Lilly Shanahan

Childhood and Adolescent Psychiatric Disorders as Predictors of Young Adult Disorders

CONTEXT Most adults with a psychiatric disorder first met diagnostic criteria during childhood and/or adolescence, yet specific homotypic and heterotypic patterns of prediction have not been firmly established. OBJECTIVE To establish which childhood and adolescent psychiatric disorders predict particular young adult disorders when accounting for comorbidities, disaggregating similar disorders, and examining childhood and adolescent predictors separately. DESIGN Eleven waves of data from the prospective population-based Great Smoky Mountains Study (N = 1420) were used. SETTING The Great Smoky Mountains Study is a longitudinal study of the development of psychiatric disorder and need for mental health services in rural and urban youth. A representative sample of children was recruited from 11 counties in western North Carolina. PARTICIPANTS Children in the community aged 9 to 16, 19, and 21 years. MAIN OUTCOME MEASURES Common psychiatric disorders were assessed in childhood (ages 9-12 years) and adolescence (ages 13-16 years) with the Child and Adolescent Psychiatric Assessment and in young adulthood (ages 19 and 21 years) with the Young Adult Psychiatric Assessment. RESULTS Adolescent depression significantly predicted young adult depression in the bivariate analysis, but this effect was entirely accounted for by comorbidity of adolescent depression with adolescent oppositional defiant disorder, anxiety, and substance disorders in adjusted analyses. Generalized anxiety and depression cross-predicted each other, and oppositional defiant disorder (but not conduct disorder) predicted later anxiety disorders and depression. Evidence of homotypic prediction was supported for substance use disorders, antisocial personality disorder (from conduct disorder), and anxiety disorders, although this effect was primarily accounted for by DSM-III-R overanxious disorder. CONCLUSIONS Stringent tests of homotypic and heterotypic prediction patterns suggest a more developmentally and diagnostically nuanced picture in comparison with the previous literature. The putative link between adolescent and young adult depression was not supported. Oppositional defiant disorder was singular in being part of the developmental history of a wide range of young adult disorders.

Cumulative Prevalence of Psychiatric Disorders by Young Adulthood: A Prospective Cohort Analysis From the Great Smoky Mountains Study.

OBJECTIVE No longitudinal studies beginning in childhood have estimated the cumulative prevalence of psychiatric illness from childhood into young adulthood. The objective of this study was to estimate the cumulative prevalence of psychiatric disorders by young adulthood and to assess how inclusion of not otherwise specified diagnoses affects cumulative prevalence estimates. METHOD The prospective, population-based Great Smoky Mountains Study assessed 1,420 participants up to nine times from 9 through 21 years of age from 11 counties in the southeastern United States. Common psychiatric disorders were assessed in childhood and adolescence (ages 9 to 16 years) with the Child and Adolescent Psychiatric Assessment and in young adulthood (ages 19 and 21 years) with the Young Adult Psychiatric Assessment. Cumulative prevalence estimates were derived from multiple imputed datasets. RESULTS By 21 years of age, 61.1% of participants had met criteria for a well-specified psychiatric disorder. An additional 21.4% had met criteria for a not otherwise specified disorder only, increasing the total cumulative prevalence for any disorder to 82.5%. Male subjects had higher rates of substance and disruptive behavior disorders compared with female subjects; therefore, they were more likely to meet criteria for a well-specified disorder (67.8% vs 56.7%) or any disorder (89.1% vs 77.8%). Children with a not otherwise specified disorder only were at increased risk for a well-specified young adult disorder compared with children with no disorder in childhood. CONCLUSIONS Only a small percentage of young people meet criteria for a DSM disorder at any given time, but most do by young adulthood. As with other medical illness, psychiatric illness is a nearly universal experience.

