Towards a youth mental health paradigm: a perspective and roadmap.

Most mental disorders have a typical onset between 12 and 25 years of age, highlighting the importance of this period for the pathogenesis, diagnosis, and treatment of mental ill-health. This perspective addresses interactions between risk and protective factors and brain development as key pillars accounting for the emergence of psychopathology in youth. Moreover, we propose that novel approaches towards early diagnosis and interventions are required that reflect the evolution of emerging psychopathology, the importance of novel service models, and knowledge exchange between science and practitioners. Taken together, we propose a transformative early intervention paradigm for research and clinical care that could significantly enhance mental health in young people and initiate a shift towards the prevention of severe mental disorders.

Persistent and distressing psychotic-like experiences using adolescent brain cognitive development℠study data.

Childhood psychotic-like experiences (PLEs) are associated with a range of impairments; a subset of children experiencing PLEs will develop psychiatric disorders, including psychotic disorders. A potential distinguishing factor between benign PLEs versus PLEs that are clinically relevant is whether PLEs are distressing and/or persistent. The current study used three waves of Adolescent Brain Cognitive Development℠ (ABCD) study PLEs assessments to examine the extent to which persistent and/or distressing PLEs were associated with relevant baseline risk factors (e.g., cognition) and functioning/mental health service utilization domains. Four groups varying in PLE persistence and distress endorsement were created based on all available data in ABCD Release 3.0, with group membership not contingent on complete data: persistent distressing PLEs (n = 272), transient distressing PLEs (n = 298), persistent non-distressing PLEs (n = 221), and transient non-distressing PLEs (n = 536) groups. Using hierarchical linear models, results indicated youth with distressing PLEs, whether transient or persistent, showed delayed developmental milestones (ß = 0.074, 95%CI:0.013,0.134) and altered structural MRI metrics (ß = -0.0525, 95%CI:-0.100,-0.005). Importantly, distress interacted with PLEs persistence for the domains of functioning/mental health service utilization (ß = 0.079, 95%CI:0.016,0.141), other reported psychopathology (ß = 0.101, 95%CI:0.030,0.170), cognition (ß = -0.052, 95%CI:0.-0.099,-0.002), and environmental adversity (ß = 0.045, 95%CI:0.003,0.0.86; although no family history effects), with the interaction characterized by greatest impairment in the persistent distressing PLEs group. These results have implications for disentangling the importance of distress and persistence for PLEs with regards to impairments, including functional, pathophysiological, and environmental outcomes. These novel longitudinal data underscore that it is often only in the context of distress that persistent PLEs were related to impairments.

The Role of the National Institute of Mental Health in Promoting Diversity in the Psychiatric Research Workforce.

The mission of the National Institute of Mental Health (NIMH) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. This mission can only be realized if full participation in the research enterprise is open to all. Nevertheless, systemic racism and other barriers remain significant obstacles to achieving a diverse workforce. To address these barriers, NIMH must ensure a just and equitable funding process, support diversity-focused training opportunities, and encourage research into mental health disparities and other areas of interest to a diverse array of scientists.

Social Media and Suicide Risk in Youth.

Importance: Youth, parents, educators, and policymakers are concerned about the potential relationship between social media use and negative mental health outcomes, including risk for suicidal thoughts and behaviors. Observations: Current research shows complex and conflicting relationships between social media use and suicide risk. A key limiting factor in clarifying these relationships is a dearth of available information on contextual factors around social media use, with most research focusing only on hours or amount of engagement. Whereas there are clear associations between some types of social media use and suicide risk, there are also many opportunities to mitigate suicide risk through social media. Several methodologic and measurement issues make research challenging. Researchers have only begun to explore how specific risk factors interact with individual vulnerabilities, how social media can be used to enhance youth well-being, and whether and under what circumstances mitigation strategies can be helpful. Conclusions and Relevance: This overview identifies research gaps and methodological challenges that need to be addressed to guide intervention strategies and future policy relevant to youth and suicide risk.

Structure of major depressive disorder in adolescents and adults in the US general population.

