Clinical decision support methods for children and youths with mental health disorders in primary care.

BACKGROUND: Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs). OBJECTIVES: This review aimed to identify CDSMs in the literature and describe their functionalities and quality. METHODS: In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols. RESULTS: Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories. CONCLUSION: Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

Mental health problems among children and youths are common and have impacts, not only on the person affected but also on families and communities. They are often not recognized and acted upon by primary care providers (PCPs), such as general practitioners. This may be due to a lack of confidence in talking to young people or insufficient knowledge about mental health problems. PCPs make decisions about managing or referring these problems to mental health specialists, which can be assisted through clinical decision support methods (CDSMs). CDSMs can be divided into electronic and non-electronic. This study provided an overview of both types of CDSMs. We focused on the capabilities of CDSMs and how they help PCPs in their decision-making. More than half of the reviewed CDSMs were electronic CDSMs; several CDSMs involved telecommunication between PCPs and mental health specialists. Two of the CDSMs comprised a combination of components of both types of CDSMs. CDSMs offered patients more information about their health while providing PCPs with suggestions for their decision-making.

Suicidal Behavior in Juvenile Delinquents: The Role of ADHD and Other Comorbid Psychiatric Disorders.

This study evaluated the role of psychiatric morbidity in relation to a history of suicidal behavior, with a particular focus on attention-deficit/hyperactivity disorder (ADHD). Suicidality and psychiatric diagnoses were assessed in 370 incarcerated male juvenile delinquents from Northern Russia using the semi-structured K-SADS-PL psychiatric interview. A lifetime history of suicidal ideation only (24.7 %) and suicidal ideation with suicide attempts (15.7 %) was common. Binary logistic regression analysis was used to assess the role of ADHD and other psychiatric disorders in suicidal ideation and suicide attempts. A history of suicidal ideation and of suicide attempts were associated with higher rates of psychiatric morbidity and with the number of comorbid psychiatric disorders. An ADHD diagnosis was associated with an increased risk for both suicidal ideation and for suicide attempts. The comorbidity of ADHD with drug dependence further increased the risk for suicidal ideation, while ADHD and alcohol dependence comorbidity increased the risk for suicide attempts. Our findings highlight the importance of adequately detecting and treating psychiatric disorders in vulnerable youths, especially when they are comorbid with ADHD.

Exploring possible association between DßH genotype (C1021T), early onset of conduct disorder and psychopathic traits in juvenile delinquents.

Early onset of conduct disorder (CD) with callous-unemotional traits has been linked to low levels of dopamine ß-hydroxylase (DßH), an enzyme involved in dopamine turnover. The C1021T polymorphism in the DßH gene is a major quantitative-trait locus, regulating the level of DßH. In this study of juvenile delinquents from Northern Russia (n = 180), the polymorphism at -1021 was associated neither with early-onset CD nor with psychopathic traits. Association was found between psychopathic traits and early-onset CD, ADHD and mania.

Language development in rural and urban Russian-speaking children with and without developmental language disorder.

Using a newly developed Assessment of the Development of Russian Language (ORRIA), we investigated differences in language development between rural vs. urban Russian-speaking children (n = 100 with a mean age of 6.75) subdivided into groups with and without developmental language disorders. Using classical test theory and item response theory approaches, we found that while ORRIA displayed overall satisfactory psychometric properties, several of its items showed differential item functioning favoring rural children, and several others favoring urban children. After the removal of these items, rural children significantly underperformed on ORRIA compared to urban children. The urbanization factor did not significantly interact with language group. We discuss the latter finding in the context of the multiple additive risk factors for language development and emphasize the need for future studies of the mechanisms that underlie these influences and the implications of these findings for our understanding of the etiological architecture of children's language development.

Enuresis in young offenders - a study on prevalence and mental health comorbidity.

