Cognitive behavioral therapy in adolescents with early-onset psychosis: a randomized controlled pilot study.

Cognitive behavioral therapy for psychosis (CBT) is an effective treatment in adult patients with schizophrenia. However, no randomized controlled and blinded trial in adolescents with early-onset psychosis (EOP) has been conducted. Therefore, the present pilot study explores the acceptance, tolerability, feasibility, and safety of a modified CBT in adolescents with EOP. Twenty-five adolescents with EOP were randomized to either 9 months (20 sessions) of CBT + treatment as usual (TAU) or TAU alone. The primary endpoint was the PANSS-positive subscale (P1-7). Secondary endpoints included psychopathology, global functioning, and quality of life (QoL). Acceptance, tolerability, feasibility, and safety were assessed. Blinded assessments took place by the end of the treatment (9 months) and at 24-month follow-up. Despite improvements in both groups and lack of statistical significance between CBT + TAU and TAU regarding the primary endpoint, we observed between-group effect sizes of at least d = 0.39 in favor of CBT + TAU at post-treatment for delusions, negative symptoms, functioning and QoL after the intervention and effect sizes of at least d = 0.35 after 24 months. CBT in EOP was highly acceptable (73.5% agreed to randomization), well-tolerated (83.1% attendance rate, no drop-outs), and safe (one serious adverse event (SAE) in CBT + TAU in comparison with six SAEs in TAU). These findings suggest that CBT adapted to the needs of adolescents with EOP is a promising approach regarding negative symptoms, functioning, and QoL. CBT is a safe and tolerable treatment. However, due to the small sample size and the pilot character of the study, these conclusions are limited, and should be tested in a larger, adequately powered randomized controlled trial.

[Developmental Aspects in the Early Detection and Intervention in Clinical High Risk States for Psychosis]. / Entwicklungsspezifische Aspekte in der Früherkennung und Frühbehandlung eines erhöhten Psychoserisikos.

Developmental Aspects in the Early Detection and Intervention in Clinical High Risk States for Psychosis The early detection and intervention in psychoses, which are a main source of disability-adjusted life years already in children and adolescents, have made good progress within the past years. In particular the attenuated and transient positive symptoms of the ultra-high risk criteria and the basic symptom criterion "Cognitive Disturbances" open promising routes to an indicated prevention and have recently been considered as diagnostic criteria of a psychosis-risk syndrome by the European Psychiatric Association (EPA). However, because their association with a development of psychosis has been weaker in children and adolescents than in adults, only the assessment and monitoring of these risk symptoms was recommended for children and adolescents, while interventions aiming at the prevention of psychoses were discouraged. Furthermore, treatment of comorbid current mental disorders and psychosocial problems over the prevention of a potential future disorder also characterizes the intervention recommendations of the EPA. Furthermore, these give primacy to psychological, in particular cognitive-behavioral interventions over psychopharmacological treatments. Yet, also with regard to an early intervention, current evidence indicates that children and adolescents might benefit less than adults. Overall, age-related or developmental peculiarities in the early detection and intervention in psychoses become more and more apparent and should be more focused in future research in this field.

[Motives and wishes to adopt children in a social change: results of a longitudinal view]. / Adoptionsmotive und -wünsche im gesellschaftlichen Wandel: Ergebnisse einer Längsschnittbetrachtung.

150 files of adopted children chosen from the archive of the protestant association for adopted and foster children in Duesseldorf-Wittlaer, being mediated to families between 1947 and 1987, were evaluated with a special evaluation document, regarding the motives and wishes to adopt children. The results indicate that the expectation of adoptive parents of their potential adopted child has changed essentially during the period that was regarded. Possible causes could be norms and values being in a social and historical change, but also changes in the adoption processes.

[Attachment in very low birthweight infants (< 1500 g) and their mothers]. / Bindungsqualität bei sehr kleinen Frühgeborenen (< 1500 g) und ihren Müttern.

