Kirstin Goth

CBCL-pediatric bipolar disorder phenotype: severe ADHD or bipolar disorder?

SummaryBackground. In children with pediatric bipolar disorder (PBD), a consistent pattern of elevations in hyperactivity, depression/anxiety, and aggression has been identified on the child behavior checklist (CBCL-PBD profile). The aim of the present study was to estimate the prevalence of the CBCL-PBD profile in a child psychiatric sample, and to determine ICD-10 diagnoses in CBCL-PBD patients.Methods. We studied a sample of 939 consecutively referred children and adolescents, aged 4–18 years. ICD-10 discharge diagnoses were established in consensus conferences. The CBCL 4–18 was completed by parents as part of the diagnostic routine.Results. A total of 62 subjects (6.6%; 95% CI=5.2–8.4) met criteria for the CBCL-PBD phenotype. More than 75% of CBCL-PBD subjects were clinically diagnosed with disruptive behavior disorders (ADHD, ODD, and CD). Two patients (0.2% of the total sample) received a formal diagnosis of bipolar disorder, but did not show the CBCL-PBD phenotype.Conclusions. A considerable number of children in Germany are referred to psychiatric care with a mixed phenotype of aggression, anxiety, depression and attention problems. Our study demonstrated a comparable prevalence and similar clinical characteristics as reported from other countries using different diagnostic approaches. However, the CBCL-PBD phenotype does not correspond with clinical consensus diagnoses of bipolar disorder, but with severe disruptive behavior disorders.

Assessment of identity development and identity diffusion in adolescence - Theoretical basis and psychometric properties of the self-report questionnaire AIDA

BackgroundIn the continuing revision of Diagnostic and Statistical Manual (DSM-V) “identity” is integrated as a central diagnostic criterion for personality disorders (self-related personality functioning). According to Kernberg, identity diffusion is one of the core elements of borderline personality organization. As there is no elaborated self-rating inventory to assess identity development in healthy and disturbed adolescents, we developed the AIDA (Assessment of Identity Development in Adolescence) questionnaire to assess this complex dimension, varying from “Identity Integration” to “Identity Diffusion”, in a broad and substructured way and evaluated its psychometric properties in a mixed school and clinical sample.MethodsTest construction was deductive, referring to psychodynamic as well as social-cognitive theories, and led to a special item pool, with consideration for clarity and ease of comprehension. Participants were 305 students aged 12–18 attending a public school and 52 adolescent psychiatric inpatients and outpatients with diagnoses of personality disorders (N = 20) or other mental disorders (N = 32). Convergent validity was evaluated by covariations with personality development (JTCI 12–18 R scales), criterion validity by differences in identity development (AIDA scales) between patients and controls.ResultsAIDA showed excellent total score (Diffusion: α = .94), scale (Discontinuity: α = .86; Incoherence: α = .92) and subscale (α = .73-.86) reliabilities. High levels of Discontinuity and Incoherence were associated with low levels in Self Directedness, an indicator of maladaptive personality functioning. Both AIDA scales were significantly different between PD-patients and controls with remarkable effect sizes (d) of 2.17 and 1.94 standard deviations.ConclusionAIDA is a reliable and valid instrument to assess normal and disturbed identity in adolescents. Studies for further validation and for obtaining population norms are in progress and may provide insight in the relevant aspects of identity development in differentiating specific psychopathology and therapeutic focus and outcome.

Severe affective and behavioral dysregulation in youth is associated with increased serum TSH

BACKGROUND The relationship of bipolar disorder (BD) and altered thyroid function is increasingly recognized. Recently, a behavioral phenotype of co-occurring deviance on the Anxious/Depressed (A/D), Attention Problems (AP), and Aggressive Behavior (AB) syndrome scales has been identified as the Child Behavior Checklist Dysregulation Profile (CBCL-DP), which itself has been linked to BD. This study tested for differences in thyroid function within a sample of n=114 psychiatric children and adolescents with and without the CBCL-DP. METHOD A CBCL-DP score was generated based on the composite of the crucial CBCL syndrome scales (A/D, AP, AB). Participants with a CBCL-DP score >or=2.5 SDs above average constituted the CBCL-DP subgroup (n=53). Those with CBCL-DP scores of 1 SD or less above average percentile were regarded as controls (n=61). Groups were compared regarding serum levels of TSH, fT3 and fT4. RESULTS In participants showing the CBCL-DP, basal serum TSH was elevated compared to controls. More CBCL-DP subjects than controls showed subclinical hypothyroidism. No differences were observed for serum fT3 and fT4 levels. CONCLUSIONS This is the first study to demonstrate associations between CBCL-DP and subclinical hypothyroidism. Future research should address the long-term outcome of CBCL-DP with coexisting hypothyroidism, the potential benefits of supplementation with thyroid hormone, and the association between severe dysregulation and the bipolar spectrum.