BACKGROUND: Although techniques such as latent class analysis have been used to derive empirically based subtypes of depression in adult samples, there is limited information on subtypes of depression in youth. AIMS: To identify empirically based subtypes of depression in a nationally representative sample of US adolescents, and to test the comparability of subtypes of depression in adolescents with those derived from a nationally representative sample of adults. METHOD: Respondents included 912 adolescents and 805 adults with a 12-month major depressive disorder, selected from the National Comorbidity Survey Adolescent Supplement and the National Comorbidity Survey Replication samples respectively. Latent class analysis was used to identify subtypes of depression across samples. Sociodemographic and clinical correlates of derived subtypes were also examined to establish their validity. RESULTS: Three subtypes of depression were identified among adolescents, whereas four subtypes were identified among adults. Two of these subtypes displayed similar diagnostic profiles across adolescent and adult samples (P = 0.43); these subtypes were labelled 'severe typical' (adults 45%, adolescents 35%) and 'atypical' (adults 16%, adolescents 26%). The latter subtype was characterised by increased appetite and weight gain. CONCLUSIONS: The structure of depression observed in adolescents is highly similar to the structure observed in adults. Longitudinal research is necessary to evaluate the stability of these subtypes of depression across development.

The Role of the National Institute of Mental Health in Promoting Diversity in the Psychiatric Research Workforce.

The mission of the National Institute of Mental Health (NIMH) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. This mission can only be realized if full participation in the research enterprise is open to all. Nevertheless, systemic racism and other barriers remain significant obstacles to achieving a diverse workforce. To address these barriers, NIMH must ensure a just and equitable funding process, support diversity-focused training opportunities, and encourage research into mental health disparities and other areas of interest to a diverse array of scientists.

Mental Health Surveillance Among Children - United States, 2013-2019.

Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor. Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children's mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators of children's mental health, particularly mental disorders. The 2013-2019 data from these data systems show that mental disorders begin in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders diagnosed among U.S. children and adolescents aged 3-17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting approximately one in 11 (9.4%-9.8%) children. Among children and adolescents aged 12-17 years, one fifth (20.9%) had ever experienced a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and 18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10-19 years died by suicide in 2018 and 2019. Among children and adolescents aged 3-17 years, 9.6%-10.1% had received mental health services, and 7.8% of all children and adolescents aged 3-17 years had taken medication for mental health problems during the past year, based on parent report. Approximately one in four children and adolescents aged 12-17 years reported having received mental health services during the past year. In federal data systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children's mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

Replication of Associations With Psychotic-Like Experiences in Middle Childhood From the Adolescent Brain Cognitive Development (ABCD) Study.

The fields of psychology and psychiatry are increasingly recognizing the importance of replication efforts. The current study aimed to replicate previous findings examining the construct validity and psychometric properties of a psychotic-like experiences (PLEs) measure in middle childhood using an independent subset of the baseline Adolescent Brain Cognitive Development (ABCD) sample. Using a remainder baseline sample of 7013 nine- to eleven-year-old children with complete data, we examined measurement invariance across race/ethnicity and sex, and examined the associations between the Prodromal Questionnaire Brief-Child Version (PQ-BC) and other measures of PLEs, internalizing symptoms, neuropsychological test performance, and developmental milestones, to determine whether previously obtained results replicated in this nonoverlapping baseline sample subset. The results replicated measurement invariance across ethnicity and sex, and analyses again found higher PQ-BC scores for African American (ß = .364, 95% CI = 0.292, 0.435) and Hispanic (ß = .255, 95% CI = 0.185, 0.324) groups. We also replicated that higher PQ-BC scores were associated with psychosis risk measures, higher rates of child-reported internalizing symptoms (Distress: ß = .378, 95% CI = 0.357,0.398), neuropsychological test performance deficits (eg, working memory; Distress: ß = -.069, 95% CI = -0.096, -0.042), and motor (Distress: ß = .026, 95% CI = 0.003, 0.049) and speech (Distress: ß = .042, 95% CI = 0.018, 0.065) developmental milestone delays. The current results replicated many findings from the original study examining the PQ-BC. We replicated evidence for mean differences in race/ethnicity, and associations with other PLE measures, greater internalizing symptoms, cognitive impairments, and developmental milestone delays. These findings indicate robust and reliable associations between PLEs and hypothesized correlates can be found in middle childhood nonclinical samples.