A long hospital stay, along with the worries about the survival and the possible disabilities the child might suffer from, mark the start into life of very low birth weight premature infants (VLBW). The goal of this trial was to study the stability of the attachment representations of very low birthweight infants (birthweight < 1500 g) and the accordance of the attachment representations of the children and their primary care givers. In continuation of the Kölner Frühgeborenen Studie, we measured the attachment patterns of 40 VLBW children at the age of seven and their mothers. For the children we used the Geschichtenergänzungsverfahrens zur Bindung (GEV-B) and for the mothers the Adult Attachment Projective (AAP) to determine the attachment representation. The attachment representations first corresponded to a normal distribution pattern and shifted over time to a more insecure attachment. We could not determine a significant link between the attachment patterns of the child and their mother.

Clinical high-risk criteria of psychosis in 8-17-year-old community subjects and inpatients not suspected of developing psychosis.

BACKGROUND: In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity. AIM: To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients. METHODS: In the mainly cross-sectional examinations, 8-17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive-compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ 2 tests and nonparametric tests with Cramer's V and Rosenthal's r as effect sizes, and their association with functioning using correlation analyses. RESULTS: The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ 2 (4) = 9.425; P = 0.051, Cramer's V = 0.132; and Z = -4.281, P < 0.001; Rosenthal's r = 0.184], and thought pressure [χ 2 (4) = 11.019; P = 0.026, Cramer's V = 0.143; and Z = -2.639, P = 0.008; Rosenthal's r = 0.114], derealization [χ 2 (4) = 32.380; P < 0.001, Cramer's V = 0.245; and Z = -3.924, P < 0.001; Rosenthal's r = 0.169] and visual perception disturbances [χ 2 (4) = 10.652; P = 0.031, Cramer's V = 0.141; and Z = -2.822, P = 0.005; Rosenthal's r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive-compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall's tau = -0.172, P < 0.001). CONCLUSION: The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

Multimodal Machine Learning Workflows for Prediction of Psychosis in Patients With Clinical High-Risk Syndromes and Recent-Onset Depression.

Importance: Diverse models have been developed to predict psychosis in patients with clinical high-risk (CHR) states. Whether prediction can be improved by efficiently combining clinical and biological models and by broadening the risk spectrum to young patients with depressive syndromes remains unclear. Objectives: To evaluate whether psychosis transition can be predicted in patients with CHR or recent-onset depression (ROD) using multimodal machine learning that optimally integrates clinical and neurocognitive data, structural magnetic resonance imaging (sMRI), and polygenic risk scores (PRS) for schizophrenia; to assess models' geographic generalizability; to test and integrate clinicians' predictions; and to maximize clinical utility by building a sequential prognostic system. Design, Setting, and Participants: This multisite, longitudinal prognostic study performed in 7 academic early recognition services in 5 European countries followed up patients with CHR syndromes or ROD and healthy volunteers. The referred sample of 167 patients with CHR syndromes and 167 with ROD was recruited from February 1, 2014, to May 31, 2017, of whom 26 (23 with CHR syndromes and 3 with ROD) developed psychosis. Patients with 18-month follow-up (n = 246) were used for model training and leave-one-site-out cross-validation. The remaining 88 patients with nontransition served as the validation of model specificity. Three hundred thirty-four healthy volunteers provided a normative sample for prognostic signature evaluation. Three independent Swiss projects contributed a further 45 cases with psychosis transition and 600 with nontransition for the external validation of clinical-neurocognitive, sMRI-based, and combined models. Data were analyzed from January 1, 2019, to March 31, 2020. Main Outcomes and Measures: Accuracy and generalizability of prognostic systems. Results: A total of 668 individuals (334 patients and 334 controls) were included in the analysis (mean [SD] age, 25.1 [5.8] years; 354 [53.0%] female and 314 [47.0%] male). Clinicians attained a balanced accuracy of 73.2% by effectively ruling out (specificity, 84.9%) but ineffectively ruling in (sensitivity, 61.5%) psychosis transition. In contrast, algorithms showed high sensitivity (76.0%-88.0%) but low specificity (53.5%-66.8%). A cybernetic risk calculator combining all algorithmic and human components predicted psychosis with a balanced accuracy of 85.5% (sensitivity, 84.6%; specificity, 86.4%). In comparison, an optimal prognostic workflow produced a balanced accuracy of 85.9% (sensitivity, 84.6%; specificity, 87.3%) at a much lower diagnostic burden by sequentially integrating clinical-neurocognitive, expert-based, PRS-based, and sMRI-based risk estimates as needed for the given patient. Findings were supported by good external validation results. Conclusions and Relevance: These findings suggest that psychosis transition can be predicted in a broader risk spectrum by sequentially integrating algorithms' and clinicians' risk estimates. For clinical translation, the proposed workflow should undergo large-scale international validation.

