Clinical Research Updates

Evi Drosopoulou

National and Kapodistrian University of Athens, Athens, Greece

Psychiatric disorders, and psychotic disorders in particular, are associated with NEET (“not in education, employment or training”), which means that the person is not studying, working, or participating in a job search program for some time in their life. Despite the severe effects of withdrawal from education and work experienced by many people diagnosed with psychotic disorders, the evaluation of risk factors affecting it, and potential rehabilitation targets remain understudied.

Ringbom et al. (2022) aimed to examine whether individuals diagnosed with psychotic disorders in adolescence had been out of work or education for more than 5 years (long-term NEET) compared with the general population. They also aimed to investigate risk markers for the development of long-term NEET and whether there is a correlation between socioeconomic and educational factors and inequalities in the use of rehabilitation services. They used data from the 1987 Finnish Birth Cohort study, which included 59,476 individuals born in Finland between January 1 and December 31, 1987, and from several Finish administrative registers. The study lasted until 2015 and therefore enabled the researchers to follow individuals up until the age of 28. In total, 55,171 individuals were eventually included in the analysis. Exclusion criteria were a diagnosis of intellectual disability, being diagnosed with a psychotic disorder between 1998–2003, not surviving until 31 December 2015, and having emigrated. The study found that 0.5% of the cohort (288 people) were diagnosed with a psychotic disorder (F20–F29) between the ages of 16 and 20 years. More than a third (35.8%) of them met criteria for long-term NEET, and in those diagnosed with schizophrenia or schizoaffective disorder, this figure was 57% as opposed to 2.2% in young people without psychosis. In relation to sociodemographic characteristics, it was observed that 58.3% of individuals with psychotic disorders had a parent receiving welfare benefits and that 78.6% of individuals had no upper secondary education diploma by the end of 2008. At the same time, in terms of comorbidity, the researchers found that more than half of people with psychosis had also been diagnosed with a depressive disorder. Younger age of psychosis onset within the 16–20 years bracket was not associated with long-term NEET. The study also found that the most common form of rehabilitation was specialized vocational rehabilitation (24.4% of cases) and much less so psychotherapy; this form of rehabilitation was given especially to people who were long-term NEET which may indicate that rehabilitation was given late when the person had already been away from school or work for years.

These findings suggest that long-term NEET is a significant concern for young people with psychotic disorders. Intensive rehabilitation as early as possible in the course of the illness may be associated with improved long-term outcomes. The study had several strengths, including sample size, study duration, and the fact that it linked many registers to a birth cohort. The authors highlighted a few limitations including the need for longitudinal studies in other countries with less homogeneous populations to further explore the association between psychosis and long-term NEET, including information on race and ethnicity.

Ringbom, I., Suvisaari, J., Kääriälä, A., Sourander, A., Gissler, M., Kelleher, I., & Gyllenberg, D. (2022). Psychotic disorders in adolescence and later long-term exclusion from education and employment. Schizophrenia Bulletin, sbac151. doi: 10.1093/schbul/sbac151

Sofia Kleisari

National and Kapodistrian University of Athens, Athens, Greece

Adverse childhood experiences, such as childhood maltreatment, undermine the normal development of emotional skills and have been linked to the development of alexithymia. Alexithymia is a phenomenon characterized by difficulties in recognizing, describing, distinguishing, and expressing one's own emotions and is associated with difficulties in one's ability to form healthy interpersonal relationships. Alexithymia may act as a mediator between childhood maltreatment and adult psychopathology and might also serve as a potential coping mechanism when exposed to adverse emotional expression as well as punishment for expressing specific types of emotions. Literature shows that certain types of childhood maltreatment, such as emotional and physical neglect, may be associated with alexithymia, while findings on physical and sexual abuse are not consistent.

Khan and Jafee (2022) in this systematic review and meta-analysis investigated the degree to which maltreatment in childhood and adolescence was associated with alexithymia, as measured in adulthood. A total of 88 studies with 43,076 individuals were included. Most of the studies (N = 68) used The Childhood Trauma Questionnaire to measure childhood maltreatment while the rest used standardized measures, self-reports, and clinical interviews. Self-report measures were used for alexithymia. The meta-analysis estimated the association of alexithymia with all types of childhood maltreatment combined as well as separately for each subtype (physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect). Meta-regressions were applied for examining the role of moderators, such as gender, race, sample type, age, continent, maltreatment measurement, and quality of the study. The authors identified a small, statistically significant effect size for the association between alexithymia and overall maltreatment (r = .22). All subtypes of maltreatment were significantly linked to alexithymia; stronger associations were found between alexithymia and emotional neglect (r = .24), physical neglect (r = .23), and emotional abuse (r = .21). Only gender seemed to act as a moderator, with the association between alexithymia and maltreatment being greater in females than males.

This meta-analysis demonstrated that childhood emotional and physical neglect are the subtypes of maltreatment most strongly associated with alexithymia. Limitations of the analyzed studies include the use of retrospective self-report measures which are subject to recall bias and have poor reliability, and suboptimal reporting of sample demographics which affects conclusions on the generalizability of findings. Further studies could investigate the effects of chronicity and cooccurrence of maltreatment subtypes in the development of alexithymia. Targeting alexithymia in treatment may promote emotional development and mental health.

