Study Highlights Need to Screen Young Children With Depression for Suicidal Behaviors

Children diagnosed with major depressive disorder between the ages of 3 and 6—known as preschool-onset MDD—are more likely than their peers to express suicidal thoughts and behaviors before the age of 13, a report in the Journal of the American Academy of Child and Adolescent Psychiatry suggests.

“While general [suicidal thoughts and behaviors] screening is not indicated for children under age 8, suicide assessment should be conducted if warning signs such as mood disturbances are present,” wrote Laura Hennefield, Ph.D., of the Washington University School of Medicine and colleagues. “Children with [preschool-onset] MDD would likely benefit from increased suicide screening, proactive safety planning, and early interventions.”

The study included 137 children aged 8 to 12 years who met the criteria for preschool-onset MDD and 53 children aged 8 to 12 with no history of depression.

The children with preschool-onset MDD and their caregivers had initially participated in a study testing the effectiveness of a parent-child psychotherapy for early childhood depression. As part of that study, caregivers completed multiple assessments about their children, such as the Kiddie Schedule for Affective Disorders and Schizophrenia-Early Childhood (K-SADS-EC). When the children were between 8 and 12 years, the researchers asked the caregivers to complete the K-SADS-Present and Lifetime (K-SADS-PL), which included questions on lifetime and current symptoms of depression as well as suicidal thoughts, behaviors, and attempts. The children also reported on their own lifetime and current symptoms. A child was considered to have suicidal thoughts and behaviors if such behaviors were reported by the caregiver or the child.

The researchers found that 67.9% of 8-to 12-year-old children who had preschool-onset MDD expressed suicidal thoughts and behaviors by preadolescence, including 26.3% over the prior month. In contrast, 22.6% of children without a history of depression endorsed suicidal thoughts and behaviors by preadolescence, including 3.8% over the prior month. The children with preschool-onset MDD were also significantly more likely to have made a suicide attempt by age 12 compared with peers without depression history.

Further analysis revealed that children with preschool-onset MDD who achieved remission following parent-child psychotherapy (defined as at least 50% reduction in symptom severity and loss of preschool-onset MDD diagnosis) were less likely to experience suicidal thoughts and behaviors after preschool.

“Studying those with or at risk for [suicidal thoughts and behaviors] early in development holds promise for identifying at-risk children for targeted preventative intervention to alter risk trajectories away from persistent or escalating [suicidal thoughts and behaviors],” the researchers said.

For related information, see the Psychiatric News article “Suicidal Thoughts Begin Early for Some Youth.”

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Don’t Shut Down Conversations When Youth Present With ‘Trending’ Disorders, Psychiatrist Says

Youth increasingly rely on social media to diagnose themselves with a variety of psychiatric illnesses—a trend that has been met with more than a few raised eyebrows.

In a short article in the Journal of the American Academy of Child & Adolescent Psychiatry, child and adolescent psychiatrist David C. Rettew, M.D., described how he works with youth with so-called “trending presentations” and cautions against the dangers of oversimplifying such cases. 

• Ask patients direct questions about whether they have a specific diagnosis in mind, as well as the research that led them to this conclusion: “[I]t is common for my new patients to get a little sheepish when disclosing the source of their investigations, as most commonly the ideas come from social media platforms such as YouTube or TikTok rather than the medical textbooks that used to make medical students wonder about being stricken with lots of exotic ailments,” he described.
• Reject the tendency to dismiss or deny the patient’s narrative “because it does not fit our current scientific or political perspective”: “Science has shown us repeatedly that virtually everything when it comes to mental functioning—from common personality traits to psychopathology to gender typical behavior—comes from a complicated mash-up of mutually interacting genetic and environmental factors. These environmental contributors include things such as peers and media influences, and their presence in the mix should not immediately disqualify someone’s history as undeserving.”
• The more complicated a clinical situation appears, the more important it is to stick to the basics: Establish good rapport with the patient, be thorough, validate while maintaining some skepticism, and give yourself time to conceptualize, he said. “[I]n so doing, we may find that those supposed trending presentations are an accurate description of symptoms that have been long experienced and suppressed by the individual until they are living in an environment supportive enough for their expression. … Or maybe we find out that, indeed, someone really has been heavily influenced by what they have heard from a peer or seen on a social media video as part of developmentally appropriate needs to feel connected socially and developmentally appropriate introspection at this age about their identity,” he wrote.

Rettew concluded, “Rigid and oversimplistic thinking often fails us and our patients by closing conversations before they ever truly open. The pathways through which our patients find their way to our office are incredibly rich and diverse. We lump them into convenient boxes at our peril, virtually begging our patients to reveal to us the deficiencies of our mental shortcuts.”

Rettew works for Lane County Behavioral Health in Eugene, Ore.

For more on this topic, see the Psychiatric News article “‘Outbreak’ of Sudden Tics Among Teen Girls Has Surprising Global Similarity.”

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Study Identifies Maternal Risk Factors Associated With Behavioral Challenges in Youth

Developing an infection and/or smoking while pregnant are just two of several factors that a study in the Journal of the American Academy of Child & Adolescent Psychiatry suggests may put offspring at risk of emotional, cognitive, and behavioral dysregulation.