Design and field procedures in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A).

An overview is presented of the design and field procedures of the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a US face-to-face household survey of the prevalence and correlates of DSM-IV mental disorders. The survey was based on a dual-frame design that included 904 adolescent residents of the households that participated in the US National Comorbidity Survey Replication (85.9% response rate) and 9244 adolescent students selected from a nationally representative sample of 320 schools (74.7% response rate). After expositing the logic of dual-frame designs, comparisons are presented of sample and population distributions on Census socio-demographic variables and, in the school sample, school characteristics. These document only minor differences between the samples and the population. The results of statistical analysis of the bias-efficiency trade-off in weight trimming are then presented. These show that modest trimming meaningfully reduces mean squared error. Analysis of comparative sample efficiency shows that the household sample is more efficient than the school sample, leading to the household sample getting a higher weight relative to its size in the consolidated sample relative to the school sample. Taken together, these results show that the NCS-A is an efficient sample of the target population with good representativeness on a range of socio-demographic and geographic variables.

Trends in Children's Mental Health Services Research Funding: Response to Hoagwood and Colleagues' Commentary.

In their recent JAACAP Commentary, Hoagwood et al.1 examined data extracted from the National Institutes of Health Research Portfolio Online Reporting Tools (RePORT) and concluded there has been a decrease in National Institute of Mental Health (NIMH) funding for child and adolescent services and intervention research during the 10-year period from 2005 to 2015. They eloquently argued for the importance of research that can guide practice and inform the organization and delivery of children's mental health services in the current context of unmet need and the state of mental health service delivery.

Assessment of the Prodromal Questionnaire-Brief Child Version for Measurement of Self-reported Psychoticlike Experiences in Childhood.

Importance: Childhood psychoticlike experiences (PLEs) are associated with greater odds of a diagnosis of a psychotic disorder during adulthood. However, no known, well-validated self-report tools have been designed to measure childhood PLEs. Objective: To examine the construct validity and psychometric properties of a measure of PLEs, the Prodromal Questionnaire-Brief Child Version (PQ-BC). Design, Setting, and Participants: This validation study used data from the first wave of the Adolescent Brain and Cognitive Development (ABCD) Study, a prospective longitudinal study aimed at assessing risk factors associated with adverse physical and mental health outcomes from ages 9 to 10 years into late adolescence and early adulthood. The population-based sample of 3984 children within the ABCD data set was recruited from 20 research sites across the United States. Data for this study were collected from June 1, 2016, through August 31, 2017. Main Outcomes and Measures: The PQ-BC Total and Distress scores were analyzed for measurement invariance across race/ethnicity and sex, their associations with measures of PLEs, and their associations with known correlates of PLEs, including internalizing and externalizing symptoms, neuropsychological test performance, and developmental milestones. Results: The study analyses included 3984 participants (1885 girls [47.3%] and 2099 boys [52.7%]; mean [SE] age, 10.0 [0.01] years). The results demonstrated measurement invariance across race/ethnicity and sex. A family history of psychotic disorder was associated with higher mean (SE) PQ-BC Total (3.883 [0.352]; ß = 0.061; 95% CI, 0.027-0.094) and Distress (10.210 [1.043]; ß = 0.051; 95% CI, 0.018-0.084) scores, whereas a family history of depression or mania was not. Higher PQ-BC scores were associated with higher rates of child-rated internalizing symptoms (Total score: ß range, 0.218 [95% CI, 0.189-0.246] to 0.273 [95% CI, 0.245-0.301]; Distress score: ß range, 0.248 [95% CI, 0.220-0.277] to 0.310 [95% CI, 0.281-0.338]), neuropsychological test performance deficits such as working memory (Total score: ß = -0.042 [95% CI, -0.077 to -0.008]; Distress score: ß = -0.051 [95% CI, -0.086 to -0.017]), and motor and speech developmental milestone delays (Total score: ß = 0.057 [95% CI, 0.026-0.086] for motor; ß = 0.042 [95% CI, 0.010-0.073] for speech; Distress score: ß = 0.048 [95% CI, 0.017-0.079] for motor; ß = 0.049 [95% CI, 0.018-0.081] for speech). Conclusions and Relevance: These results provide support for the construct validity and demonstrate adequate psychometric properties of a self-report instrument designed to measure childhood PLEs, providing evidence that the PQ-BC may be a useful measure of early risk for psychotic disorders. Furthermore, these data suggest that PLEs at school age are associated with many of the same familial, cognitive, and emotional factors associated with psychotic symptoms in older populations, consistent with the dimensionality of psychosis across the lifespan.