Khan, A.N., & Jaffee, S.R. (2022). Alexithymia in individuals maltreated as children and adolescents: A meta-analysis. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.13616

Mara Ktena

National and Kapodistrian University of Athens, Athens, Greece

Depression may present early in life, even during the preschool period. Preschool depressive disorders are frequently accompanied by other mental disorders, are related to functional impairment in multiple domains, and carry an increased risk for subsequent depressive episodes in middle childhood and adolescence. These early depressive episodes may also constitute predictive indicators of sequential comorbidity (i.e., subsequent anxiety, attention deficit hyperactivity disorder, and disruptive behavior disorders). However, the clinical and prognostic significance of early childhood depression requires further elucidation.

Silver et al. (2022) conducted a follow-up study to investigate first, whether 3- and 6-year-old depressed children were at a higher risk to exhibit episodes of depression and other psychiatric disorders in the future, and, second, whether they present with subsequent functional impairment. The participants (N = 516) were initially assessed for psychopathology during the age of 3 and 6 using the Preschool-Age Psychiatric Assessment (PAPA) and later at ages 9, 12, and 15 years using the Kiddie Schedule for Affective Disorders and Schizophrenia. The former was administered solely to parents, whereas the latter was both to a parent and to the child. In addition, the Children's Global Assessment Scale was used for the measurement of global functioning at each age. The findings indicated that participants who met the criteria for depressive disorders at age 3/6 were at a greater risk of developing a subsequent episode of depressive disorder (32.6%) and were more likely to present later with anxiety disorders (30.6%), attention deficit hyperactivity disorder (18.6%), and suicidality (15.7%) compared with children without depressive disorders at that age. Moreover, a strong link was found between mothers reporting depressive symptoms and early childhood depression. Finally, the study suggests that children who experienced depression at a very early age had lower levels of global and interpersonal functioning and higher rates of treatment at age 15 years in comparison with those who did not.

The present study highlights the clinical significance and the prognostic value of early childhood depression and has several advantages including multiple follow-up waves and parent-rated and children-based measures of psychopathology and functional impairment. It has also some limitations related to the generalizability of its findings since the sample was not randomly selected and predominantly consisted of white and middle-class families. Another limitation is related to the low prevalence of depressive disorders in this community sample and the heterogeneity of the depressed group that included participants with major depression, dysthymia, and depression NOS.

Silver, J., Olino, T.M., Carlson, G.A., Dougherty, L.R., Bufferd, S.J., & Klein, D.N. (2022). Depression in 3/6-year-old children: clinical and psychosocial outcomes in later childhood and adolescence. Journal of Child Psychology and Psychiatry, 63, 984–991.

Eleftheria Vanioti

National and Kapodistrian University of Athens, Athens, Greece

Adolescents need adequate sleep for optimal development and health. However, several lines of research have shown that the majority of adolescents do not have a consistent sleep schedule. Reduced sleep at that age has been associated with poorer general and mental health, academic underachievement, and increased risk-taking behaviors.

Maskevich et al. (2022) studied adolescents' daily sleep self-regulation by investigating the planning and execution of their plans as well as sleep opportunities. This study used ecological momentary assessment (EMA) to collect daily adolescents' bedtime and rise time plans. For 28 days, including school and vacation weeks, 205 adolescents (54.1% female, 64.4% non-White) from years 10 to 12 reported their sleep plans and wore an Actiwatch to measure actual daily sleep. The results showed that one in five adolescents never planned bedtime (school days 19.5%, nonschool days 53.2%). Furthermore, less than a third of those who planned it did so consistently only on school nights. On average, actual bedtime was delayed by about an hour (71 min delay on nonschool nights, 46 min on school nights), and only a third of adolescents went to bed as planned. More adolescents executed their sleep plans (within 15 min) consistently at school than on nonschool days and nights. In addition, with increasing age, consistent sleep planning decreased in females but increased or remained stable in males. As far as sleep opportunity is concerned, when bedtime was planned and executed by plans then time in bed was more. Therefore, planning and plan execution were protective factors of sleep opportunities. In addition, a large number of adolescents (~40%) reported parental influence on sleep planning, and most adolescents planned more time in bed than they perceived they needed. However, about half of adolescents considered that they needed less than 8 hr of sleep on both school and nonschool days.

These findings demonstrate that adolescents need support for sleep self-regulation. Planning and execution of plans about bedtime are protective factors for sleep opportunities on school nights. Likewise, adolescents' perception of sleep needed is an important therapeutic intervention target.

Maskevich, S., Shen, L., Drummond, S.P.A., Bei B. (2022). What time do you plan to sleep tonight? An intense longitudinal study of adolescent daily sleep self-regulation via planning and its associations with sleep opportunity. Journal of Child Psychology and Psychiatry. 63, 900–911.

No ethical approval was required for these updates.