“Emotional, cognitive, and behavioral dysregulation in childhood is associated with impaired psychosocial functioning, poor school performance and with increased rates of psychiatric disorders, suicidality, and functional impairment in adulthood,” wrote Jean Frazier, M.D., of UMass Chan Medical School and colleagues.

Frazier and colleagues used data from the National Institutes of Health Environmental Influences on Child Health Outcomes (ECHO) research program. The seven-year research project includes 69 pediatric longitudinal cohorts and aims to investigate the effects of environmental exposures on child health. The ECHO data include information about mothers, including family history of psychiatric illnesses; tobacco use during pregnancy; pre-pregnancy body mass index; educational attainment; gestational diabetes diagnoses; and prenatal infections such as fever, flu, or sexually transmitted infections. Frazier and colleagues limited their analysis to include only ECHO studies in which researchers collected information about children aged 6 to 18 using the Child Behavior Checklist as well as mothers’ experience with prenatal infection. No studies with less than 10 children were included in the analysis.

The Child Behavior Checklist is a tool that is administered to parents and includes 120 questions about the child/adolescent’s behavior. Children are considered to meet the criteria for a dysregulation profile if their sum scores for three of the checklist’s subscales (attention, anxious/depressed, and aggression) is 180 or higher.

The authors analyzed data from 4,595 youth from 18 ECHO cohorts (25% of these youth were born preterm, or before 37 weeks gestation; 17% were born extremely preterm, or before 28 weeks gestation). Over 600 children (13.4%) met the criteria for a dysregulation profile. The frequency of dysregulation profiles was 11.5% for girls and 15.1% for boys. Additional findings include the following:

• Youth with a dysregulation profile had higher odds of having a close relative (parent or sibling) with a psychiatric disorder than those without the dysregulation profile.
• Youth with a mother who had less than a high school education had higher odds of having a dysregulation profile compared with those whose mothers had some college or above.
• Compared with those without a dysregulation profile, youth with a dysregulation profile were more likely to be born to mothers considered overweight prior to pregnancy, more likely to be exposed to prenatal tobacco use, and more likely to be exposed to a prenatal infection.

“Social and educational interventions could possibly target the modifiable risk factors (e.g., maternal obesity, prenatal tobacco use, maternal education) and modify the developmental trajectories associated with the [dysregulation profile], particularly if there are multiple modifiable risk factors seen in an individual child,” the authors concluded. “Critically important to the overall management of these dysregulated youth is more fully understanding the drivers behind a child’s behavior and providing support and intervention in a sustained way.”

For related information, see the Psychiatric News article “Special Report: Stress and Distress During Pregnancy—How to Protect Both Mother and Child.”

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Family Bereavement Program Offers Long-Term Protection Against Depression

Children who experience the death of a parent are known to be at an increased risk of depression and other internalizing problems later in life. A study in the Journal of the American Academy of Child & Adolescent Psychiatry has found that children who together with their families participated in a bereavement program within 2.5 years of the death were less likely to experience depression up to 15 years later.

“The findings from this study have implications for future research on the prevention of depression,” wrote Irwin Sandler, Ph.D., of Arizona State University and colleagues.

Sandler and colleagues enrolled 244 youth aged 8 to 16 who had experienced the death of a parent 3 to 30 months prior to the study and their caregivers for a randomized, controlled trial. A total of 156 families participated in 12 sessions of a family bereavement program or were mailed three age-appropriate books about dealing with grief (literature control).

The family bereavement program included separate group sessions for the children and their caregivers. The caregiver sessions focused on supporting grieving caregivers, strengthening positive parenting techniques such as active listening, and reducing children’s exposure to stressful life events. The youth sessions focused on strengthening positive coping and emotion regulation skills. The children and their caregivers then came together for two joint sessions, where they could together practice their learned skills.

Sandler and colleagues conducted follow-up interviews with the youth to assess grief, intrusive thoughts, internalizing symptoms, depression, and anxiety; these interviews were conducted immediately after the family bereavement or control program, 11 months later, 6 years later, and 15 years later. A total of 186 children (now adults) were still in the trial at the 15-year follow-up.

Between the 6- and 15-year follow-up, 13.46% of the adults who had participated in the family bereavement program as children met the criteria for depression (assessed with the World Health Organization’s World Mental Health Composite International Diagnostic Interview) compared with 28.05% of those in the literature group; 4.81% of the adults who participated in the family bereavement program as children had generalized anxiety disorder as adults compared with 12.20% in the literature group.

After adjusting for multiple variables, Sandler and colleagues calculated that youth who participated in the family bereavement program were 67% less likely to have depression 15 years later compared with youth who had not participated in the program. Youth who participated in the family bereavement program were also less likely to develop anxiety disorders as adults.

“It may [be] that the FBP [family bereavement program] reduces MDD [major depressive disorder] in part through its reduction of negative self-referential processing of the stressors involved in grappling with academic, career, and romantic developmental tasks of early adulthood,” Sandler and colleagues wrote. “Future research is needed to study how preventive interventions such as the FBP may reduce negative self-referential processing as a pathway to the prevention of MDD.”

