Clinical research updates

Ioannis Rokas

National and Kapodistrian University of Athens

Psychosis risk identification has been a major focus of psychiatric research for the past 25 years, with the ultra high-risk or clinical high-risk (CHR) approach, based on psychotic symptoms, being the dominant paradigm. However, the CHR approach identifies only a small proportion (4.4%–13.7%) of individuals at risk for psychosis. An alternative approach is to investigate systems where psychosis risk factors are concentrated during childhood. Child and Adolescent Mental Health Services (CAMHS) could be a high-risk system for psychosis and bipolar disorder when attendees are followed into adulthood.

Lang et al. (2022) conducted a longitudinal study of all Finns (N = 59,476) born in 1987, using data from the nationwide 1987 Finnish Birth Cohort study, until 2015, in order to explore this hypothesis. The study involved 55,875 individuals (48.5% females), with 12.5% having one or more contacts with CAMHS in childhood or adolescence and 4% having at least one inpatient CAMHS admission. The authors found that 12.8% of all individuals who attended CAMHS during childhood or adolescence received a diagnosis of a psychotic or bipolar disorder by the age of 28 years, compared to 1.8% of the rest of the population (OR = 7.9, 95% CI: 7.2–8.7). This risk was much higher when individuals had at least one inpatient CAMHS admission (24%). More than one third of young people with a first CAMHS inpatient admission when aged 13–17 years had been diagnosed with psychosis or bipolar disorder by the age of 28 years. In nearly 60% of these cases, the diagnosis was first made later in life, on average 3 years after the initial contact. In addition, at least half of all individuals diagnosed with psychosis or bipolar disorder by the age of 28 years had, at some point in their childhood or adolescence, attended specialist CAMHS. Just 16.6% of these psychosis or bipolar disorder cases were diagnosed within 3 months of first attending outpatient CAMHS or on first inpatient CAMHS admission. For the majority (83.4%), the median time from first CAMHS contact to psychosis or bipolar diagnosis was >6 years. Individuals who attended CAMHS but received no mental disorder diagnosis within the first 3 months (when this was assessed) had an equally high risk of psychosis and bipolar disorder as individuals who did receive a diagnosis. A diagnosis of mood disorder and disruptive behavior disorder, at that time point, was associated with increased risk and a diagnosis of neurodevelopmental disorders with reduced risk of developing psychosis or bipolar disorder.

A key strength of this study was the use of total population and official service data. It highlights the elevated risk of future diagnosis of psychosis or bipolar disorder among children and young people attending CAMHS, especially those who require inpatient admission. One limitation of the study is that except for psychosis and bipolar disorder, the other CAMHS diagnoses were those recorded 3 months after the initial contact which may have underestimated the risk some diagnoses, for example, neurodevelopmental disorders, may carry towards the study outcome and overestimate the risk of no diagnosis having been made at that timepoint. In addition, the findings of this study are system-specific, applying to specialist CAMHS, and should not be extrapolated to other (e.g., primary care) mental health services for children and adolescents.

Lång, U., Ramsay, H., Yates, K., Veijola, J., Gyllenberg, D., Clarke, M. C., … & Kelleher, I. (2022). Potential for prediction of psychosis and bipolar disorder in Child and Adolescent Mental Health Services: A longitudinal register study of all people born in Finland in 1987. World Psychiatry, 21, 436–443.

Vasiliki Kokkinakou

National and Kapodistrian University of Athens

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are neurodevelopmental conditions that have been found to coexist in children and young people. However, the trajectories of respective symptoms in these disorders and their relationship have not been extensively studied.

Shakeshaft et al. (2023) investigated the concurrent evolution of ADHD-autistic traits of 7156 subjects between the ages of 7 and 25 years within the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective longitudinal birth cohort in England. They used the hyperactivity subscale of the Strengths and Difficulties Questionnaire (SDQ) to measure ADHD symptoms and the Social Communication Disorder Checklist (SCDC) to measure autistic traits. The effects of sociodemographic, perinatal, psychopathology, cognition and social functioning variables on different trajectories were explored and associations with neurodevelopmental/psychiatric polygenic scores (PGS) were tested. Employing parallel-process growth mixture modeling, the authors identified three classes: one with consistently low levels of ADHD-autistic traits at all assessed ages (87%), one displaying a trajectory of declining ADHD-autistic traits from childhood to adolescence (6%), and one manifesting late-onset ADHD-autistic traits (6%). The latter two classes were associated with more emotional and conduct problems, low IQ, and childhood seizures compared with the former one. Notably, the child/adolescent-declining class exhibited the highest incidence of preterm birth at 8% (compared with 5% in the other classes), and a higher proportion of males. A greater prevalence of low family income, an increased likelihood of peer-related issues throughout all ages, and a higher frequency of individuals not engaged in education, employment, or training at age 25 years were identified in the declining and late-emerging symptoms classes relative to the low-stable class. In addition, emotional, conduct, and peer problems were more prevalent during childhood in the declining class compared with other classes but were more prevalent in young adulthood in the late-emerging class. Elevated ADHD PGS was identified in both atypical classes. The late-emerging class exhibited elevated schizophrenia PGS and decreased executive function PGS, whereas the declining class showed elevated broad depression PGS.