Background: Enuresis is a common disorder in the school-age period, and is often associated with a variety of behavioral, psychological, and social problems. While early studies suggested an association between enuresis and delinquent behavior, there has been no recent research assessing the prevalence of enuresis and its comorbid psychopathology in young offenders. The aim of this study was to therefore assess the prevalence of enuresis and its associated psychiatric comorbidity in incarcerated young offenders. Methods: The prevalence of past and current enuresis and comorbid psychopathology was assessed using a semi-structured psychiatric interview and self-reports from 366 incarcerated male young offenders [age 14 to 19 years (mean age = 16.4)] from Northern Russia. Results: Seventy-three (20.0%) adolescents reported a previous history of enuresis, and in addition almost 10% of the youth reported current enuresis symptoms. Delinquent youth with enuresis did not significantly differ from other youth in the prevalence of comorbid psychiatric diagnoses when assessed by a clinical diagnostic interview, but had significantly higher levels of self-reported mental health problems, and suicidal ideation and attempts. Conclusion: Problems with enuresis are common among delinquent youth and may be associated with increased mental health problems. Given the potentially increased risk for suicidal thoughts and behavior in young offenders with enuresis, comprehensive mental health screening of those who are detected with this condition should be considered in the juvenile justice system.

Bulimia Symptoms in Russian Youth: Prevalence and Association With Internalizing Problems.

BACKGROUND: There has been limited research on bulimia symptoms in adolescents from the general population outside the United States. This study aimed to evaluate the prevalence of bulimia symptoms in Russian youth and explore the associations between a clinical level of self-reported probable bulimia nervosa (BN) and internalizing problems, binge drinking and functional impairment by gender. METHODS: Data were collected from a representative sample of school students (N = 2,515, 59.5% female) from Northern Russia [age M (SD) = 14.89 ± 1.13 years]. Probable BN and internalizing psychopathology were assessed using self-report scales. Chi-square and independent sample t-tests were used to compare respondents' demographic characteristics and disordered eating behaviors. GLM multivariate analysis of covariance was used to assess the associations between probable BN, functional impairment and mental health problems (MHP) by gender. RESULTS: Analyses showed that the 3-month prevalence of probable BN was higher in girls (3.9%) than in boys (1.2%). Probable BN was associated with depressive and anxiety symptoms, somatic anxiety, somatic complaints, binge drinking and functional impairment. Boys reported a higher level of problem scores in relation to probable BN. CONCLUSIONS: Our findings suggest that bulimia symptoms are prevalent in Russian adolescents and are associated with MHP and functional impairment. Timely recognition of bulimia symptoms and associated MHP is important for early prevention and intervention strategies.

Risky sexual behaviour among Russian adolescents: association with internalizing and externalizing symptoms.

BACKGROUND: Risky sexual behaviour (RSB) is regarded as a major health problem during adolescence. Russia has one of the highest rates of teenage pregnancy, abortion and newly diagnosed HIV infections in the world, but research on RSB in Russian youth has been limited. To address this deficit, this study examined the role of several factors, including internalizing and externalizing symptoms, in RSB among Russian adolescents. METHODS: Self-reported data were collected from 2573 Russian adolescents aged 13-17 years old (59.4 % girls; Mean age = 14.89) regarding RSB (unprotected sex, early pregnancy, multiple sexual partners and substance use during sexual encounters). Information was also obtained on externalizing (conduct problems and delinquent behaviour) and internalizing (depression, anxiety and posttraumatic stress) symptoms, as well as interpersonal risk and protective factors (affiliation with delinquent peers, parental involvement and teacher support). Hierarchical multiple binary logistic regression analysis was used to examine the associations between these variables and RSB. RESULTS: Boys reported engaging in more RSB than girls. Externalizing symptoms and affiliation with delinquent peers were most strongly associated with RSB, whereas symptoms of anxiety were negatively associated with RSB. There was an interaction effect for sex and affiliation with delinquent peers on RSB with boys reporting RSB when having more delinquent peers. Neither parental involvement nor teacher support were protective against RSB. CONCLUSIONS: Early detection of and interventions for RSB and associated externalizing symptoms may be important for adolescent physical and mental wellbeing. Affiliation with delinquent peers should, especially among boys, be regarded as a risk marker for RSB.

Aggressive behavior, related conduct problems, and variation in genes affecting dopamine turnover.