Longitudinal Patterns of Anxiety From Childhood to Adulthood: The Great Smoky Mountains Study

OBJECTIVE The aims of this study were 2-fold: to provide a brief introduction to the prospective longitudinal Great Smoky Mountains Study and review recent findings; and to use this sample to conduct an epidemiologic analysis of common childhood anxiety disorders. METHOD The population-based Great Smoky Mountains Study assessed 1,420 participants from 11 counties in the southeastern United States up to 11 times between ages 9 and 26 years with the structured Child and Adolescent Psychiatric Assessment and its upward extension, the Young Adult Psychiatric Assessment. RESULTS The U-shaped age prevalence curve for any anxiety disorder was the product of high levels of childhood separation anxiety and adult panic, agoraphobia, and generalized anxiety. More than 1 in 5 subjects met criteria for an anxiety disorder by early adulthood. In terms of cumulative comorbidity, there was evidence of overlap between anxiety disorders, but the level of overlap was generally consistent with what is seen among other common childhood disorders. All childhood anxiety disorders were associated with adverse functioning in at least 1 young adult functional domain, with the poorest outcomes for childhood generalized anxiety and DSM-III-R overanxious disorder. CONCLUSION Clinically significant anxiety is a common mental health problem to have had by adulthood. There was little evidence to support the consolidation of anxiety disorders, and some evidence to justify reintroduction of DSM-III-R overanxious disorder. The transition to young adulthood appears to be a key period for understanding the development of common adult anxiety disorders such as panic and agoraphobia.

Outcomes of Early Pubertal Timing in Young Women: A Prospective Population-Based Study

OBJECTIVE Early pubertal timing in girls is associated with psychosocial problems throughout adolescence, but it is unclear whether these problems persist into young adulthood. The authors analyzed outcomes in adolescence and young adulthood in girls in a longitudinal study. METHOD The data for this study were from the prospective population-based Great Smoky Mountains Study (N=1,420), which initially recruited children at ages 9, 11, and 13 and followed them into young adulthood. Pubertal timing was defined on the basis of self-reported Tanner stage and age at menarche. Outcome measures included functioning related to crime, substance use, school/peer problems, family relationships, sexual behavior, and mental health in adolescence (ages 13 to 16) as well as crime, substance use, education/socioeconomic status, sexual behavior, and mental health in young adulthood (ages 19 and 21). RESULTS In adolescence, early-maturing girls displayed higher levels of self-reported criminality, substance use problems, social isolation, early sexual behavior, and psychiatric problems. By young adulthood, most of these differences had attenuated. Functioning for early maturers improved in some areas; in others, on-time and late maturers had caught up with their early-maturing peers. Nevertheless, early-maturing girls, particularly those with a history of adolescent conduct disorder, were more likely to be depressed in young adulthood compared to their counterparts. Early maturers were also more likely to have had many sexual partners. CONCLUSIONS The effects of early pubertal timing on adolescent psychosocial problems were wide ranging but diminished by young adulthood for all but a small group.

Cumulative depression episodes predict later C-reactive protein levels: a prospective analysis.

BACKGROUND Depression is associated with elevated levels of the inflammation marker C-reactive protein (CRP); yet, the direction of this association remains unclear. This study tested bi-directional longitudinal associations between CRP and depression in a sample of adolescents and young adults. The study compared the effect of current depression with the effect of cumulative episodes of depression over time. METHODS Nine waves of data from the prospective population-based Great Smoky Mountains Study (n = 1420) were used, covering children in the community aged 9 to 16, 19, and 21 years old. Structured interviews were used to assess depressive symptoms, depression diagnosis, and cumulative depressive episodes. Bloodspots were collected at each observation and assayed for CRP levels. RESULTS CRP levels were not associated with later depression status. In contrast, all depression-related variables displayed evidence of association with later CRP levels. The associations with depressive symptoms and diagnostic status were attenuated after controlling for covariates, particularly body mass index, smoking, and medication use. The effect of cumulative depressive episodes, however, continued to be significant after accounting for a range of covariates. Body mass index, smoking behavior, and recent infections may mediate a portion of the effect of cumulative episodes on later CRP, but cumulative depressive episodes continued to predict CRP levels independently. CONCLUSIONS The occurrence of multiple depressive episodes exerted the greatest effect on later CRP levels. This suggests that risk for the diseases of middle and old age--cardiovascular and metabolic disease--may begin in childhood and depend, in part, on long-term emotional functioning.

