The Great Smoky Mountains Study: developmental epidemiology in the southeastern United States.

AIMS: To describe the Great Smoky Mountains Study (GSMS). METHODS: GSMS is a longitudinal study of child psychiatric disorders that began in 1992 to look at need for mental health services in a rural area of the USA. Over 20 years it has expanded its range to include developmental epidemiology more generally, not only the development of psychiatric and substance abuse problems but also their correlates and predictors: family and environmental risk, physical development including puberty, stress and stress-related hormones, trauma, the impact of poverty, genetic markers, and epigenetics. Now that participants are in their 30s the focus has shifted to adult outcomes of childhood psychopathology and risk, and early physical, cognitive, and psychological markers of aging. RESULTS: This paper describes the results from over 11,000 interviews, examples of the study's contributions to science and policy, and plans for the future. CONCLUSIONS: Longitudinal studies can provide insights that aid in policy planning.

Genome-Wide Meta-Analysis of Longitudinal Alcohol Consumption Across Youth and Early Adulthood.

The public health burden of alcohol is unevenly distributed across the life course, with levels of use, abuse, and dependence increasing across adolescence and peaking in early adulthood. Here, we leverage this temporal patterning to search for common genetic variants predicting developmental trajectories of alcohol consumption. Comparable psychiatric evaluations measuring alcohol consumption were collected in three longitudinal community samples (N=2,126, obs=12,166). Consumption-repeated measurements spanning adolescence and early adulthood were analyzed using linear mixed models, estimating individual consumption trajectories, which were then tested for association with Illumina 660W-Quad genotype data (866,099 SNPs after imputation and QC). Association results were combined across samples using standard meta-analysis methods. Four meta-analysis associations satisfied our pre-determined genome-wide significance criterion (FDR<0.1) and six others met our 'suggestive' criterion (FDR<0.2). Genome-wide significant associations were highly biological plausible, including associations within GABA transporter 1, SLC6A1 (solute carrier family 6, member 1), and exonic hits in LOC100129340 (mitofusin-1-like). Pathway analyses elaborated single marker results, indicating significant enriched associations to intuitive biological mechanisms, including neurotransmission, xenobiotic pharmacodynamics, and nuclear hormone receptors (NHR). These findings underscore the value of combining longitudinal behavioral data and genome-wide genotype information in order to study developmental patterns and improve statistical power in genomic studies.

Distinct neural signatures of threat learning in adolescents and adults.

Most teenage fears subside with age, a change that may reflect brain maturation in the service of refined fear learning. Whereas adults clearly demarcate safe situations from real dangers, attenuating fear to the former but not the latter, adolescents' immaturity in prefrontal cortex function may limit their ability to form clear-cut threat categories, allowing pervasive fears to manifest. Here we developed a discrimination learning paradigm that assesses the ability to categorize threat from safety cues to test these hypotheses on age differences in neurodevelopment. In experiment 1, we first demonstrated the capacity of this paradigm to generate threat/safety discrimination learning in both adolescents and adults. Next, in experiment 2, we used this paradigm to compare the behavioral and neural correlates of threat/safety discrimination learning in adolescents and adults using functional MRI. This second experiment yielded three sets of findings. First, when labeling threats online, adolescents reported less discrimination between threat and safety cues than adults. Second, adolescents were more likely than adults to engage early-maturing subcortical structures during threat/safety discrimination learning. Third, adults' but not adolescents' engagement of late-maturing prefrontal cortex regions correlated positively with fear ratings during threat/safety discrimination learning. These data are consistent with the role of dorsolateral regions during category learning, particularly when differences between stimuli are subtle [Miller EK, Cohen JD (2001) Annu Rev Neurosci 24:167-202]. These findings suggest that maturational differences in subcortical and prefrontal regions between adolescent and adult brains may relate to age-related differences in threat/safety discrimination.

Children with both asthma and depression are at risk for heightened inflammation.

