[The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results]. / Zürcher Sprechstunde für Jugendliche mit Genderdysphorie ­ erste Verlaufsergebnisse.

The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results The specialist clinic for children and adolescents with gender dysphoria (GD) of the Psychiatric University Hospital of Zurich shows an increasing number of referrals since its foundation in 2009. Since 2014 we started an observational study including adolescents aged 13 years and older. At the time of the first appointment (T0) N = 77 participants completed a battery of questionnaires assessing demographic factors, general psychopathology, quality of life as well as gender identity, social transitioning and GD treatment modalities. Few of the adolescents were socially transitioned and had hormone therapy but 77.9 % wished to get hormone therapy. Follow up assessment T1 was performed after at least one year of treatment in our specialist clinic. 51 adolescents completed an online follow-up examination including the same questionnaires and baseline parameters as well as a scale measuring treatment satisfaction. At T0, 77.3 % of the adolescents scored in the clinical range of the Youth Self Report (YSR) total score, which did not decrease significantly until T1 in our preliminary follow up sample. Puberty blocking before T0 correlated negatively with the YSR score, indicating less psychopathology in treated patients. Preliminary longitudinal analysis suggests that social transitioning influences quality of life (Kidscreen subscale autonomy and parental relationship). At T1, 52 % of the adolescents were socially transitioned in all contexts and 70 % received gender affirming hormonal treatment. Gender identity changed between T0 and T1 in about 18 % of the cases. Treatment satisfaction in most cases was high.

European Multicentre Tics in Children Studies (EMTICS): protocol for two cohort studies to assess risk factors for tic onset and exacerbation in children and adolescents.

Genetic predisposition, autoimmunity and environmental factors [e.g. pre- and perinatal difficulties, Group A Streptococcal (GAS) and other infections, stress-inducing events] might interact to create a neurobiological vulnerability to the development of tics and associated behaviours. However, the existing evidence for this relies primarily on small prospective or larger retrospective population-based studies, and is therefore still inconclusive. This article describes the design and methodology of the EMTICS study, a longitudinal observational European multicentre study involving 16 clinical centres, with the following objectives: (1) to investigate the association of environmental factors (GAS exposure and psychosocial stress, primarily) with the onset and course of tics and/or obsessive-compulsive symptoms through the prospective observation of at-risk individuals (ONSET cohort: 260 children aged 3-10 years who are tic-free at study entry and have a first-degree relative with a chronic tic disorder) and affected individuals (COURSE cohort: 715 youth aged 3-16 years with a tic disorder); (2) to characterise the immune response to microbial antigens and the host's immune response regulation in association with onset and exacerbations of tics; (3) to increase knowledge of the human gene pathways influencing the pathogenesis of tic disorders; and (4) to develop prediction models for the risk of onset and exacerbations of tic disorders. The EMTICS study is, to our knowledge, the largest prospective cohort assessment of the contribution of different genetic and environmental factors to the risk of developing tics in putatively predisposed individuals and to the risk of exacerbating tics in young individuals with chronic tic disorders.

Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: a clinical comparison study between four clinics.

Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this.

Combining genetic and epigenetic parameters of the serotonin transporter gene in obsessive-compulsive disorder.

While genetic variants have been reported to be associated with obsessive-compulsive disorder (OCD), the small effect sizes suggest that epigenetic mechanisms such as DNA methylation may also be relevant. The serotonin transporter (SLC6A4) gene has been extensively investigated in relation to OCD, since serotonin reuptake inhibitors are the pharmacological treatment of choice for the disorder. The current study set three questions: Firstly, whether the high expressing loci of the SLC6A4 polymorphisms, 5-HTTLPR + rs25531, rs25532 and rs16965628 are associated with family-based (n = 164 trios) and case-control OCD (n = 186, 152, respectively). This was also examined by a meta-analysis. Secondly, whether DNA methylation and RNA levels of the SLC6A4 differ in saliva and blood of a subset of samples from pediatric and adult OCD patients and matched controls. And lastly, whether morning awakening cortisol levels correlate with the above. A meta-analysis confirmed the association of the LA-allele with OCD (OR = 1.21, p = 0.00018), maintaining significance in the early-onset OCD subgroup (OR = 1.21, p = 0.022). There was no association between rs25532 or rs16965628 and OCD. Our preliminary data showed that SLC6A4 DNA methylation levels in an amplicon located at the beginning of the first intron were significantly higher in the saliva of pediatric OCD patients compared to controls and adult patients with OCD, but no alterations in RNA levels or in polymorphism interactions were observed. Morning awakening salivary cortisol levels positively correlated with methylation levels, and negatively correlated with RNA levels. This study further supports the involvement of the SLC6A4 gene in OCD through both genetic and epigenetic mechanisms. This finding needs to be explored further in an independent large sample.