A number of dopamine-related genes have been implicated in the etiology of violent behavior and conduct problems. Of these genes, the ones that code for the enzymes that influence the turnover of dopamine (DA) have received the most attention. In this study, we investigated 12 genetic polymorphisms in four genes involved with DA functioning (COMT, MAOA and MAOB, and DbetaH) in 179 incarcerated male Russian adolescents and two groups of matched controls: boys without criminal records referred to by their teachers as (a) "troubled-behavior-free" boys, n=182; and (b) "troubled-behavior" boys, n=60. The participants were classified as (1) being incarcerated or not, (2) having the DSM-IV diagnosis of conduct disorder (CD) or not, and (3) having committed violent or nonviolent crimes (for the incarcerated individuals only). The findings indicate that, although no single genetic variant in any of the four genes differentiated individuals in the investigated groups, various linear combinations (i.e., haplotypes) and nonlinear combinations (i.e., interactions between variants within and across genes) of genetic variants resulted in informative and robust classifications for two of the three groupings. These combinations of genetic variants differentiated individuals in incarceration vs. nonincarcerated and CD vs. no-CD groups; no informative combinations were established consistently for the grouping by crime within the incarcerated individuals. This study underscores the importance of considering multiple rather than single markers within candidate genes and their additive and interactive combinations, both with themselves and with nongenetic indicators, while attempting to understand the genetic background of such complex behaviors as serious conduct problems.

Psychopathy and violence in juvenile delinquents: what are the associated factors?

The purpose of the present study was a) to examine the discriminative power of the Antisocial Process Screening Device (APSD), aggressive traits, impulsiveness, antisocial attitudes and alcohol-related problems between subgroups of Russian juvenile delinquents (n=175) with low versus high levels of violent behavior; and b) to compare the predictive value of these variables in two subgroups defined by higher versus lower levels of psychopathic traits. Results demonstrated that the APSD score, traits of physical aggression and alcohol-related problems were able to discriminate between groups with various levels of violence. Furthermore, the level of violence was the only variant factor when comparing levels of psychopathy. Finally, different sets of predictors emerged for the group with higher versus lower psychopathy scores. The results are discussed in relation to specific features of psychopathy and environmental factors in general and the use of alcohol in particular.

Platelet MAO-B, personality, and psychopathology.

The article investigates the relationships between platelet monoamine oxidase-B (MAO-B) activity, personality, and psychopathology (Diagnostic and Statistical Manual of Mental Disorders [4th ed.; American Psychiatric Association, 1994] diagnoses. These relationships were assessed in 178 incarcerated male juvenile delinquents. Even after controlling for smoking, the authors found that both Internalizing and Externalizing Psychopathology were negatively related to MAO-B activity. In the final reduced model, novelty seeking fully mediated the relationships between MAO-B and Externalizing Psychopathology but not between MAO-B and Internalizing Psychopathology. It was hypothesized that low platelet MAO-B activity does not directly predispose individuals to psychopathology but is related to specific personality traits, which in turn represent a vulnerability factor for psychopathology. Future studies should help clarify the nature of the relationships between personality, biological markers, and psychopathology.

Pro-bullying attitudes among incarcerated juvenile delinquents: antisocial behavior, psychopathic tendencies and violent crime.

The objective was to evaluate a new scale aimed at assessing antisocial attitudes, the Pro-bullying Attitude Scale (PAS), on a group of 259 voluntarily-recruited male juvenile delinquents from a juvenile correctional institution in Arkhangelsk, North-western Russia. Exploratory factor analysis gave a two-factor solution: Factor 1 denoted Callous/Dominance and Factor 2 denoted Manipulativeness/Impulsiveness. Subjects with complete data on PAS and Childhood Psychopathy Scale (CPS) (n=171) were divided into extreme groups (first and fourth quartiles) according to their total scores on PAS and the two factor scores, respectively. The extreme groups of total PAS and PAS Factor 1 differed in CPS ratings and in violent behavior as assessed by the Antisocial Behavior Checklist (ABC). They also differed in the personality dimension Harm Avoidance as measured by use of the Temperament and Character Inventory (TCI), and in delinquent and aggressive behavior as assessed by the Youth Self Report (YSR). The extreme groups of PAS Factor 2, in turn, differed in aggressive behavior as assessed by the YSR, and in the TCI scale Self-Directedness. When PAS was used as a continuous variable, total PAS and PAS Factor 1 (Callous/Dominance) were significantly positively related to registered violent crime. The possible usefulness of PAS in identifying high-risk individuals for bullying tendencies among incarcerated delinquents is discussed.

Variation in the catechol-O-methyltransferase Val 158 Met polymorphism associated with conduct disorder and ADHD symptoms, among adolescent male delinquents.

