Prognostic Factors in Child and Adolescent Psychiatry.

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Prognostic Factors in Child and Adolescent
Psychiatry.

• A. James
• Oxford University.

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Continuities.
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Childhood and Adolescent Psychiatric Disordersas
Predictors of Young Adult Disorders

• Copeland et al, Arch Gen Psych 2009.

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Childhood and Adolescent Psychiatric Disordersas
Predictors of Young Adult DisordersCopeland, et
al Arch Gen Psych, 66 2009

• To study homotypic and heterotypic continuities
  while controlling for comorbidities, and
  examining child and adolescent predictors
  separately.

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Childhood and Adolescent Psychiatric Disordersas
Predictors of Young Adult DisordersCopeland, et
al Arch Gen Psych, 66 2009

• Adolescent depression significantly predicted
  young adult depression, but this effect was
  entirely accounted for by comorbidity of
  adolescent depression with adolescent
  oppositional defiant disorder, anxiety, and
  substance disorders in adjusted analyses.

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Childhood and Adolescent Psychiatric Disordersas
Predictors of Young Adult DisordersCopeland, et
al Arch Gen Psych, 66 2009

• 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

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Eating Disorders
AN
BN
Transdiagnosis
EDNOS
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Improvement or merely change?
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Early-Onset Schizophrenia.
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Factors associated with poor prognosis in EOS

• Compared with the adult-onset form of
  schizophrenia EOS, and in particular the most
  early onset cases, may be associated with worse
  prognosis
• (Jacobsen et al, 1998).

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Factors associated with poor prognosis in EOS

• Most follow up studies have found the majority of
  young persons being chronically ill, with very
  few having good functioning, and the majority
  showing poor or very poor outcomes on clinical
  measures.  

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• More optimistic outcomes have also been reported
  (Asarnow et al, 1994 Russell, 1994 Pencer et
  al, 2005) with up to around 60 showing
  significant improvement at follow up.

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Factors associated with poor prognosis in EOS

• Premorbid developmental delay.
• Premorbid function.
• Mode and age of onset.
• Degree of recovery and negative symptoms.

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Lay et al. (2000)

• 65 EOS patients over a period of more than 10
  years
• 83 of the patients as having at least one
  further episode needing hospitalisation 74 being
  under psychiatric treatment.
• At least moderate educational and occupational
  impairment was noted in 57 of this sample and
  serious social disability was found in 66.

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Eggers and Bunk, 1997 Remschmidt et al, 2006

• Eggers and Bunk 1977 44 EOS patients,
• 50 were found to have continuous symptoms and
  25 to be in partial remission.

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Remschmidt et al (2006)

• 38 patients retrospective ICD-10 diagnosis 42
  years after the initial presentation
• The overall prognosis of this cohort was poor
• less than a sixth have a favourable outcome
• 60 have a poor outcome.
• More than 70 did not graduate from school and
  were unemployed at the time of follow up.
• Significantly raised total death rate.

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ADAPT Study (Br J Psychiatry. 2009, 194334-41).

• There is great heterogeneity of clinical
  presentation and outcome in paediatric
  depression.
• Method
• RCT 192 adolescents with unipolar major
• Participants were treated for 28 weeks with
  routine psychosocial care and selective serotonin
  reuptake inhibitors (SSRIs), with half also
  receiving cognitive-behavioural therapy (CBT).

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ADAPT Study (Br J Psychiatry. 2009, 194334-41).

• Depression at 28 weeks was predicted by the
  additive effects of severity, obsessive-compulsive
  disorder and suicidal ideation at entry together
  with presence of at least one disappointing life
  event over the follow-up period.

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ADAPT Study (Br J Psychiatry. 2009, 194334-41).

• CONCLUSIONS Clinicians should assess for
  severity, suicidality and comorbid
  obsessive-compulsive disorder at presentation and
  should monitor closely for subsequent life events
  during treatment.

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The OPUS trial in Denmark and the Lambeth Early
Onset (LEO) in the UK

• Trial compared specialist multidisciplinary teams
  with standard care in community mental health
  settings.
• OPUS trial, specialist care included assertive
  community treatment, low-dose atypical
  antipsychotic medication, social skills training,
  multifamily psychoeducation.
• More of those randomized to specialist treatment
  had independent living arrangements, and fewer
  were homeless, better global functioning at
  2-year follow-up.
• More participants in the intervention group had
  resumed
• formal education and there was a greater
  reduction in
• positive and negative symptoms and less comorbid
  drug
• and alcohol abuse or dependence.

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Eating Disorders.(Steinhausen et al 2009).

• In AN, there are an almost 18-fold increase in
  mortality including a high suicide rate.
• Chronic courses in approximately 20 per cent of
  the cases.
• More than half of the patients show either a
  complete or a partial eating disorder in
  combination with another psychiatric disorder or
  another psychiatric disorder without an eating
  disorder.