OBJECTIVE: To test whether children and adolescents with co-occurring asthma and depression are at risk for elevated inflammation-concurrently and at the next assessment. STUDY DESIGN: Up to 6 yearly assessments per person from the prospective, population-based Great Smoky Mountains Study (N = 1420) were used, covering children in the community aged 10-16 years old. High-sensitivity C-reactive protein (CRP) was assayed from annual bloodspot collections and provided indicators of elevated inflammation at CRP > 1, CRP > 2, and CRP > 3 mg/L. Depression was assessed with the Child and Adolescent Psychiatric Assessment. Asthma was assessed using a form adapted from the Centers for Disease Control and Prevention National Health Interview Survey. RESULTS: Controlling common covariates of CRP, the co-occurrence of asthma and depression predicted heightened CRP-concurrently and at the next assessment. In turn, elevated CRP was relatively stable from one assessment to the next. CONCLUSIONS: The co-occurrence of asthma and depression in childhood poses a risk for substantially elevated inflammation concurrently and over time, which could contribute to pathophysiological processes involved in the development of additional chronic diseases and also to asthma--related morbidity and mortality.

Impact of bullying in childhood on adult health, wealth, crime, and social outcomes.

Bullying is a serious problem for schools, parents, and public-policymakers alike. Bullying creates risks of health and social problems in childhood, but it is unclear if such risks extend into adulthood. A large cohort of children was assessed for bullying involvement in childhood and then followed up in young adulthood in an assessment of health, risky or illegal behavior, wealth, and social relationships. Victims of childhood bullying, including those that bullied others (bully-victims), were at increased risk of poor health, wealth, and social-relationship outcomes in adulthood even after we controlled for family hardship and childhood psychiatric disorders. In contrast, pure bullies were not at increased risk of poor outcomes in adulthood once other family and childhood risk factors were taken into account. Being bullied is not a harmless rite of passage but throws a long shadow over affected people's lives. Interventions in childhood are likely to reduce long-term health and social costs.

Diagnostic transitions from childhood to adolescence to early adulthood.

BACKGROUND: Quantifying diagnostic transitions across development is needed to estimate the long-term burden of mental illness. This study estimated patterns of diagnostic transitions from childhood to adolescence and from adolescence to early adulthood. METHODS: Patterns of diagnostic transitions were estimated using data from three prospective, longitudinal studies involving close to 20,000 observations of 3,722 participants followed across multiple developmental periods covering ages 9-30. Common DSM psychiatric disorders were assessed in childhood (ages 9-12; two samples), adolescence (ages 13-18; three samples), and early adulthood (ages 19 to age 32; three samples) with structured psychiatric interviews and questionnaires. RESULTS: Having a disorder at an early period was associated with at least a threefold increase in odds for having a disorder at a later period. Homotypic and heterotypic transitions were observed for every disorder category. The strongest evidence of continuity was seen for behavioral disorders (particularly ADHD) with less evidence for emotional disorders such as depression and anxiety. Limited evidence was found in adjusted models for behavioral disorders predicting later emotional disorders. Adult substance disorders were preceded by behavioral disorders, but not anxiety or depression. CONCLUSIONS: Having a disorder in childhood or adolescence is a potent risk factor for a range of psychiatric problems later in development. These findings provide further support for prevention and early life intervention efforts and suggest that treatment at younger ages, while justified in its own right, may also have potential to reduce the risk for disorders later in development.

Prevalence of psychiatric disorders in preschoolers.