Sleep Problems Predict and Are Predicted by Generalized Anxiety/Depression and Oppositional Defiant Disorder

OBJECTIVE We tested whether sleep problems co-occur with, precede, and/or follow common psychiatric disorders during childhood and adolescence. We also clarified the role of comorbidity and tested for specificity of associations among sleep problems and psychiatric disorders. METHOD Data came from the Great Smoky Mountains Study, a representative population sample of 1,420 children, assessed 4 to 7 times per person between ages 9 and 16 years for major Diagnostic and Statistical Manual-Fourth Edition (DSM-IV) disorders and sleep problems. Sleep-related symptoms were removed from diagnostic criteria when applicable. RESULTS Sleep problems during childhood and adolescence were common, with restless sleep and difficulty falling asleep being the most common symptoms. Cross-sectional analyses showed that sleep problems co-occurred with many psychiatric disorders. Longitudinal analyses revealed that sleep problems predicted increases in the prevalence of later generalized anxiety disorder (GAD) and high GAD/depression symptoms, and oppositional defiant disorder (ODD). In turn, GAD and/or depression and ODD predicted increases in sleep problems over time. CONCLUSIONS Sleep problems both predict and are predicted by a diagnostic cluster that includes ODD, GAD, and depression. Screening children for sleep problems could offer promising opportunities for reducing the burden of mental illness during the early life course.

Childhood bullying involvement predicts low-grade systemic inflammation into adulthood

Significance Bullying is a common childhood experience that affects children at all income levels and racial/ethnic groups. Being a bully victim has long-term adverse consequences on physical and mental health and financial functioning, but bullies themselves display few ill effects. Here, we show that victims suffer from greater increases in low-grade systemic inflammation from childhood to young adulthood than are seen in others. In contrast, bullies showed lower increases in inflammation into adulthood compared with those uninvolved in bullying. Elevated systemic low-grade inflammation is a mechanism by which this common childhood social adversity may get under the skin to affect adult health functioning, even many years later. Bullying is a common childhood experience that involves repeated mistreatment to improve or maintain one’s status. Victims display long-term social, psychological, and health consequences, whereas bullies display minimal ill effects. The aim of this study is to test how this adverse social experience is biologically embedded to affect short- or long-term levels of C-reactive protein (CRP), a marker of low-grade systemic inflammation. The prospective population-based Great Smoky Mountains Study (n = 1,420), with up to nine waves of data per subject, was used, covering childhood/adolescence (ages 9–16) and young adulthood (ages 19 and 21). Structured interviews were used to assess bullying involvement and relevant covariates at all childhood/adolescent observations. Blood spots were collected at each observation and assayed for CRP levels. During childhood and adolescence, the number of waves at which the child was bullied predicted increasing levels of CRP. Although CRP levels rose for all participants from childhood into adulthood, being bullied predicted greater increases in CRP levels, whereas bullying others predicted lower increases in CRP compared with those uninvolved in bullying. This pattern was robust, controlling for body mass index, substance use, physical and mental health status, and exposures to other childhood psychosocial adversities. A child’s role in bullying may serve as either a risk or a protective factor for adult low-grade inflammation, independent of other factors. Inflammation is a physiological response that mediates the effects of both social adversity and dominance on decreases in health.

Configurations of common childhood psychosocial risk factors

BACKGROUND Co-occurrence of psychosocial risk factors is commonplace, but little is known about psychiatrically-predictive configurations of psychosocial risk factors. METHODS Latent class analysis (LCA) was applied to 17 putative psychosocial risk factors in a representative population sample of 920 children ages 9 to 17. The resultant class structure was retested in a representative population sample of 1420 children aged 9 to 13. In each sample, the child and one parent were interviewed with the Child and Adolescent Psychiatric Assessment. Concurrent psychiatric status was used to validate class membership. RESULTS LCA identified five latent classes in both samples: two low risk classes; two moderate risk classes both involving family poverty configured with various other risk factors; and a high risk class characterized by family relational dysfunction and parental risk characteristics. Of the primary sample, 48.6% were categorized as low risk, 42.8% as moderate risk, and 8.6% as high risk. Moderate risk classes differed in their prediction of disruptive and emotional disorders depending on their specific risk factor configurations. High risk youth had the highest levels of both emotional and disruptive disorders. Combining our latent classes with a cumulative risk approach best accounted for the effects of risk factors on psychopathology in our primary sample. CONCLUSIONS Particular risk configurations have specific associations with psychiatric disorders. Configurational approaches are an important asset for large-scale epidemiological studies that integrate information about patterns of risk and disorders.