Demographic, physical and mental health assessments in the adolescent brain and cognitive development study: Rationale and description.

The Adolescent Brain and Cognitive Development (ABCD) Study incorporates a comprehensive range of measures assessing predictors and outcomes related to both mental and physical health across childhood and adolescence. The workgroup developed a battery that would assess a comprehensive range of domains that address study aims while minimizing participant and family burden. We review the major considerations that went into deciding what constructs to cover in the demographics, physical health and mental health domains, as well as the process of selecting measures, piloting and refining the originally proposed battery. We present a description of the baseline battery, as well as the six-month interim assessments and the one-year follow-up assessments. This battery includes assessments from the perspectives of both the parent and the target youth, as well as teacher reports. This battery will provide a foundational baseline assessment of the youth's current function so as to permit characterization of stability and change in key domains over time. The findings from this battery will also be utilized to identify both resilience markers that predict healthy development and risk factors for later adverse outcomes in physical health, mental health, and substance use and abuse.

Fear-potentiated startle to threat, and prepulse inhibition among young adult nonsmokers, abstinent smokers, and nonabstinent smokers.

BACKGROUND: Evidence suggests that the transition from experimental to regular smoking is facilitated by the influence of tobacco on affective and attentional mechanisms. The objective of this study was to examine affective and attentional responses in young adult smokers using fear-potentiated startle and prepulse inhibition. METHODS: Participants were 56 college nonsmokers, nonabstinent smokers, and overnight-abstinent smokers. The fear-potentiated startle test examined phasic responses to imminent threat cues and more sustained responses to unpredictable aversive events. Prepulse inhibition investigated responses to attended and ignored prepulse stimuli. RESULTS: Abstinent and nonabstinent smokers showed increased sustained potentiation of startle to contextual cues, compared to controls. Abstinent smokers showed increased fear-potentiated startle to threat cues, compared to nonsmokers. PPI did not discriminate between abstinent or nonabstinent smokers and controls. CONCLUSIONS: These findings suggest that negative affectivity or anxiety is associated with smoking, particularly during short withdrawal. Potentiated startle may provide a valuable tool in understanding the biologic mechanisms underlying nicotine withdrawal and inform cessation and prevention efforts.

Implications of high-risk family studies for prevention of depression.

The high-risk family study is a powerful design that facilitates identification of early forms of expression of depression and premorbid vulnerability, risk, and protective factors that are important for defining prevention targets and program foci. This paper (1) highlights the strengths of high-risk studies for informing early intervention efforts; (2) summarizes findings of familial aggregation from controlled high-risk studies of depression; and (3) briefly reviews evidence for potential mediators (i.e., early forms of expression, vulnerability factors) that explain familial risk and for moderators (i.e., interactive risk and protective factors) that enhance or minimize familial risk. New data from the Yale High-Risk Study of Comorbidity of Substance Use and Affective Disorders are presented to exemplify strategies for identifying specific familial pathways to depression among offspring of parents with substance and anxiety disorders. Likewise, parental depression is associated with a range of emotional and behavioral problems, including anxiety and conduct disorder, in their offspring. These nonspecific effects, together with emerging findings on mechanisms of risk, support early intervention efforts that target a range of youth at risk for depression through multipronged approaches that attend to the individual characteristics of the child and parent, clinical comorbidity, and the broader family and social context.

The National Institute of Mental Health Research Domain Criteria and Clinical Research in Child and Adolescent Psychiatry.