BACKGROUND: Many disorders in childhood and adolescence were already present in the preschool years. However, there is little empirical research on the prevalence of psychiatric disorders in young children. A true community study using structured diagnostic tools has yet to be published. METHODS: All children born in 2003 or 2004 in the city of Trondheim, Norway, who attended the regular community health check-up for 4-year-olds (97.2% of eligible children) whose parents consented to take part in the study (N = 2,475, 82.0%) were screened for behavioral and emotional problems with the Strengths and Difficulties Questionnaire (SDQ). A screen-stratified subsample of 1,250 children took part in a furthermore comprehensive study including a structured diagnostic interview (the Preschool Age Psychiatric Assessment, PAPA), which 995 parents (79.6%) completed. RESULTS: The estimated population rate for any psychiatric disorder (excluding encopresis - 6.4%) was 7.1%. The most common disorders were attention deficit hyperactivity disorder (1.9%), oppositional defiant disorder (1.8%), conduct disorder (0.7%), anxiety disorders (1.5%), and depressive disorders (2.0%). Comorbidity among disorders was common. More emotional and behavioral disorders were seen in children whose parents did not live together and in those of low socioeconomic status. Boys more often had attention-deficit/hyperactivity disorder (ADHD) and depressive disorders than girls. CONCLUSIONS: The prevalence of disorders among preschoolers was lower than in previous studies from the USA. Comorbidity was frequent and there was a male preponderance in ADHD and depression at this early age. These results underscore the fact that the most common disorders of childhood can already be diagnosed in preschoolers. However, rates of disorder in Norway may be lower than in the USA.

Trends in psychopathology across the adolescent years: what changes when children become adolescents, and when adolescents become adults?

BACKGROUND: Little is known about changes in the prevalence of psychiatric disorders between childhood and adolescence, and adolescence and adulthood. METHODS: We reviewed papers reporting prevalence rates of psychiatric disorders separately for childhood, adolescence, and early adulthood. Both longitudinal and cross-sectional papers published in the past 15 years were included. RESULTS: About one adolescent in five has a psychiatric disorder. From childhood to adolescence there is an increase in rates of depression, panic disorder, agoraphobia, and substance use disorders (SUD), and a decrease in separation anxiety disorder (SAD) and attention-deficit hyperactivity disorder (ADHD). From adolescence to early adulthood there is a further increase in panic disorder, agoraphobia, and SUD, and a further decrease in SAD and ADHD. Other phobias and disruptive behavior disorders also fall. CONCLUSIONS: Further study of changes in rates of disorder across developmental stages could inform etiological research and guide interventions.

Longitudinal dimensionality of adolescent psychopathology: testing the differentiation hypothesis.

BACKGROUND: The differentiation hypothesis posits that the underlying liability distribution for psychopathology is of low dimensionality in young children, inflating diagnostic comorbidity rates, but increases in dimensionality with age as latent syndromes become less correlated. This hypothesis has not been adequately tested with longitudinal psychiatric symptom data. METHODS: Confirmatory factor analyses of DSM-IV symptoms from seven common Axis I syndromes--major depression, generalized anxiety, separation anxiety, social anxiety, attention deficient hyperactivity, conduct, and oppositional defiant disorders--were conducted longitudinally, from ages 9 to 16, using the general-population Great Smoky Mountains Study sample. RESULTS: An eight-syndrome model fit well at all ages, and in both genders. It included social anxiety, separation anxiety, oppositional defiant, and conduct syndromes, along with a multidimensional attention deficit-hyperactivity syndrome (i.e., inattention, hyperactivity, and impulsivity) and a unidimensional major depression/generalized anxiety syndrome. A high degree of measurement invariance across age was found for all syndromes, except for major depression/generalized anxiety. Major depression and generalized anxiety syndromes slightly diverged at age 14-16, when they also began to explain more symptom variance. Additionally, correlations between some emotional and disruptive syndromes showed slight differentiation. CONCLUSIONS: Marked developmental differentiation of psychopathology, as implied by the orthogenetic principle, is not a prominent cause of preadolescent and adolescent psychiatric comorbidity.

Association of family income supplements in adolescence with development of psychiatric and substance use disorders in adulthood among an American Indian population.

