Khrista Boylan

Comorbidity of internalizing disorders in children with oppositional defiant disorder

Oppositional defiant disorder (ODD) is often comorbid with other psychiatric disorders in childhood. Its association with attention deficit hyperactivity disorder and conduct disorder has been well studied. Recent studies suggest that children with ODD have substantial comorbidity with anxiety and depressive (internalizing) disorders, as well. Identifying the pattern of internalizing comorbidity with ODD in childhood and adolescence and how this varies across age and gender may help to identify mechanisms of such comorbidity. This systematic review presents evidence on the association of internalizing disorders with ODD across childhood and adolescence. Data from cross-sectional and longitudinal studies in clinic, community and epidemiologic samples are considered separately. Findings suggest that while internalizing comorbidity with ODD is present at all ages, the degree of comorbidity may vary over time in particular groups of children. Girls and boys appear to have different patterns of ODD comorbidity with either anxiety or depression, as well as ages of onset of ODD, however more large studies are required. Children with ODD in early life require further study as they may be a subgroup at increased risk for anxiety and affective disorders. This could have important implications for the treatment of these ODD children and the prevention of sequential comorbidity.

Functional outcomes of child and adolescent oppositional defiant disorder symptoms in young adult men

BACKGROUND Oppositional defiant disorder(ODD) is considered to be a disorder of childhood, yet evidence suggests that prevalence rates of the disorder are stable into late adolescence and trajectories of symptoms persist into young adulthood. Functional outcomes associated with ODD through childhood and adolescence include conflict within families, poor peer relationships, peer rejection, and academic difficulties. Little examination of functional outcomes in adulthood associated with ODD has been undertaken. METHOD Data for the present analyses come from a clinic referred sample of 177 boys aged 7-12 followed up annually to age 18 and again at age 24. Annual parental report of psychopathology through adolescence was used to predict self-reported functional outcomes at 24. RESULTS Controlling for parent reported symptoms of attention deficit hyperactivity disorder (ADHD), Conduct disorder (CD), depression and anxiety, ODD symptoms from childhood through adolescence predicted poorer age 24 functioning with peers, poorer romantic relationships, a poorer paternal relationship, and having nobody who would provide a recommendation for a job. CD symptoms predicted workplace problems, poor maternal relationship, lower academic attainment, and violent injuries. Only parent reported ODD symptoms and child reported CD symptoms predicted a composite of poor adult outcomes. CONCLUSION Oppositional defiant disorder is a disorder that significantly interferes with functioning, particularly in social or interpersonal relationships. The persistence of impairment associated with ODD into young adulthood calls for a reconsideration of ODD as a disorder limited to childhood.

Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder

Objective: To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement. Method: A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓?); and strong, against (↓↓). Results: For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidones major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects. Conclusion: When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use.

Increased depressive symptoms in female but not male adolescents born at low birth weight in the offspring of a national cohort.

Objectives: To test if being born at low birth weight (LBW; <2500 g) or being small for gestational age (SGA; <10th percentile for gestational age [GA]) are associated with increased levels of depressive symptoms in youth and, if so, when these first emerge, if the relation is sex-specific, and whether this effect is direct or mediated by early life difficulties. Method: Associations between LBW, SGA, and depressive symptoms at ages 4 to 7 years and 10 to 14 years were tested in 1230 children born to the female participants of the National Longitudinal Study of Youth using linear regression models adjusting for maternal age, ethnicity, education, weight, depressive symptoms, marital status, and income. We also adjusted for GA, the childs age, and depressive symptoms at ages 4 to 7 years. Attention-deficit hyperactivity disorder (ADHD) symptoms and short-term memory at ages 8 to 10 years were also assessed for their putative role in mediating this relation. Results: LBW and SGA were associated with increased levels of depressive symptoms in adolescent girls only. This persisted despite adjustment for perinatal factors and was not accounted for by putative mediators. In males and females, increased levels of depressive symptoms were associated with elevated maternal pre-pregnancy weight, depression, and single marital status, as well as childhood ADHD and depressive symptoms. Similar results were found for infants born SGA. Conclusions: Our results support the existence of a female-specific association between LBW, SGA, and adolescent depressive symptoms. Differences in exposures to maternal mediators of stress or developmental factors may underlie these findings.

Psychopharmacologic treatment of pediatric major depressive disorder.