High resolution chromosomal microarray analysis in paediatric obsessive-compulsive disorder.

BACKGROUND: Obsessive-Compulsive Disorder (OCD) is a common and chronic disorder in which a person has uncontrollable, reoccurring thoughts and behaviours. It is a complex genetic condition and, in case of early onset (EO), the patients manifest a more severe phenotype, and an increased heritability. Large (>500 kb) copy number variations (CNVs) previously associated with autism and schizophrenia have been reported in OCD. Recently, rare CNVs smaller than 500 kb overlapping risk loci for other neurodevelopmental conditions have also been reported in OCD, stressing the importance of examining CNVs of any size range. The aim of this study was to further investigate the role of rare and small CNVs in the aetiology of EO-OCD. METHODS: We performed high-resolution chromosomal microarray analysis in 121 paediatric OCD patients and in 124 random controls to identify rare CNVs (>50 kb) which might contribute to EO-OCD. RESULTS: The frequencies and the size of the observed rare CNVs in the patients did not differ from the controls. However, we observed a significantly higher frequency of rare CNVs affecting brain related genes, especially deletions, in the patients (OR = 1.98, 95% CI 1.02-3.84; OR = 3.61, 95% CI 1.14-11.41, respectively). Similarly, enrichment-analysis of CNVs gene content, performed with three independent methods, confirmed significant clustering of predefined genes involved in synaptic/brain related functional pathways in the patients but not in the controls. In two patients we detected de-novo CNVs encompassing genes previously associated with different neurodevelopmental disorders (NRXN1, ANKS1B, UHRF1BP1). CONCLUSIONS: Our results further strengthen the role of small rare CNVs, particularly deletions, as susceptibility factors for paediatric OCD.

Age-dependent and -independent changes in attention-deficit/hyperactivity disorder (ADHD) during spatial working memory performance.

OBJECTIVES: Attention-deficit/hyperactivity disorder (ADHD) has been associated with spatial working memory as well as frontostriatal core deficits. However, it is still unclear how the link between these frontostriatal deficits and working memory function in ADHD differs in children and adults. This study examined spatial working memory in adults and children with ADHD, focussing on identifying regions demonstrating age-invariant or age-dependent abnormalities. METHODS: We used functional magnetic resonance imaging to examine a group of 26 children and 35 adults to study load manipulated spatial working memory in patients and controls. RESULTS: In comparison to healthy controls, patients demonstrated reduced positive parietal and frontostriatal load effects, i.e., less increase in brain activity from low to high load, despite similar task performance. In addition, younger patients showed negative load effects, i.e., a decrease in brain activity from low to high load, in medial prefrontal regions. Load effect differences between ADHD and controls that differed between age groups were found predominantly in prefrontal regions. Age-invariant load effect differences occurred predominantly in frontostriatal regions. CONCLUSIONS: The age-dependent deviations support the role of prefrontal maturation and compensation in ADHD, while the age-invariant alterations observed in frontostriatal regions provide further evidence that these regions reflect a core pathophysiology in ADHD.

Classifying adolescent attention-deficit/hyperactivity disorder (ADHD) based on functional and structural imaging.