CONTEXT: In a natural experiment in which some families received income supplements, prevalence of adolescent behavioral symptoms decreased significantly. These adolescents are now young adults. OBJECTIVE: To examine the effects of income supplements in adolescence and adulthood on the prevalence of adult psychiatric disorders. DESIGN: Quasi-experimental, longitudinal. POPULATION AND SETTING: A representative sample of children aged 9, 11, or 13 years in 1993 (349 [25%] of whom are American Indian) were assessed for psychiatric and substance use disorders through age 21 years (1993-2006). Of the 1420 who participated in 1993, 1185 were interviewed as adults. From 1996, when a casino opened on the Indian reservation, every American Indian but no non-Indians received an annual income supplement that increased from $500 to around $9000. MAIN OUTCOME MEASURES: Prevalence of adult psychiatric disorders and substance use disorders based on the Diagnostic and Statistical Manual of Mental Disorders in 3 age cohorts, adjusted for age, sex, length of time in the family home, and number of Indian parents. RESULTS: As adults, significantly fewer Indians than non-Indians had a psychiatric disorder (106 Indians [weighted 30.2%] vs 337 non-Indians [weighted 36.0%]; odds ratio [OR], 0.46; 95% confidence interval [CI], 0.30-0.72; P = .001), particularly alcohol and cannabis abuse, dependence, or both. The youngest age-cohort of Indian youth had the longest exposure to the family income. Interactions between race/ethnicity and age cohort were significant. Planned comparisons showed that fewer of the youngest Indian age-cohort had any psychiatric disorder (31.4%) than the Indian middle cohort (41.7%; OR, 0.43; 95% CI, 0.24-0.78; P = .005) or oldest cohort (41.3%; OR, 0.69; 95% CI, 0.51-0.94; P = .01) or the youngest non-Indian cohort (37.1%; OR, 0.66; 95% CI, 0.48-0.90; P = .008). Study hypotheses were not upheld for nicotine or other drugs, or emotional or behavioral disorders. The income supplement received in adulthood had no impact on adult psychopathology. CONCLUSION: Lower prevalence of psychopathology in American Indian youth following a family income supplement, compared with the nonexposed, non-Indian population, persisted into adulthood.

Nosology and measurement in child and adolescent psychiatry.

The last 50 years have witnessed enormous strides in the measurement and classification of child and adolescent psychiatric disorders. Debates about whether we should continue to depend upon a categorical nosology still continue, but we argue that, despite the absence of clear dividing lines between psychiatric disorders and normality and ubiquity of diagnostic comorbidity, the current official approach to nosology has served child and adolescent psychiatric research surprisingly well. In particular we point to the utility of non-developmental diagnostic criteria as tools for discovering developmental effects on psychopathology. We also maintain that the search for sharper boundaries between disorders is fundamentally mistaken. However, official nosologies have tended to privilege information collected in diagnostic interviews and to sideline observational and other methods that cannot easily be made to conform to the format of their criteria. We suggest that it is time to remedy this situation. The ICD-10 and DSM-IV are useless for children under the age of about two, while alternatives, such as the DC:0-3, suffer from a profound lack of empirical support. We suggest a way forward through the integration of methods from temperament and psychopathology research. Finally, we deplore the failure of standardized assessment techniques to have penetrated more deeply into everyday clinical assessment.

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.

Moving from ethnography to epidemiology: lessons learned in Appalachia.

BACKGROUND: Anthropologists are beginning to translate insights from ethnography into tools for population studies that assess the role of culture in human behavior, biology, and health. AIM: We describe several lessons learned in the creation and administration of an ethnographically-based instrument to assess the life course perspectives of Appalachian youth, the Life Trajectory Interview for Youth (LTI-Y). Then, we explore the utility of the LTI-Y in predicting depressive symptoms, controlling for prior depressive symptoms and severe negative life events throughout the life course. SUBJECTS AND METHODS: In a sample of 319 youths (190 White, 129 Cherokee), we tested the association between depressive symptoms and two domains of the LTI-Y - life course barriers and milestones. Longitudinal data on prior depressive symptoms and negative life events were included in the model. RESULTS: The ethnographically-based scales of life course barriers and milestones were associated with unique variance in depressive symptoms, together accounting for 11% of the variance in this outcome. CONCLUSION: When creating ethnographically-based instruments, it is important to strike a balance between detailed, participant-driven procedures and the analytic needs of hypothesis testing. Ethnographically-based instruments have utility for predicting health outcomes in longitudinal studies.

