Conduct Disorder

MONDAY, May 1, 2023 -- Growing numbers of American kids and teens are cutting or burning themselves, banging their heads against walls, pulling out their hair and even trying to die by suicide. But figuring out who is at highest risk for harming themselves has been a daunting challenge. Until now. Researchers report they have developed risk profiles that can help doctors pinpoint which kids or teens are in the most danger. "The U.S. is in the midst of a mental health crisis, with mental health diagnoses and hospitalizations surging over the past few years, and many of these hospitalizations are for self-harm events or concern for future self-harm," said study author Dr. James Antoon , an assistant professor of pediatrics and hospital medicine at Monroe Carell Jr. Children's Hospital at Vanderbilt University in Nashville, Tenn. “Self-harm is a big bucket of events from mild things like cutting on the arms or thighs to taking so much Tylenol that you die on purpose or jumping out of a window, and we wanted to find out which kids require hospitalization and more intensive treatment and monitoring," he said. There’s a pronounced shortage of in-patient hospital beds for kids with mental health issue in the United States, which makes the situation even more dire. Knowing which kids are at the highest risk can help make better use of these limited resources, Antoon noted. So, his team developed four risk profiles for serious self-harm based on age, gender and psychiatric and medical conditions. Of nearly 1,100 children hospitalized for psychiatric reasons at two children’s hospitals from April 2016 to March 2020, 37% were there for self-harm. The researchers found that boys aged 10 to 13 with ADHD, bipolar disorder, autism spectrum disorder or another developmental disorder were 80% more likely to engage in serious self-harm behavior that requires hospitalization. Meanwhile, teen girls aged 14 to 17 with depression and anxiety, substance- and trauma-related disorders, and personality and eating disorders were also at high risk for serious self-harm, the study showed. Suicide attempts comprised the majority of serious self-harm behaviors in the study. In a counterintuitive finding, kids who were at moderate risk for serious self-harm didn’t necessarily have depression, Antoon said. “It is assumed that if you are suicidal, you must be depressed, but there are other things that can drive self-harm and suicide, including anxiety disorders,” he noted. The study was published online May 1 in the journal Pediatrics . There are many reasons kids and teens will try to harm themselves, said Elizabeth Bailey , director of clinical services at the 3East Boys Intensive Program at McLean Hospital in Boston. “It can serve to help individuals self-regulate or control overwhelming emotions, escape from feelings of being numb or empty or punish themselves, and [it] also serves as a form of unspoken communication to others about one’s suffering," said Bailey, who was not involved with the study. But it's not always easy to spot the signs of self-harm in kids, as they hide evidence by wearing long sleeves to cover scars on their arms or other methods, she said. Still, there are some things to look out for. "A typically outgoing and social child who suddenly withdraws, or an academically driven and achieving child who stops completing assignments for a sustained period of time may be cause for concern,” Bailey said. Self-harming behaviors are often portrayed as problems for girls and women in the media, added Anna Precht , program director at 3East Boys Intensive Program. “The finding that the highest risk profile is characterized by boys aged 10-13 with anxiety and depression, as well as other psychiatric disorders including externalizing behaviors like ADHD and conduct disorder, highlights the importance of assessing for self-harm behaviors across diagnostic and gender presentations," said Precht, who was not part of the new research. If you are concerned that your child is engaging in self-harm, contact a psychologist, social worker or pediatrician, she advised. Help is available. “Dialectical Behavior Therapy [a type of talk therapy based on cognitive behavioral therapy] helps people to understand what factors contribute to self-injurious behaviors [as well as other problematic behaviors] and teaches skills for managing emotions more effectively,” Precht said. “This a treatment that has been shown to be effective in treating these behaviors and has been adapted for teens and their families.” Sources James Antoon, MD, PhD, MPH, assistant professor, pediatrics, hospital medicine, Monroe Carell Jr. Children’s Hospital, Vanderbilt University, Nashville, Tenn. Elizabeth Bailey, PsyD, director, clinical services, 3East Boys Intensive Program, McLean Hospital, Boston Anna Precht, PsyD, program director, 3East Boys Intensive Program, McLean Hospital Pediatrics , May 1, 2023 Posted May 2023