Adult Functional Outcomes of Common Childhood Psychiatric Problems: A Prospective, Longitudinal Study

IMPORTANCE Psychiatric problems are among the most common health problems of childhood. OBJECTIVE To test whether these health problems adversely affect adult functioning even if the problems themselves do not persist. DESIGN, SETTING, AND PARTICIPANTS Prospective, population-based study of 1420 participants from 11 predominantly rural counties of North Carolina who were assessed with structured interviews up to 6 times during childhood (9-16 years of age, for a total 6674 observations) for common psychiatric diagnoses and subthreshold psychiatric problems. The period for this study was from 1993 to 2010. MAIN OUTCOMES AND MEASURES A total of 1273 participants were assessed 3 times during young adulthood (19, 21, and 24-26 years of age, for a total of 3215 observations) for adverse outcomes related to health, the legal system, personal finances, and social functioning. RESULTS Participants with a childhood disorder had 6 times higher odds (odds ratio [OR], 5.9 [95% CI, 3.6-9.7]) of at least 1 adverse adult outcome (ie, indicator) compared with those with no history of psychiatric problems and 9 times higher odds (OR, 8.7 [95% CI, 4.3-17.8]) of 2 or more such indicators (1 indicator: 59.5% vs 19.9% [P < .001]; ≥ 2 indicators: 34.2% vs 5.6% [P < .001]). These associations persisted after statistically controlling for childhood psychosocial hardships and adult psychiatric problems. Risk was not limited to those who received a diagnosis; participants with subthreshold psychiatric problems had 3 times higher odds (OR, 2.9 [95% CI, 1.8-4.8]) of adult adverse outcomes and 5 times higher odds (OR, 5.1 [95% CI, 2.4-10.7]) of 2 or more outcomes (1 indicator: 41.9% vs 19.9% [P < .001]; ≥ 2 indicators: 23.2% vs 5.6% [P < .001]). The best diagnostic predictor of adverse outcomes was cumulative childhood exposure to psychiatric disorders. CONCLUSIONS AND RELEVANCE Common, typically moderately impairing, childhood psychiatric problems are associated with a disrupted transition to adulthood even if the problems do not persist into adulthood and even if the problems are subthreshold. Such problems provide a potential target for public health efforts to ameliorate adult suffering and morbidity.

Adult Diagnostic and Functional Outcomes of DSM-5 Disruptive Mood Dysregulation Disorder

OBJECTIVE Disruptive mood dysregulation disorder (DMDD) is a new disorder for DSM-5 that is uncommon and frequently co-occurs with other psychiatric disorders. Here, the authors test whether meeting diagnostic criteria for this disorder in childhood predicts adult diagnostic and functional outcomes. METHOD In a prospective, population-based study, individuals were assessed with structured interviews up to six times in childhood and adolescence (ages 10 to 16 years; 5,336 observations of 1,420 youths) for symptoms of DMDD and three times in young adulthood (ages 19, 21, and 24-26 years; 3,215 observations of 1,273 young adults) for psychiatric and functional outcomes (health, risky/illegal behavior, financial/educational functioning, and social functioning). RESULTS Young adults with a history of childhood DMDD had elevated rates of anxiety and depression and were more likely to meet criteria for more than one adult disorder relative to comparison subjects with no history of childhood psychiatric disorders (noncases) or individuals meeting criteria for psychiatric disorders other than DMDD in childhood or adolescence (psychiatric comparison subjects). Participants with a history of DMDD were more likely to have adverse health outcomes, be impoverished, have reported police contact, and have low educational attainment as adults compared with either psychiatric or noncase comparison subjects. CONCLUSIONS The long-term prognosis of children with DMDD is one of pervasive impaired functioning that in many cases is worse than that of other childhood psychiatric disorders.