients. Treatment outcome was determined by calculating clinically significant change on the SCL-90 R Global Severity Index (GSI) between admission and discharge. Stability of treatment outcome was determined by comparing the clinically significant changes on the GSI between admission and discharge, and between admission and follow-up.ResultsCompared to baseline, 46.7% of the patients recovered (reliable change was found and their GSI at discharge was below the cutoff point for the functional population), 20% improved (reliable change was found, but the GSI was still above the cutoff point). For the other patients no reliable change was found (12.0%) or they deteriorated (21.3%). At follow-up, compared to the base score, 52.0% recovered, 13.3% improved, 12.0% showed no reliable change, and 22.7% deteriorated. Although for the whole sample no significant change was found between discharge and follow-up, some individual patients continued to improve after discharge, while others deteriorated. Analyses show that drug usage during the follow-up period is a strong predictor for these changes.ConclusionThe results indicated that the majority of the patients recovered or improved during treatment and this treatment outcome was relatively stable at one-year follow-up. However, in a minority of patients the treatment results deteriorated during the one-year follow-up period. Drug usage turned out to be an important predictor for this deterioration.

Ethnic differences in DSM-classifications in youth mental health care practice

In community youth mental health care (YMHC), patients are mostly diagnosed according to the clinical judgment of professionals. Because validated instruments are hardly used, this process may be influenced by other factors than the diagnostic criteria, such as the ethnic background of the patient. The goal of our study was to assess differences between ethnic groups in the received clinical diagnoses. The sample consisted of children (n=1940) and adolescents (n=2484) admitted to a Dutch YMHC center. Ethnic background was specified based on the country of birth of the parents. Odds ratios on clinical diagnoses for non-native patients were calculated with the native patients as reference. The results showed that native patients more often received specific psychiatric disorders and co-morbid diagnoses on Axis I, while ethnic minority children more often received V-codes only, indicating that there was insufficient information to determine a psychiatric disorder. We therefore assume that it is harder to recognise psychiatric disorders when non-native patients are diagnosed. This could imply that immigrant children and adolescents are not adequately treated for their disorders in YMHC. We recommend that YMHC professionals should reflect on the potential biasing effect of the patients ethnic background in diagnostic procedures.