Early Pubertal Timing and Testosterone Associated With Higher Levels of Adolescent Depression in Girls.

OBJECTIVE: The prevalence of depression increases dramatically during puberty in girls. Earlier work in this sample reported that the sex steroids estradiol and testosterone were associated with increased depression in girls. Using three additional data waves (983 new observations), we retest the relative contributions of pubertal timing, pubertal status, and sex hormones on the increases in female depression. METHOD: Eight waves of data from the prospective, representative Great Smoky Mountains Study were used covering female participants in the community who were 9 to 16 years of age (3,005 assessments of 630 girls; 1993-2000). Structured interviews assessed depressive disorders. Youth rated their pubertal status using Tanner stage drawings, and sex steroids were assayed from dried blood spots. RESULTS: Risk for depression during puberty was associated with both age and Tanner stage in univariate models. In adjusted models accounting for pubertal timing and sex steroids, the apparent effects of age and Tanner stage were attenuated both in terms of statistical significance and effect size. The only significant predictors of change in depression status during puberty were early pubertal timing (odds ratio = 5.8, 95% CI = 1.9-17.9, p = .002 after age 12 years) and higher testosterone levels (odds ratio = 2.0, 95% CI = 1.1-3.8, p = .03 for quartile-split variable). CONCLUSION: The added observations have modified the original conclusions, implicating the following: testosterone only, but not estradiol; and early pubertal timing, but not age or pubertal status per se. These findings argue for multiple pubertal determinants of depression risk, including factors that are socially and biologically mediated.

Prediction from low birth weight to female adolescent depression: a test of competing hypotheses.

CONTEXT: Low birth weight (LBW) predicts later-onset hypertension and diabetes mellitus. Its role as a predictor of depression is unclear. OBJECTIVES: To examine whether LBW predicts depression in male and female children and adolescents and to compare the following 2 hypotheses: Low birth weight is one among several perinatal, childhood, and adolescent risk factors for depression (biopsychosocial hypothesis). Low birth weight is a marker for poor intrauterine conditions that provoke adjustments in fetal development, with long-term consequences for stress response (fetal programming hypothesis). DESIGN: A representative population-based sample from an 11-county area in western North Carolina was assessed annually for psychiatric disorders between the ages of 9 and 16 years. We tested the prediction from LBW and depression in models that included LBW only, LBW plus other prenatal and perinatal adversities, LBW plus significant perinatal and childhood adversities, and LBW plus significant perinatal and childhood adversities and adolescent correlates. SETTING: Academic research. PARTICIPANTS: There were 1420 participants, of whom 49% were female. Main Outcome Measure Cumulative prevalence of DSM-IV depressive disorder at 1 assessment or more during childhood (age range, 9-12 years) and during adolescence (age range, 13-16 years). RESULTS: The cumulative prevalence of depression among adolescent girls with LBW was 38.1% (95% confidence interval [CI], 16.3%-66.0%) compared with 8.4% (95% CI, 5.2%-13.3%) among adolescent girls with normal birth weight. Rates among children and adolescent boys did not exceed 4.9%. In adolescence, there was a significant interaction between LBW and sex (odds ratio, 0.2 [95% CI, 0.1-0.5]; P<.001). Low birth weight predicted female adolescent depression after controlling for other perinatal, childhood, and adolescent adversities. Girls with LBW and normal birth weight with no adversities had no adolescent depression, but each additional adversity increased the risk of in girls with LBW more than in girls with normal birth weight. Low birth weight did not predict other psychiatric disorders in either sex. CONCLUSIONS: Low birth weight predicts depression in adolescent girls but not boys. Data support fetal programming over the biopsychosocial hypothesis, suggesting vulnerability to adversities in girls with LBW after puberty.