Characterized by antisocial behaviors and low academic achievement, conduct disorder (CD) impacts an estimated 9.5% of individuals in the United States. Childhood maltreatment is a major risk factor for CD. Past CD studies have identified structural alterations in various brain regions, such as those implicated in emotion processing, learning, and social cognition. A new study has now assessed whether youths with CD who experienced childhood maltreatment differ at the brain level from those with CD without a history of maltreatment. Characterized by antisocial behaviors and low academic achievement, conduct disorder (CD) impacts an estimated 9.5% of individuals in the United States. Childhood maltreatment is a major risk factor for CD. Past CD studies have identified structural alterations in various brain regions, such as those implicated in emotion processing, learning, and social cognition. A new study appearing in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, published by Elsevier, has now assessed whether youths with CD who experienced childhood maltreatment differ at the brain level from those with CD without a history of maltreatment. The research, led by Marlene Staginnus, a PhD student at the University of Bath, UK, tested the ecophenotype model, which proposes that maltreatment-related psychopathology is distinct from forms of psychopathology that do not develop as a result of childhood maltreatment. The study included 146 healthy controls and 114 youths with CD. The researchers collected structural MRI data to study cortical structure, including the volume, area, and thickness of the cortex, the outer layer of the brain. Graeme Fairchild, PhD, Department of Psychology, University of Bath, Bath, UK, the senior author on the paper, said, "Our findings have important implications for theory, research, and clinical practice for those working in mental health or forensic services for young people. First, they suggest that, despite having the same diagnosis, conduct disordered youths with and without maltreatment differ from each other in brain structure and also differ from healthy youth in different ways. To be more specific, the conduct disordered youth with a history of childhood maltreatment showed far more extensive changes in brain structure than the non-maltreated youth with CD -- multiple brain regions were affected, and several different aspects of cortical structure (cortical thickness, surface area, and folding) were altered. The maltreated youth with CD also differed more in comparison to the healthy youth than their non-maltreated counterparts." In line with the researchers' hypotheses, maltreated and non-maltreated CD youths displayed distinct alterations compared to healthy controls. When combining the CD youths with and without maltreatment into a single group, the CD group displayed lower cortical thickness in the right inferior frontal gyrus. However, when the maltreated and non-maltreated youths were separately compared with healthy controls, those who had experienced maltreatment displayed more widespread structural changes in comparison to healthy controls that did their non-maltreated counterparts. Cameron Carter, MD, editor of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, said of the study, "the authors use structural MRI to measure the changes in brain structure associated with CD and highlight the unique contribution of childhood maltreatment to these changes. The study provides neurobiological insights into the heterogeneity of CD with implications for understanding pathophysiology and informing future treatment development." These findings may help guide research toward better understanding the prevention, assessment, and treatment of CD. They also beckon to researchers to explore whether there is a distinct pathway between maltreatment and antisocial behavior, or if such brain differences translate to differences in treatment responsiveness. Dr. Fairchild recommends that "maltreatment history be assessed in future neuroimaging studies of conduct disorder and other psychiatric disorders of childhood and adolescence."

Experiencing abuse or neglect as a child can cause multiple mental health problems, finds a new study. Experiencing abuse or neglect as a child can cause multiple mental health problems, finds a new study led by UCL researchers. The research, published in the American Journal of Psychiatry, seeks to examine the causal effects of childhood maltreatment on mental health by accounting for other genetic and environmental risk factors, such as a family history of mental illness and socioeconomic disadvantage. The first-of-its-kind research analysed 34 quasi-experimental studies, involving over 54,000 people. Quasi-experimental studies can better establish cause and effect in observational data, by using specialised samples (eg. identical twins) or innovative statistical techniques to rule out other risk factors. For example, in samples of identical twins, if a maltreated twin has mental health problems but their non-maltreated twin does not, the association cannot be due to genetics or the family environment shared between twins. Across the 34 studies, researchers found small effects of child maltreatment on a range of mental health problems, including internalising disorders (eg. Depression, anxiety, self-harm, and suicide attempt), externalising disorders (eg. alcohol and drug abuse, ADHD, and conduct problems), and psychosis. These effects were consistent regardless of the method used or way in which maltreatment and mental health were measured. The findings suggest that preventing eight cases of child maltreatment would prevent one person from developing mental health problems. Corresponding author, Dr Jessie Baldwin (UCL Psychology & Language Sciences), said: "It is well known that child maltreatment is associated with mental health problems, but it was unclear whether this relationship is causal, or is better explained by other risk factors. "This study provides rigorous evidence to suggest that childhood maltreatment has small causal effects on mental health problems. Although small, these effects of maltreatment could have far-reaching consequences, given that mental health problems predict a range of poor outcomes, such as unemployment, physical health problems and early mortality. "Interventions that prevent maltreatment are therefore not only essential for child welfare, but could also prevent long-term suffering and financial costs due to mental illness." Nevertheless, the researchers also found that part of the overall risk of mental health problems in individuals exposed to maltreatment was due to pre-existing vulnerabilities -- which might include other adverse environments (eg. socioeconomic disadvantage) and genetic liability. Dr Baldwin said: "Our findings also suggest that to minimise risk of mental health problems in individuals exposed to maltreatment, clinicians should address not only the maltreatment experience, but also pre-existing psychiatric risk factors." Researchers defined childhood maltreatment as any physical, sexual or emotional abuse or neglect before the age of 18. The study was funded by Wellcome and is in collaboration with King's College London, University of Lausanne, Yale University School of Medicine, University of Bristol and NIHR Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust. Study limitations Each of the quasi-experimental studies analysed may have been subject to potential biases. However, the findings were consistent across studies using different quasi-experimental methods, suggesting that the results are robust. Additionally, it was not possible to draw firm conclusions about the specific effects of different types of maltreatment, as it is common for different types of abuse/neglect to happen at the same time, and studies rarely account for this. The lack of available data mean that it was not possible to examine the effects of the timing of maltreatment, the interval between maltreatment and mental health issues, or differences between racial or ethnic groups. Future quasi-experimental research is needed to address these questions.