These findings are in keeping with prior observations within this cohort concerning social communication and ADHD traits when studied separately. The study underscores the parallel co-development of autism and ADHD traits throughout childhood to early adulthood. Notably, correlations between these traits intensify with age within nontypically developing subgroups. This suggests a need for clinicians to reevaluate neurodevelopmental comorbidities across the life span, rather than solely at initial childhood assessments. Limitations include the exclusive focus of the SCDC on social and communication impairments, potential rater effects due to reliance on parent-reported measures, nonrandom attrition in the cohort, and concerns regarding multiple testing and potential false-positive associations.

In conclusion, this study identified heterogeneous trajectories of ADHD and autistic traits in the general population, demonstrating diverse patterns of co-occurrence and developmental correlations. Understanding these patterns could significantly impact clinical follow-up practices for individuals with autism or ADHD, extending from childhood to adulthood.

Shakeshaft, A., Heron, J., Blakey, R., Riglin, L., Davey Smith, G., Stergiakouli, E., … & Thapar, A. (2023). Co-development of attention deficit hyperactivity disorder and autistic trait trajectories from childhood to early adulthood. Journal of Child Psychology and Psychiatry, 64, 1596–1607.

Katerina Tselika

National and Kapodistrian University of Athens

Several lines of evidence suggest that physical activity can be beneficial for the cognitive development of children and may have a positive effect on their executive function and language use. Olive et al. (2023) investigated whether the Active Early Learning (AEL) physical intervention improves the executive function of children in terms of working memory, inhibition, attention shifting and if it increases their expressive vocabulary. They also measured if the levels of physical activity, either light or intense, affect the impact of AEL on executive function and language development of children. In this study, 170 preschool children, aged 3–5 years (mean age 4.27 years) received the intervention, and 144 children (mean age 4.32 years) were in the control group. The sample was recruited from 16 private childcare centers in Southeast Queensland and Northern New South Wales, Australia. The schools were randomly assigned to either the intervention or control group.

The AEL program lasted 6 months and it was mainly coordinated and conducted by the AEL coaches. AEL coaches were appropriately trained by the researchers of the study, and they were responsible for conducting the program and training the educators of each center. The AEL intervention included a variety of activities related to the physical, psychological, social, and cognitive development of children including group/mat time and transitions between different events, movement education, and cross-curricular movement education like book reading and free play. The executive function and expressive vocabulary of the children were assessed by the researchers prior to the beginning of the program and 6 months later. The intensity of the physical activity was measured by accelerometers placed in elastic belts each child had to wear on the right side of their hip for three consecutive days. Data was collected through daily online logbooks the AEL coach had to keep and a record of daily intervention activities the educators had to complete on a wall chart. The study identified a small but statistically significant effect of AEL intervention on inhibition and expressive vocabulary. The volume of physical activity measured by the accelerometers did not seem to affect any of the executive function domains studied.

Despite these promising results, a causative relationship between physical activity, executive function and language development cannot be established. The reason is that there might be other factors associated with physical education that might be proven beneficial to executive function and language development including the child-to-child and child-to-educator interaction and the engagement of children with fun activities like free play and story/book reading. Limitations of the study include the short period of the intervention (6 months), the lack of longitudinal data, and the lack of consideration of the type of motor skills which was included in the physical activities of the intervention.

Olive, L. S., Telford, R. M., Westrupp, E., Telford, R. D. (2023). Physical activity intervention improves executive function and language development during early childhood: The active early learning cluster randomized controlled trial. Child Development. doi: 10.1111/cdev.14014.

No ethical approval was required for these updates.