OBJECTIVE: This review discusses the relevance of the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) to clinical research in child and adolescent psychiatry. METHOD: We summarize the characteristics of the NIMH RDoC project and then provide examples of RDoC designs that are of relevance to clinical investigators in child and adolescent psychiatry. The final section addresses questions regarding the impact of RDoC on clinical care. RESULTS: RDoC encourages investigators to investigate psychopathology dimensionally: greater or lesser degrees of healthy/adapted functioning of neurobiological, cognitive, and behavioral processes (constructs) that cut across current diagnostic categories. Elucidation of the developmental components of RDoC constructs is needed to ensure they are fully validated. Integrating RDoC approaches into clinical research of child and adolescent psychopathology is contributing to our understanding of development as an aspect of the heterogeneity within DSM disorders and commonalities across seemingly disparate disorders. Continued efforts promise to also explain the processes that lead to mental illness in at-risk populations. CONCLUSION: Incorporating an RDoC approach in clinical research in child and adolescent psychiatry promises to be a fruitful avenue of research into the root causes and manifestations of mental illness, which will eventually lead to more precise treatments. Although the long-term aspiration of RDoC is to help reduce the burden of suffering for those with mental illnesses, it is not intended to be used for practical clinical purposes at this early stage.

Longitudinal trajectories of depression and anxiety in a prospective community study: the Zurich Cohort Study.

BACKGROUND: The dearth of long-term follow-up studies of community-based samples and differences in methodology in existing studies highlight the need for research designed to examine the stability, comorbidity, and diagnostic thresholds of depression and anxiety in the community. METHODS: Prospective study of a community-based cohort aged 19 and 20 years from the canton of Zurich, Switzerland. Semistructured diagnostic interviews were administered by clinically experienced interviewers at 5 assessment points during a 15-year period. The format of the interview permitted assessment of major mental disorders at both the diagnostic and subthreshold levels. RESULTS: Comorbid anxiety and depression tended to be far more persistent than either syndrome alone. Individuals with anxiety states alone tended to develop either depression alone or comorbid anxiety and depression as they progressed through adulthood. In contrast, depression alone and depression comorbid with anxiety tended to be more stable than anxiety alone over time. The patterns of stability were similar for subthreshold- and threshold-level disorders. CONCLUSIONS: These findings have important implications for classification and treatment of affective disorders. The greater stability of comorbid anxiety and depression than either disorder alone illustrates the importance of further investigation of comorbid states compared with noncomorbid states in etiologic and treatment research. The persistence of subthreshold-level depression and anxiety from early to mid adulthood also suggests the importance of characterizing the continuum of expression of depression and anxiety rather than adhering to strict diagnostic thresholds.

Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment.

OBJECTIVE: To present the 12-month prevalence of DSM-IV major depressive disorder (MDD) and severe MDD; to examine sociodemographic correlates and comorbidity; and to describe impairment and service use. METHOD: Data are from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative survey of 10,123 adolescents aged 13 to 18 years that assesses DSM-IV disorders using the Composite International Diagnostic Interview (CIDI) Version 3.0. One parent or surrogate of each participating adolescent was also asked to complete a self-administered questionnaire. RESULTS: Lifetime and 12-month prevalence of MDD were 11.0% and 7.5%, respectively. The corresponding rates of severe MDD were 3.0% and 2.3%. The prevalence of MDD increased significantly across adolescence, with markedly greater increases among females than among males. Most cases of MDD were associated with psychiatric comorbidity and severe role impairment, and a substantial minority reported suicidality. The prevalence of severe MDD was about one-fourth of that of all MDD cases; estimates of impairment and clinical correlates were of 2- to 5-fold greater magnitude for severe versus mild/moderate depression, with markedly higher rates for suicidal thoughts and behaviors. Treatment in any form was received by the majority of adolescents with 12-month DSM-IV MDD (60.4%), but only a minority received treatment that was disorder-specific or from the mental health sector. CONCLUSION: Findings underscore the important public health significance of depression among US adolescents and the urgent need to improve screening and treatment access in this population.