[Aggressive behaviour and substance abuse among schizophrenic adolescents compared to antisocial adolescents--a follow-up study]. / Aggressives Verhalten und Substanzmittelkonsum bei an Schizophrenie erkrankten Jugendlichen im Vergleich zu dissozialen Jugendlichen, eine follow-up Studie.

OBJECTIVES: The objective of this study was to analyze aggressive behaviour towards others by schizophrenic as opposed to antisocial adolescents, and the influence of substance abuse before, during and after their hospitalization. METHODS: We analyzed 21 schizophrenic adolescents and compared their aggressive behaviour and their substance abuse to that of 21 antisocial juveniles before and during their hospitalization and again at the time of a follow-up interview. The two samples were matched for age, sex and intelligence. In a first step, data were gathered from the hospital records, in a second step, for follow-up data we conducted standardized telephone interview with the patient and his or her parent or caregiver. Within the analysis we focused on aggressive behaviour towards other people and objects, as well as on criminal acts and regular substance abuse. RESULTS: We found less aggressive behaviour among psychotic patients during and post-hospitalization than among their antisocial counterparts. As inpatients, the acutely psychotic juveniles were at higher risk for aggressive acts, but adequate treatment subdued their offensive behaviour. In the long term, there were fewer criminal arrests among psychotic patients. Only in connection with their substance abuse, their aggressive misconduct towards others increased. CONCLUSIONS: Our results suggest that drug treatment during adolescence might help to lessen the risk of aggressive behaviour towards others.

The Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY): practicability and discriminative validity.

BACKGROUND: Basic symptom (BS) criteria have been suggested to complement ultra-high risk (UHR) criteria in the early detection of psychosis in adults and in children and adolescents. To account for potential developmental particularities and a different clustering of BS in children and adolescents, the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was developed. AIMS: The SPI-CY was evaluated for its practicability and discriminative validity. METHOD: The SPI-CY was administered to 3 groups of children and adolescents (mean age 16; range = 8-18; 61% male): 23 at-risk patients meeting UHR and/or BS criteria (AtRisk), 22 clinical controls (CC), and 19 children and adolescents from the general population (GPS) matched to AtRisk in age, gender, and education. We expected AtRisk to score highest on the SPI-CY, and GPS lowest. RESULTS: The groups differed significantly on all 4 SPI-CY subscales. Pairwise post-hoc comparisons confirmed our expectations for all subscales and, at least on a descriptive level, most items. Pairwise subscale differences indicated at least moderate group effects (r ≥ 0.37) which were largest for Adynamia (0.52 ≤ r ≥ 0.70). Adynamia also performed excellent to outstanding in ROC analyses (0.813 ≤ AUC ≥ 0.981). CONCLUSION: The SPI-CY could be a helpful tool for detecting and assessing BS in the psychosis spectrum in children and adolescents, by whom it was well received. Furthermore, its subscales possess good discriminative validity. However, these results require validation in a larger sample, and the psychosis-predictive ability of the subscales in different age groups, especially the role of Adynamia, will have to be explored in longitudinal studies.

The significance of at-risk symptoms for psychosis in children and adolescents.

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.