Prognostic Factors in Child and Adolescent Psychiatry.

1. Prognostic Factors in Child and Adolescent Psychiatry. A. James Oxford University.

2. Continuities.

3. Childhood and Adolescent Psychiatric Disordersas Predictors of Young Adult Disorders Copeland et al, Arch Gen Psych 2009.

4. 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.

5. 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.

6. 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

7. Eating Disorders AN BN Transdiagnosis EDNOS

8. Improvement or merely change?

9. Early-Onset Schizophrenia.

10. 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).

11. 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.  

12. 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.

13. Factors associated with poor prognosis in EOS Premorbid developmental delay. Premorbid function. Mode and age of onset. Degree of recovery and negative symptoms.

14. 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%.

15. 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.

16. 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.

17. ADAPT Study (Br J Psychiatry. 2009, 194:334-41). • 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).

18. ADAPT Study (Br J Psychiatry. 2009, 194:334-41). • 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.

19. ADAPT Study (Br J Psychiatry. 2009, 194:334-41). • CONCLUSIONS: Clinicians should assess for severity, suicidality and comorbid obsessive-compulsive disorder at presentation and should monitor closely for subsequent life events during treatment.

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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.

27. 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.

28. Cytochrome P450 2D6 Genotyping: Potential Role in Improving Treatment Outcomes in Psychiatric Disorders

29. Irritability: Stringaris et al, AGP 2009

30. 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.

31. 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.

32. Research on developmental pathways shows that ODD and CD symptoms appear to be stepping stones to serious forms of delinquency. • Loeber’s 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.

33. 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 children’s exposure to risk factors is prior to adolescence.

34. 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.