OBJECTIVE: Variation in the catechol-O-methyltransferase gene (COMT) has been associated with antisocial behavior in populations with attention deficit/hyperactivity disorder (ADHD). This study examined whether COMT would predict antisocial behavior in a sample with high levels of behavior problems, not necessarily ADHD. In addition, because previous research suggests that COMT may be associated with ADHD in males, association between COMT and ADHD symptoms was examined. METHOD: This study tested whether variation in three polymorphisms of the COMT gene was predictive of symptoms of conduct disorder and ADHD, in a sample of 174 incarcerated Russian adolescent male delinquents. RESULTS: The Val allele of the ValMet polymorphism was significantly associated with conduct disorder diagnosis and symptoms, whereas the Met allele was associated with ADHD symptoms. CONCLUSION: The ValMet polymorphism of the COMT gene shows a complex relation to behavior problems, influencing conduct disorder and ADHD symptoms in opposite directions in a high-risk population.

Association between polymorphisms in the dopamine transporter gene and depression: evidence for a gene-environment interaction in a sample of juvenile detainees.

Previous research has generated examples of how genetic and environmental factors can interact to create risk for psychopathology. Using a gene-by-environment (G x E) interaction design, we tested whether three polymorphisms in the dopamine transporter gene (DAT1, also referred to as SLC6A3, located at 5p15.33) interacted with maternal parenting style to predict first-onset episodes of depression. Participants were male adolescents (N= 176) recruited from a juvenile detention center in northern Russia. As hypothesized, one of the polymorphisms (rs40184) moderated the effect of perceived maternal rejection on the onset of major depressive disorder, as well as on suicidal ideation. Further, this G x E interaction was specific to depression; it did not predict clinically significant anxiety. These results highlight the need for further research investigating the moderating effects of dopaminergic genes on depression.

Exploring interactive effects of genes and environments in etiology of individual differences in reading comprehension.

It is established that reading and reading-related processes are heritable; genes thus play an important role in the foundation of individual differences in reading. In this article, we focus on one facet of reading-comprehension. Comprehension is a higher order cognitive skill that requires many other cognitive processes for it to unfold completely and successfully. One such process is executive functioning, which has been associated with genetic variation in the catechol-O-methyltransferase (COMT) gene. Genotypes and haplotypes of four single nucleotide polymorphisms in COMT were investigated in 179 incarcerated adolescent delinquents. Four hierarchical logistic regression models predicting the presence/absence of comprehension difficulties were fitted to the data; genetic variation in COMT and the presence/absence of maternal rejection were investigated as main effects and as effects acting interactively. Three out of four interaction terms were found to be important predictors of individual differences in comprehension. These findings were supported by the results of the haplotype analyses, in which the four investigated polymorphisms were considered simultaneously.

Depressive symptoms and associated psychopathology in urban adolescents: a cross-cultural study of three countries.

The study aimed to compare cross-cultural trends of comorbid internalizing and externalizing psychopathology, prosocial beliefs, and perceptions of risk in adolescents with and without clinical levels of self-reported depressive symptoms. The Social and Health Assessment, a self-report survey, was conducted in a representative sample of 3309 adolescents 14 to 17 years old from urban communities in the United States (N = 1343), Belgium (N = 946), and Russia (N = 1009). In all three countries, girls reported higher levels of depressive symptoms than boys. The findings also demonstrate that in both genders, depressive symptoms were associated with increased levels of internalizing and externalizing problems, as well as lower levels of prosocial beliefs and low perceptions of harm from risk-taking behavior. Depressed boys had relatively higher levels of externalizing problems than depressed girls. Greater levels of internalizing problems observed in depressed youth, as compared with their nondepressed counterparts, were not gender-specific. Current findings suggest that the relationships between depression and comorbid psychopathology are not culture-specific and have similar patterns in different populations.

Alcohol expectancies in relation to personality and aggression among juvenile delinquents in Northern Russia.

The relationships between alcohol expectancies, level of alcohol use, alcohol-related problems, aggression, and personality factors in 198 Russian male juvenile delinquents were assessed. A clustering procedure was used in order to establish main patterns of alcohol expectancies, yielding three major clusters. Level of alcohol use, alcohol-related problems, aggression, and personality factors were compared across the identified clusters. It was established that juvenile delinquents with a high level of positive alcohol expectancies and aggression represented a risk-group for higher involvement in drinking behavior as well as problem drinking, which in turn are related to specific personality traits. Implications of these findings for alcohol prevention among the youth are discussed.