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Eating Disorders.(Steinhausen et al 2009).

• Vomiting, bulimia and purgative abuse,
  chronicity, and obsessive-compulsive features
  represent unfavourable prognostic factors.
• Mitigating factors of the outcome include onset
  of the disorder during adolescence and longer
  duration of follow-up.

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Eating Disorders (Papadopoulos et al, BJP 2009).

• The overall SMR for anorexia nervosa was 6.2 (95
  CI 5.5-7.0). Anorexia nervosa, psychoactive
  substance use and suicide had the highest SMR.
• The SMR was significantly increased for almost
  all natural and unnatural causes of death.
• The SMR 20 years or more after the first
  hospitalisation remained significantly high.
• Lower mortality was found during the last two
  decades.
• Younger age and longer hospital stay at first
  hospitalisation was associated with better
  outcome, and psychiatric and somatic comorbidity
  worsened the outcome

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OCD. Ginsburg et al, JAACAP 2009

• Meta-analysis (6 cognitive-behavioral therapy,
  13 medication, and 2 combination studies).
• Among all of the studies, there was little
  evidence that sex, age, or duration of illness
  (age at onset) was associated with treatment
  response.
• Baseline severity of obsessive-compulsive
  symptoms and family dysfunction were associated
  with poorer response to cognitive-behavioural
  therapy,
• Comorbid tics and externalizing disorders were
  associated with poorer response in
  medication-only studies.

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OCD (Masi et al, 2009)

• Paediatric obsessive-compulsive disorder (OCD)
  can cause substantial impairment in academic,
  social and family functioning.
• Evaluation of cognitive-behavioural therapy
  (CBT)/- enhancement in a consecutive series of
  257 patients (174 males and 83 females mean age
  13.6/-2.7 years) diagnosed with OCD.
• 37 children improved significantly after
  psychotherapy and were excluded. The remaining
  220 patients were included in the study.
• Eighty-nine patients (40.5) were managed with
  SRI monotherapy and 131 with an SRI in
  combination with another medication.

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OCD

• Compared with those who needed polypharmacy,
  patients managed with SRI monotherapy were
  younger at the time of the first consultation,
  had less severe symptoms at baseline, and more
  frequently presented with co-occurring anxiety
  and depressive disorders.
• Patients receiving polypharmacy presented with
  higher rates of bipolar disorder, tic disorder
  and disruptive behaviour disorders.

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OCD

• 135 patients (61.4) achieved a positive clinical
  response and were considered responders.
• Responders had less severe disease at baseline,
  were younger at the time of the first
  consultation, more frequently presented with the
  contamination/cleaning phenotype and less
  frequently presented with the hoarding phenotype.

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Cytochrome P450 2D6 Genotyping Potential Role in
Improving Treatment Outcomes in Psychiatric
Disorders
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Irritability Stringaris et al, AGP 2009
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Loeber

• 1. Factor analyses suggest that two ODD factors
  exist, one of negative affect and the other
  representing defiance.
• 2. The negative affect but not the defiant
  component of ODD predicts later depression.
• 3. ODD rather than CD may explain the comorbidity
  between CD and depression.
• 4. It is not clear whether and how child
  temperament may be distinguished from ODD
• symptoms.

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• Psychopathic features in childhood are about as
  stable as ODD/CD symptoms, but developmental
  changes have also been noted.
• Psychopathic features independently predict
  later conduct problems and antisocial behavior
• beyond earlier initial conduct problem severity.
• Aetiological factors of psychopathic features
  appear similar to those factors associated
• with ODD and CD, but there is a need to document
  etiological factors that are unique
• to psychopathic features.

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• Research on developmental pathways shows that ODD
  and CD symptoms appear to be stepping stones to
  serious forms of delinquency.
• Loebers pathway model shows three pathways
  (overt, covert, and authority conflict) to
  serious delinquency. Children can be on more than
  one pathway.
• Research on developmental trajectories often
  shows four groups
• problem behavior remains high over time,
• problem behavior remains low,
• problem behavior increases,
• behavior decreases between childhood and early
  adulthood.

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• Most of the risk factors predicting delinquency
  also predict symptoms of disruptive behavior.
• There is replicated evidence of a dose-response
  relationship between children and adolescents
  exposure to an accumulation of risk factors
  across multiple domains and an increased
  probability of later adverse outcomes.
• It is probable that the most salient risk window
  of childrens exposure to risk factors is prior
  to adolescence.

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• The sum of promotive and risk factors is a better
  predictor of later problems compared to knowledge
  of risk or promotive factors only.
• Promotive factors tend to buffer the impact of
  risk factors.
• The natural occurring balance between risk and
  promotive factors may change over time
• The prevalence of promotive factors appears
  highest in middle childhood, and risk compared to
  promotive factor tends to be more dominant during
  adolescence.