Traumatic events and posttraumatic stress in childhood.

CONTEXT: Traumatic events are common and are related to psychiatric impairment in childhood. Little is known about the risk for posttraumatic stress disorder (PTSD) across different types of trauma exposure in children. OBJECTIVE: To examine the developmental epidemiology of potential trauma and posttraumatic stress (PTS) in a longitudinal community sample of children. METHODS: A representative population sample of 1420 children aged 9, 11, and 13 years at intake were followed up annually through 16 years of age. Main Outcome Measure Traumatic events and PTS were assessed from child and parent reports annually to 16 years of age. Risk factors and DSM-IV disorders were also assessed. RESULTS: More than two thirds of children reported at least 1 traumatic event by 16 years of age, with 13.4% of those children developing some PTS symptoms. Few PTS symptoms or psychiatric disorders were observed for individuals experiencing their first event, and any effects were short-lived. Less than 0.5% of children met the criteria for full-blown DSM-IV PTSD. Violent or sexual trauma were associated with the highest rates of symptoms. The PTS symptoms were predicted by previous exposure to multiple traumas, anxiety disorders, and family adversity. Lifetime co-occurrence of other psychiatric disorders with traumatic events and PTS symptoms was high, with the highest rates for anxiety and depressive disorders. CONCLUSIONS: In the general population of children, potentially traumatic events are fairly common and do not often result in PTS symptoms, except after multiple traumas or a history of anxiety. The prognosis after the first lifetime trauma exposure was generally favorable. Apart from PTSD, traumatic events are related to many forms of psychopathology, with the strongest links being with anxiety and depressive disorders.

Childhood psychiatric disorders and young adult crime: a prospective, population-based study.

OBJECTIVE: While psychopathology is common in criminal populations, knowing more about what kinds of psychiatric disorders precede criminal behavior could be helpful in delineating at-risk children. The authors determined rates of juvenile psychiatric disorders in a sample of young adult offenders and then tested which childhood disorders best predicted young adult criminal status. METHOD: A representative sample of 1,420 children ages 9, 11, and 13 at intake were followed annually through age 16 for psychiatric disorders. Criminal offense status in young adulthood (ages 16 to 21) was ascertained through court records. RESULTS: Thirty-one percent of the sample had one or more adult criminal charges. Overall, 51.4% of male young adult offenders and 43.6% of female offenders had a child psychiatric history. The population-attributable risk of criminality from childhood disorders was 20.6% for young adult female participants and 15.3% for male participants. Childhood psychiatric profiles predicted all levels of criminality. Severe/violent offenses were predicted by comorbid diagnostic groups that included both emotional and behavioral disorders. CONCLUSIONS: The authors found that children with specific patterns of psychopathology with and without conduct disorder were at risk of later criminality. Effective identification and treatment of children with such patterns may reduce later crime.

Proximal psychiatric risk factors for suicidality in youth: the Great Smoky Mountains Study.