Severe affective and behavioural dysregulation is associated with significant psychosocial adversity and impairment

BACKGROUND Recently, a highly heritable behavioral phenotype of simultaneous deviance on the Anxious/Depressed, Attention Problems, and Aggressive Behavior syndrome scales has been identified on the Child Behavior Checklist (CBCL-Dysregulation Profile, CBCL-DP). This study aims to investigate psychosocial adversity and impairment of the CBCL-DP. METHODS A total of 9024 patients aged 4-18 years were assessed using the CBCL, and the axes V and VI of ICD-10. RESULTS ANOVA revealed significant differences regarding psychosocial adversity and impairment between patients with CBCL-DP phenotype and the clinical control group, patients with attention problems, and patients with attention problems and additional anxious/depressed symptoms as assessed by the CBCL. Patients with CBCL-DP showed significant psychosocial adversity and impairment. However, in most cases patients with aggressive behavior showed equal psychosocial adversity as patients with CBCL-DP. CONCLUSIONS Findings suggest the CBCL-DP phenotype to be associated with significant psychosocial adversity and impairment either as a cause or an effect of the syndrome. Clinicians should carefully address psychosocial adversity and impairment with particular attention to the adversity and impairment of adolescents with CBCL-DP.

Identity development in adolescents with mental problems

BackgroundIn the revision of the Diagnostic and Statistical Manual (DSM-5), “Identity” is an essential diagnostic criterion for personality disorders (self-related personality functioning) in the alternative approach to the diagnosis of personality disorders in Section III of DSM-5. Integrating a broad range of established identity concepts, AIDA (Assessment of Identity Development in Adolescence) is a new questionnaire to assess pathology-related identity development in healthy and disturbed adolescents aged 12 to 18 years. Aim of the present study is to investigate differences in identity development between adolescents with different psychiatric diagnoses.MethodsParticipants were 86 adolescent psychiatric in- and outpatients aged 12 to 18 years. The test set includes the questionnaire AIDA and two semi-structured psychiatric interviews (SCID-II, K-DIPS). The patients were assigned to three diagnostic groups (personality disorders, internalizing disorders, externalizing disorders). Differences were analyzed by multivariate analysis of variance MANOVA.ResultsIn line with our hypotheses, patients with personality disorders showed the highest scores in all AIDA scales with T>70. Patients with externalizing disorders showed scores in an average range compared to population norms, while patients with internalizing disorders lay in between with scores around T=60. The AIDA total score was highly significant between the groups with a remarkable effect size of f= 0.44.ConclusionImpairment of identity development differs between adolescent patients with different forms of mental disorders. The AIDA questionnaire is able to discriminate between these groups. This may help to improve assessment and treatment of adolescents with severe psychiatric problems.

[Personality and social responsiveness in autism spectrum disorders and attention deficit/hyperactivity disorder].

OBJECTIVES This study addresses the question whether personality dimensions differ between children with autism spectrum disorders (ASD) and attention deficit/hyperactivity disorder (ADHD), and whether these personality characteristics influence social problems in these groups of children. METHODS 68 children with ADHD (n = 32) and ASD (n = 36) were assessed with the Junior Temperament and Character Inventory (JTCI 7-11 R) and the Social Responsiveness Scale (SRS), as rated by the parents. Diagnosis of ASD was confirmed with standardized diagnostic instruments (ADOS und ADI-R). RESULTS Both children with ASD and ADHD displayed significantly decreased scores in persistence, self-directedness and cooperativeness compared to normative values. Additionally, children with ASD showed extremely low reward dependence and differed significantly from children with ADHD in the temperament dimensions harm avoidance and reward dependence as well as in the character dimensions self-directedness and cooperativeness. In both groups, personality dimensions, especially reward dependence, were predictive of social responsiveness, as assessed by the SRS. CONCLUSION The results suggest that specific personality characteristics are present already in young children with ASD and ADHD and may have an impact on their social competence.