RationaleThe role of pharmacotherapy in the treatment of major depressive disorder (MDD) in youth has received much attention in recent years due to concerns of efficacy and safety of the antidepressants for the treatment of MDD in youth.ObjectivesThis review describes the existing published and unpublished literature regarding the efficacy and short-term safety of the antidepressants and decision-making process required for the use of these medications for youth with MDD. In addition, current continuation and maintenance treatments are discussed.ResultsIn general, nine depressed youth must be treated with an antidepressant to obtain one clinical response above that achieved with placebo. To date, fluoxetine has showed the most consistent positive treatment effects. Depressed youth had also acutely responded to other antidepressants, but the response to placebo has also been high. Overall, the antidepressants are well tolerated, but 1–3 children and adolescents of 100 taking antidepressants showed onset or worsening of suicidal ideation and, more rarely, suicide attempts.ConclusionsThere is a positive risk–benefit ratio for the use of antidepressants in the acute treatment of depressed youth. First-line antidepressant treatment with—or without—specific types of psychotherapy is indicated for youth with MDD of at least moderate severity. All youth taking antidepressants must be closely monitored for suicidality and medication side effects. Many youth will likely require psychotherapy or additional medication treatments to address comorbid disorders. Treatments to prevent relapses and recurrences require further study.

Bisphenol A, phthalates and lead and learning and behavioral problems in Canadian children 6–11 years of age: CHMS 2007–2009

Childhood developmental disorders and related problems such as learning disabilities and attention deficit hyperactivity disorder (ADHD) account for a growing burden on the family, education and health care systems. Exposure to environmental chemicals such as bisphenol A (BPA) and phthalates may play a role in the development of child behavioral problems. Using cross-sectional data from Cycle 1 of the Canadian Health Measures Survey (CHMS), we examined the potential association between urinary concentrations of BPA and various phthalate metabolites and child learning and behavioral problems, considering important covariates such as gender, blood lead and environmental tobacco smoke (ETS). The Strengths and Difficulties Questionnaire (SDQ) outcomes of interest were emotional symptoms, hyperactivity/inattention, and a total difficulties score with borderline and abnormal scores grouped together and compared with children with normal scores. Other outcomes studied included any reported learning disability, a subset of learning disabilities reported as ADD/ADHD (attention deficit disorder) and use of psychotropic medications in the past month. Among children ages 6-11 years, the prevalences of any learning disability, ADD, and ADHD were 8.7%, 1.5% and 2.8%, respectively. Estimated prevalences for SDQ hyperactivity/inattention, emotional symptoms and total difficulties scores were 16.9%, 15.0%, and 13.0%, respectively. Childs urinary BPA was associated with taking psychotropic medications (OR 1.59; 95% CI 1.05-2.40). Urinary MBzP concentration was significantly associated with emotional symptoms in girls (OR 1.38 95% CI 1.09-1.75) but not in boys (OR 1.05 95% CI 0.82-1.36).) Blood lead was significantly associated with several of the outcomes examined, with a significant interaction observed between prenatal smoking and blood lead for the total difficulties score (OR=10.57; 95% CI 2.81-39.69 vs. OR=1.98; 95% CI 1.41-2.79 if mother did not smoke during pregnancy). Although limited by the cross-sectional nature of the study which precludes examining causation, the results suggest that although some indicators of child behavior were significantly associated with their urinary BPA and phthalate concentrations, the major chemical associated with adverse behavioral indicators was lead.

Predicting borderline personality disorder symptoms in adolescents from childhood physical and relational aggression, depression, and attention-deficit/hyperactivity disorder

Developmental cascade models linking childhood physical and relational aggression with symptoms of depression and attention-deficit/hyperactivity disorder (ADHD; assessed at ages 10, 11, 12, 13, and 14) to borderline personality disorder (BPD) features (assessed at age 14) were examined in a community sample of 484 youth. Results indicated that, when controlling for within-time covariance and across-time stability in the examination of cross-lagged relations among study variables, BPD features at age 14 were predicted by childhood relational aggression and symptoms of depression for boys, and physical and relational aggression, symptoms of depression, and symptoms of ADHD for girls. Moreover, for boys BPD features were predicted from age 10 ADHD through age 12 depression, whereas for girls the pathway to elevated BPD features at age 14 was from depression at age 10 through physical aggression symptoms at age 12. Controlling for earlier associations among variables, we found that for girls the strongest predictor of BPD features at age 14 was physical aggression, whereas for boys all the risk indicators shared a similar predictive impact. This study adds to the growing literature showing that physical and relational aggression ought to be considered when examining early precursors of BPD features.