CONTEXT: Psychiatric disorder is a major risk factor for suicidality but has poor positive predictive value. OBJECTIVES: To characterize proximal risks for suicidality associated with anxiety, depressive, disruptive behavior, and substance use disorders, and to test whether there are critical combinations of disorders that discriminate at-risk youth independent of severity of psychopathology. DESIGN: The Great Smoky Mountains Study, a representative sample of children and adolescents aged 9 to 16 years from the southeastern United States. Subjects and their parents were interviewed on multiple occasions from 1993 to 2000 about the subjects' recent psychiatric and suicidal history. SETTING: An epidemiological sample of youth. PARTICIPANTS: The sample included 1420 individual subjects with 6676 records across 8 waves of data collection. MAIN OUTCOME MEASURES: Wanting to die, suicidal ideation, suicide plans, or suicide attempt during the past 3 months. RESULTS: Eleven broad psychiatric profiles discriminated suicidal youth. Risk was greatest in association with current depression plus anxiety (specifically GAD [generalized anxiety disorder]) (odds ratio, 468.53) or depression plus a disruptive disorder (primarily ODD [oppositional-defiant disorder]) (odds ratio, 222.94). Unless comorbid, anxiety and substance use disorders were not proximally associated with suicidality. The severity of symptom-related impairment and, in some cases, total symptom load explained risk associated with all psychiatric profiles except depression plus anxiety, specifically GAD (adjusted odds ratio, 50.16). Severity of impairment and poverty defined by federal guidelines for families were both independent risk factors, irrespective of psychiatric profile. Suicidal youth without diagnosable disorders had subthreshold (mostly disruptive) disorders, disabling relationship difficulties, or psychiatric symptoms without associated impairment. CONCLUSIONS: Severity of symptom-related impairment and total symptom load explained most of the risk for suicidality associated with current psychiatric disorders. Only depression plus GAD discriminated at-risk youth independent of severity of psychopathology.

Pubertal maturation and the development of alcohol use and abuse.

OBJECTIVE: To examine the impact of various aspects of puberty on risk of using alcohol and developing alcohol use disorder (AUD). METHODS: Data come from the Great Smoky Mountains Study, a longitudinal study of a representative sample of 1420 youth aged 9-13 at recruitment. Participants were interviewed annually to age 16. A parent was also interviewed. Information was obtained about use of a range of drugs including alcohol, drug abuse and dependence, other psychiatric disorders, life events, and a wide range of family characteristics. Pubertal hormones were assayed annually from blood samples, and morphological development was assessed using a pictorial measure of Tanner stage. RESULTS: Controlling for age, Tanner stage predicted alcohol use and AUD in both boys (OR 1.58, 95% CI 1.18-2.22) and girls (OR 1.62, 95% CI 1.17-2.23). The effect of morphological development was strongest in those who matured early. Early pubertal maturation predicted alcohol use in both sexes, and AUD in girls. The highest level of excess risk for alcohol use was seen in early maturing youth with conduct disorder and deviant peers. Lax supervision predicted alcohol use in early maturing girls, while poverty and family problems were predictive in early maturing boys. CONCLUSIONS: Among the many biological, morphological, and social markers of increasing maturation, the visible signs of maturity are important triggers of alcohol use and AUD, especially when they occur early and in young people with conduct problems, deviant peers, problem families and inadequate parental supervision.

Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children.

BACKGROUND: Controversy concerning the diagnosis of pediatric bipolar disorder (BD) has focused attention on children with chronic irritability and hyperarousal. This syndrome has been called the "broad BD phenotype" or severe mood dysregulation (SMD). This study examines prevalence, concurrent Axis I diagnoses, and longitudinal outcome of SMD in an epidemiologic sample. METHODS: Data were drawn from the Great Smoky Mountains Study, a longitudinal epidemiological study. Items from the Child and Adolescent Psychiatric Assessment were used to generate SMD criteria. RESULTS: Among 1420 children, the lifetime prevalence of SMD in children ages 9-19 was 3.3%. Most (67.7%) SMD youth had an Axis I diagnosis, most commonly attention-deficit/hyperactivity disorder (26.9%), conduct disorder (25.9%), and/or oppositional defiant disorder (24.5%). In young adulthood (mean age 18.3 +/- 2.1 years), youth who met criteria for SMD in the first wave (mean age 10.6 +/- 1.4 years) were significantly more likely to be diagnosed with a depressive disorder (odds ratio 7.2, confidence interval 1.3-38.8, p = .02) than youth who never met criteria for SMD. CONCLUSIONS: Severe mood dysregulation is relatively common in childhood and predicts risk for early adulthood depressive disorders. Research should continue to explore the course of illness in children with SMD.