Attention-deficit/hyperactivity disorder (ADHD) is a common disabling psychiatric disorder associated with consistent deficits in error processing, inhibition and regionally decreased grey matter volumes. The diagnosis is based on clinical presentation, interviews and questionnaires, which are to some degree subjective and would benefit from verification through biomarkers. Here, pattern recognition of multiple discriminative functional and structural brain patterns was applied to classify adolescents with ADHD and controls. Functional activation features in a Flanker/NoGo task probing error processing and inhibition along with structural magnetic resonance imaging data served to predict group membership using support vector machines (SVMs). The SVM pattern recognition algorithm correctly classified 77.78% of the subjects with a sensitivity and specificity of 77.78% based on error processing. Predictive regions for controls were mainly detected in core areas for error processing and attention such as the medial and dorsolateral frontal areas reflecting deficient processing in ADHD (Hart et al., in Hum Brain Mapp 35:3083-3094, 2014), and overlapped with decreased activations in patients in conventional group comparisons. Regions more predictive for ADHD patients were identified in the posterior cingulate, temporal and occipital cortex. Interestingly despite pronounced univariate group differences in inhibition-related activation and grey matter volumes the corresponding classifiers failed or only yielded a poor discrimination. The present study corroborates the potential of task-related brain activation for classification shown in previous studies. It remains to be clarified whether error processing, which performed best here, also contributes to the discrimination of useful dimensions and subtypes, different psychiatric disorders, and prediction of treatment success across studies and sites.

Role of the medial prefrontal cortex in impaired decision making in juvenile attention-deficit/hyperactivity disorder.

IMPORTANCE: Attention-deficit/hyperactivity disorder (ADHD) has been associated with deficient decision making and learning. Models of ADHD have suggested that these deficits could be caused by impaired reward prediction errors (RPEs). Reward prediction errors are signals that indicate violations of expectations and are known to be encoded by the dopaminergic system. However, the precise learning and decision-making deficits and their neurobiological correlates in ADHD are not well known. OBJECTIVE: To determine the impaired decision-making and learning mechanisms in juvenile ADHD using advanced computational models, as well as the related neural RPE processes using multimodal neuroimaging. DESIGN, SETTING, AND PARTICIPANTS: Twenty adolescents with ADHD and 20 healthy adolescents serving as controls (aged 12-16 years) were examined using a probabilistic reversal learning task while simultaneous functional magnetic resonance imaging and electroencephalogram were recorded. MAIN OUTCOMES AND MEASURES: Learning and decision making were investigated by contrasting a hierarchical Bayesian model with an advanced reinforcement learning model and by comparing the model parameters. The neural correlates of RPEs were studied in functional magnetic resonance imaging and electroencephalogram. RESULTS: Adolescents with ADHD showed more simplistic learning as reflected by the reinforcement learning model (exceedance probability, Px = .92) and had increased exploratory behavior compared with healthy controls (mean [SD] decision steepness parameter ß: ADHD, 4.83 [2.97]; controls, 6.04 [2.53]; P = .02). The functional magnetic resonance imaging analysis revealed impaired RPE processing in the medial prefrontal cortex during cue as well as during outcome presentation (P < .05, family-wise error correction). The outcome-related impairment in the medial prefrontal cortex could be attributed to deficient processing at 200 to 400 milliseconds after feedback presentation as reflected by reduced feedback-related negativity (ADHD, 0.61 [3.90] µV; controls, -1.68 [2.52] µV; P = .04). CONCLUSIONS AND RELEVANCE: The combination of computational modeling of behavior and multimodal neuroimaging revealed that impaired decision making and learning mechanisms in adolescents with ADHD are driven by impaired RPE processing in the medial prefrontal cortex. This novel, combined approach furthers the understanding of the pathomechanisms in ADHD and may advance treatment strategies.

Pervasive refusal syndrome. Three German cases provide further illustration.