Confirmatory factor structure of anxiety and depression: evidence of item variance across childhood

The distinctiveness of anxiety and depressive symptoms in children has previously been questioned based on their high degree of comorbidity, shared risk factors, and treatment response. Developing children may show an unstable presentation of anxiety and depressive symptoms that would complicate interpretation of studies of comorbidity. The present study examined the measurement stability of anxiety and depressive symptoms across time and sex using a large epidemiologic sample of children. A nationally representative cohort of 1329 children (624 girls and 705 boys) aged four to seven in 1994 were drawn from the National Longitudinal Survey of Youth (NLSY). Using eight years of prospective data we examined whether a one or two factor structure of anxiety (five items) and depressive (four items) symptoms would be invariant across time and sex. Despite item variability within each factor across time, confirmatory factor analysis revealed distinct factors for anxiety and depression that were stable across time and sex. Results provide support that covariation between anxiety and depression is not likely the result of measurement overlap. However, items indicating factors of anxiety and depression in the NLSY may not be sufficient to permit developmentally‐sensitive measurement of these factors. Copyright

Processed data for CHMS 2007–2009: Bisphenol A, phthalates and lead and learning and behavioral problems in Canadian children 6–19 years of age

This article presents processed data from an analysis of cross-sectional data from Cycle 1 of the Canadian Health Measures Survey (CHMS) to examine the potential association between urinary concentrations of BPA and phthalate metabolites and child learning and behavioral problems, considering important covariates such as gender, blood lead and environmental tobacco smoke (ETS). These processed data are related to the research on a subset of the children (Arbuckle et al., 2016) [1]. The Strengths and Difficulties Questionnaire (SDQ) outcomes of interest were emotional symptoms, hyperactivity/inattention, and a total difficulties SDQ score, with borderline and abnormal scores grouped together and compared with children with normal scores. Other outcomes studied included reported learning disability, ADD/ADHD (attention deficit disorder/attention deficit hyperactivity disorder) and use of psychotropic medications to treat behavioral disorders in the past month. Data are presented for all children 6–19 years of age combined. Weighted simple logistic regression estimates for important covariates of each of the outcomes from CHMS Cycle 1 children are reported. Odds ratios based on weighted multiple logistic regression estimates for urinary BPA and phthalate metabolites (including specific gravity as a covariate) and blood lead are presented for the reported outcomes ADD/ADHD, learning disability and psychotropic medications, as well as the SDQ outcomes emotional symptoms, hyperactivity/inattention and total difficulties.

Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update

Objective: To update and extend our previous systematic review on first- (FGAs) and second-generation antipsychotics (SGAs) for treatment of psychiatric and behavioral conditions in children, adolescents, and young adults (aged ≤24 years). This article focuses on the evidence for harms. Method: We searched (to April 2016) 8 databases, gray literature, trial registries, Food and Drug Administration reports, and reference lists. Two reviewers conducted study screening and selection independently, with consensus for selection. One reviewer extracted and another verified all data; 2 reviewers independently assessed risk of bias. We conducted meta-analyses when appropriate and network meta-analysis across conditions for changes in body composition. Two reviewers reached consensus for ratings on the strength of evidence for prespecified outcomes. Results: A total of 135 studies (95 trials and 40 observational) were included, and 126 reported on harms. FGAs caused slightly less weight gain and more extrapyramidal symptoms than SGAs. SGAs as a class caused adverse effects, including weight gain, high triglyceride levels, extrapyramidal symptoms, sedation, and somnolence. They appeared to increase the risk for high cholesterol levels and type 2 diabetes. Many outcomes for individual drug comparisons were of low or insufficient strength of evidence. Olanzapine caused more short-term gains in weight and body mass index than several other SGAs. The dose of SGAs may not make a difference over the short term for some outcomes. Conclusions: Clinicians need to weigh carefully the benefit-to-harm ratio when using antipsychotics, especially when treatment alternatives exist. More evidence is needed on the comparative harms between antipsychotics over the longer term.