Temperament und soziale Reaktivit?t bei Autismus-Spektrum-St?rungen und ADHS

OBJECTIVES This study addresses the question whether personality dimensions differ between children with autism spectrum disorders (ASD) and attention deficit/hyperactivity disorder (ADHD), and whether these personality characteristics influence social problems in these groups of children. METHODS 68 children with ADHD (n = 32) and ASD (n = 36) were assessed with the Junior Temperament and Character Inventory (JTCI 7-11 R) and the Social Responsiveness Scale (SRS), as rated by the parents. Diagnosis of ASD was confirmed with standardized diagnostic instruments (ADOS und ADI-R). RESULTS Both children with ASD and ADHD displayed significantly decreased scores in persistence, self-directedness and cooperativeness compared to normative values. Additionally, children with ASD showed extremely low reward dependence and differed significantly from children with ADHD in the temperament dimensions harm avoidance and reward dependence as well as in the character dimensions self-directedness and cooperativeness. In both groups, personality dimensions, especially reward dependence, were predictive of social responsiveness, as assessed by the SRS. CONCLUSION The results suggest that specific personality characteristics are present already in young children with ASD and ADHD and may have an impact on their social competence.

Psychometric Results of the Music Therapy Scale (MAKS) for Measuring Expression and Communication

The Music Therapy Rating Scale (MAKS), originally developed in 1996, was evaluated again in 2009 using a sample of 62 children from a psychiatric unit and from different primary schools, with measures at three different time points during therapy process. The scale is intended as an objective rating of a client’s musical behavior. The evaluation of the scale was to determine any possible ambiguity or weakness in the discriminatory power of the scale items. After excluding such items, the results show high reliability ( a > .75) and good objectivity with trained raters (r > .70) for the two main scales and a significant sensitivity to change. Keywords musical communication, musical expression, music therapy, rating scale MAKS

Psychopharmakotherapie einer ambulanten und stationären Inanspruchnahmepopulation adoleszenter Patienten mit Borderline-Persönlichkeitsstörung

OBJECTIVE The majority of adult patients with borderline personality disorder (BPD) are treated with psychotropic drugs. However, there are no data on psychotropic therapy in adolescents. This study examines the prevalence of BPD in an adolescent population undergoing either inpatient or outpatient psychiatric treatment and assesses psychotropic prescription patterns in adolescent in- and outpatients with BPD. METHODS Out of a population of adolescents undergoing psychiatric treatment over a seven-year observation period, 58 adolescent patients with BPD (16.7 +/- 2.5 years) were investigated retrospectively with regard to their first episode of treatment, type of medication, and different risk variables. RESULTS Out of the investigated population, 37 inpatients and 21 outpatients received treatment. Inpatients were shown to have higher rates of risk variables (approx. 68% with co-morbid disorders and approx. 49% with self-harmful behaviour, significantly (p < .001) more attempted suicides in their patient history) and higher rates of psychotropic treatment (p < .001). Antidepressants (SSRI and NaSSA) were most commonly prescribed, followed by neuroleptics. More than 50% of the medicated patients were treated with multiple psychotropic drugs administered simultaneously. CONCLUSIONS Pharmacotherapy in BPD has a high and increasing therapeutic value, with the prescription of psychotropic drugs being primarily symptom-orientated. Pharmacotherapy of co-morbid disorders should be accorded equal treatment priority. In line with this, psychotropic treatment of BPD in adolescents is increasingly important. Inpatient adolescents are more burdened in terms of psychiatric risk variables, and also receive medication more often.

Background and practical use of the assessment of identity development in adolescence (AIDA)

A paradigm shift towards early detection and intervention of personality disorders in adolescence to prevent persistent and chronic suffering is currently taking place. Aside further distinct areas of impaired psychosocial integrity, disturbed identity development is seen as one core component of personality disorders. Thus, the detection of early antecedents of impaired identity development is an important step to allow for early intervention. The self-report questionnaire Assessment of Identity Development in Adolescence (AIDA) is a reliable and valid diagnostic instrument to detect disturbed identity development. This questionnaire allows for global assessment of identity and a differentiation in fundamental subdomains as well and distinguishes between identity diffusion on one side and consolidated and stable identity on the other. In clinical practice, it supports the differentiation between severely disturbed identity as the core component of personality disorders and identity crisis or stable identity development that can be found in other mental disorders.