Pervasive refusal syndrome (PRS) has been proposed as a new diagnostic entity among child and adolescent psychiatric disorders. It is characterized by a cluster of life-threatening symptoms including refusal of hood intake, decreased or complete lack of mobilization, and lack of communication as well as retreat from normal life activities. Active refusal to accept help as well as neglect of personal care have been core features of PRS in the limited number of cases reported in the last decade. There have, however; been cases with predominantly passive resistance, indicating the possibility that there may be a continuum from active refusal to passive resistance within PRS. Postulating this continuum allows for the integration of "depressive devitalization" -- a refusal syndrome mainly characterized by passive resistance -- into the concept of PRS. Here, three case vignettes of adolescent patients with PRS are presented. The patients' symptomatology can be allocated on this continuum of PRS. PRS and dissociative disorders are compared in greater detail and contrasted within this discussion of differential diagnoses at the poles of such a continuum. PRS is a useful diagnosis for cases involving symptoms of predominating refusal and retreat which cannot satisfactorily be classified by existing diagnostic categories, and which can mostly clearly be separated from dissociative disorder.

Developmental changes in coping: situational and methodological influences.

Previous studies on the development of coping have shown rather inconsistent findings regarding the developmental trajectories for different coping dimensions. The aim of this study is to search for possible influences that might explain these inconsistencies. The analysis focuses on methodological influences (longitudinal vs. cross-sectional assessments) and situational influences. Two samples of children were traced longitudinally with yearly assessments from grade 2 to 5 (sample 1, N =432) and from grade 4 to 7 (sample 2, N =366). A third sample (N =849) was added with cross-sectional assessments from grade 2 to 7. The assessed coping dimensions were related to (a) problem solving, (b) seeking social support, (c) palliative coping, (d) externalizing emotional coping, and (e) avoidant coping. The use of the coping strategies had to be assessed for six stress-evoking situations. The results show only small differences between the longitudinal and the cross-sectional coping assessments. There are, however, clear situational influences on the choice of the coping strategies and also on the resulting developmental trajectories.

Contingency experiences of 3-month-old children and their relation to later developmental achievements.

In this study, the authors investigated the relation between early social contingency experiences and infants' competencies to detect nonsocial contingencies. In this study of 87 three-month-old infants, the authors operationalized early social contingencies as prompt, contingent maternal responses and coded microanalytically on the basis of video-recorded mother-infant interactions. The authors assessed competence to detect nonsocial contingencies by 2 methods: (a) the mobile conjugate reinforcement paradigm, which focuses on detecting contingencies between the infants' actions (kicking) and nonsocial consequences (mobile moving) and (b) the visual expectation paradigm, which focuses on detecting contingencies between 1 event (a smiley face projected on a screen) that was followed by a 2nd event (a complex picture projected on the other side of the screen). The results showed that early social contingencies are related to the competency to detect nonsocial action-consequence contingencies in the mobile conjugate reinforcement paradigm.

The prediction of health-related behaviour in elementary school children.

This study investigates the importance of psychological concepts with regard to health-related behaviour in elementary school children based on self-report data of 802 second- and fourth-graders. The results show significant relations of self-efficacy and the choice of appropriate coping strategies to positive health-related behaviours. The amount of stress experiences (measured by the Youth Self-Report) is associated to health-risky behaviours for the total sample and for the gender subgroups, while the other predictor variables show inconsistent relations for different subgroups. The significance of the results for health-promotion during early developmental stages is discussed.

Warmth and contingency and their relationship to maternal attitudes toward parenting.

In this study, the authors addressed the question of whether maternal parenting behaviors in terms of sensitivity, warmth, and contingency with respect to small infants were equally represented in attitudes toward parenting. Sixty mothers from central Germany with middle-class socioeconomic backgrounds were videotaped with their 1st born 3-month-old infant in a free-play and a caregiving episode in their home. The different maternal parenting components were behaviorally analyzed. Maternal attitudes toward parenting were assessed with self-report measures. The results showed that behavioral sensitivity was significantly associated with attitudes related to contingency, whereas behavioral warmth and contingency were not associated with maternal attitudes. The authors interpreted differential associations as a reflection of intuitive and explicit parenting strategies, with only sensitivity being explicitly represented.