Alcohol abuse in Russian delinquent adolescents. Associations with comorbid psychopathology, personality and parenting.

INTRODUCTION: Adolescent delinquency and alcohol abuse have become a growing concern in Russia. Psychopathology, a dysfunctional family and specific personality factors have all been linked to addictive and antisocial behavior. Since delinquent youth represent a specific risk group, where alcohol misuse tends to be more pronounced than in the general population, the objectives of this study were: 1) to compare differences in personality and parenting factors, and in psychopathology in juvenile delinquents with and without alcohol abuse; and 2) to evaluate the associations between alcohol abuse, personality and parenting factors, after controlling for comorbid psychopathology. METHODS: Psychopathology, including alcohol abuse, was assessed by means of a psychiatric interview in 229 Russian incarcerated male juvenile delinquents. In addition, alcohol use, personality, and parenting factors were assessed by self-reports. RESULTS: Alcohol-abusing delinquents (n=138) scored significantly higher on novelty seeking and maternal emotional warmth and reported higher levels of psychopathology, as compared to nonalcohol-abusing delinquents (n=91). Logistic regression analysis demonstrated that personality and parenting factors were significantly related to alcohol abuse, even after controlling for comorbid psychopathology. CONCLUSION: Alcohol-abusing delinquents are at risk for a wide spectrum of psychiatric disorders. Alcohol abuse is associated with personality and parenting factors independently of comorbid psychopathology. Early interventions with high-risk youths may help to reduce their psychiatric problems and alcohol abuse.

Sense of coherence: a mediator between violence exposure and psychopathology in Russian juvenile delinquents.

Previous research has demonstrated that exposure to community violence tends to have a hazardous impact on the health and well being of youth. In this context, sense of coherence is related to indicators of well being and mental health and is considered crucial for human information processing in resolving conflicts and coping with enduring stress. The aim of the present study was to explore the role of sense of coherence as a potential mediator in the relationships between community violence exposure and psychopathology, controlling for involvement in severe problem behavior. The study was conducted with a group of Russian juvenile delinquents (N = 159; a highly traumatized population with a history of frequent exposure to violence), who completed a set of questionnaires assessing their exposure to community violence, psychopathology, involvement in severe problem behaviors, and sense of coherence. The relationships among the variables of interest were explored using a structural equation modeling approach. Sense of coherence partially mediated the link between victimization and psychopathology. The direct relationships between victimization and psychopathology decreased in size, suggesting that higher levels of sense of coherence can potentially reduce the levels of psychopathology. These results have an important theoretical value and are meaningful for clinical work, suggesting that preventive and therapeutic interventions should aim at increasing sense of coherence, which might be especially valuable in populations at risk.

Suicidal ideations and attempts in juvenile delinquents.

BACKGROUND: Suicidality among adolescents is a common focus of clinical attention. In spite of links to disruptive behaviors and other types of psychopathology, it is not clear whether other factors commonly associated with suicide, such as personality and parenting, predict suicidality over and above psychopathology. The purpose of the present study was to assess suicidal ideations and attempts and their relationship to psychopathology, violence exposure, personality traits and parental rearing in Russian male juvenile delinquents with conduct disorder (CD). METHOD: Suicidality and psychopathology were assessed using a semi-structured psychiatric interview in 271 incarcerated male juvenile delinquents diagnosed with CD. Violence exposure, personality characteristics and perceived parental rearing were assessed via self-reports. RESULTS: Thirty-four percent of those diagnosed with CD (92 subjects) reported a lifetime history of either suicidal thoughts or attempts. Suicidal ideators and attempters did not differ significantly on any variable of interest, but both reported significantly higher rates of psychopathology and violence exposure than the non-suicidal group, as well as higher levels of harm avoidance, lower self-directedness, and higher rates of perceived negative parental rearing. Finally, even when controlling for the relationship with psychopathology, personality and perceived parental rearing factors showed significant associations with suicidality. CONCLUSIONS: Juvenile delinquents with CD have high rates of suicidal ideations and attempts, related to a wide spectrum of psychopathology and specific personality traits. These findings suggest that a combination of intrinsic and extrinsic factors create vulnerability to stressors, which under the influence of situational factors (e.g., repeated traumatization) may lead to suicidal thoughts and acts. Factors potentially contributing to vulnerability for suicidality should be identified when planning prevention and rehabilitation efforts for troubled youth.