To read more on this topic, see the American Journal of Psychiatry study “CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial.”

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Youth With Anxiety May Experience Worsening Symptoms After COVID-19

Youth with anxiety disorders who contract COVID-19 may experience worsening anxiety symptoms, suggests a small study reported in a letter in the Journal of the American Academy of Child & Adolescent Psychiatry.

Jeffrey R. Strawn, M.D., of the University of Cincinnati and colleagues analyzed data collected from a longitudinal study of adolescents aged 12 to 17 who had been diagnosed with primary anxiety disorders and were being treated with duloxetine or escitalopram. At the start of the study in December 2019, these youth participated in weekly follow-up visits, where they were evaluated using several measures, including the Generalized Anxiety Disorder-7 (GAD-7) and Clinical Global Impression-Severity (CGI-S) scales.

Strawn and colleagues focused their analysis on data obtained from 26 patients who were about 14 years old and had been evaluated weekly for 7 to 96 weeks. All patients met criteria for generalized anxiety disorder, 19% had separation anxiety disorder, 78% had social anxiety disorder, 30% had panic disorder, 26% had ADHD, and 37% had a history of a depressive disorder. All patients were treated with either duloxetine (30-120 mg/day) or escitalopram (5-20 mg/day) at the start of the study.

The researchers examined 1,308 weeks of data—including 1,019 patient-weeks from patients who did not contract COVID-19, 289 patient-weeks from patients with COVID-19 infection, and 139 patient-weeks post-COVID-19. All patients with COVID-19 were unvaccinated and experienced mild symptoms, the researchers noted.

The researchers found that post-COVID-19, patients’ anxiety symptoms were significantly worse on all GAD-7 subscales (including feelings of nervousness, irritability, and dread) and the CGI-S scale.

“Adolescents with more severe anxiety may experience greater or more severe long COVID symptoms or COVID-19–related worsening anxiety may potentiate long COVID symptoms,” Strawn and colleagues wrote. “Ultimately, understanding the neuropsychiatric effects of COVID-19 and long COVID … may inform novel treatments or optimization of existing interventions.”

For related information, see the Psychiatric News article “Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden.”

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How Will End of PHE Impact You? Practice Management Helpline Wants to Know

The COVID-19 Public Health Emergency (PHE) will end on Thursday, May 11. APA wants to hear from you on how this change might affect your practice and your patients. Please email the Practice Management Helpline at practicemanagement@psych.org with a short description about how the requirement to have an in-person visit with a patient to prescribe controlled substances, the requirement to have a DEA license in any state in which you are prescribing controlled substances, and/or how the controlled substances shortages are affecting your practice. By sharing your story, we may use de-identified information in our advocacy efforts. Please let us know if you would be comfortable if we contacted you for more information.

Excessive Crying, Irritability in Infancy Associated With Later Behavioral Problems

Infants who cry excessively (more than 3 hours at least 1 day/week) may be more likely to experience behavioral problems in childhood and adolescence than infants who cry less, suggests a report published yesterday in the Journal of the Academy of Child & Adolescent Psychiatry. Brain scans of these children at age 10 also revealed that the amygdala—a part of the brain involved with assessing threat and regulating emotional responses—was smaller in those who cried excessively and/or were irritable as infants.

“Most infants who cry excessively grow to be healthy, typically developing children, and it remains reasonable to remind parents of the good prognosis,” wrote Sara Sammallahti, Ph.D., of Erasmus MC Sophia Children’s Hospital in the Netherlands and colleagues. “Nonetheless, … our results suggest parent-reported excessive crying should not be simply shrugged off: it could reflect one of the earliest child markers of vulnerability to develop behavioral problems.”

The researchers analyzed data from the Generation R Study cohort, which included 4,751 children born in the Netherlands between 2002 and 2006. As part of the study, parents were asked to report if their three-month-old infants cried excessively by answering yes or no to the question “Has your child ever cried for more than 3 hours a day (24 hours) during the last week?” and/or if the baby was irritable, using the Mother and Baby Scales irritability scale. The parents were also asked to complete the Child Behavior Checklist (CBCL) when the children were 1.5, 3, 6, and 10 years. The CBCL measures internalizing problems (such as anxiety) and externalizing problems (such as aggression). At age 14, the youth completed the Youth Self-Report, which also measures internalizing and externalizing problems in adolescence. The children also underwent a structural brain MRI around the age of 10.

Children who cried excessively in infancy had higher parent-rated internalizing and externalizing problems throughout childhood compared with those who did not cry excessively in infancy; higher infant irritability was also associated with higher parent-rated internalizing and externalizing problems. Similarly, children who cried excessively and/or were more irritable as infants had smaller amygdala volume at 10 years.

“Excessive crying and irritability in infancy may reflect an early vulnerability to behavioral problems and be linked with neurobiological differences in the development of the amygdala,” Sammallahti and colleagues wrote.

They continued, “Neurobiological differences can manifest in crying behavior; however, behavior could also precede neurobiological differences: the experiences of irritable, excessively crying infants could impact structural amygdala development … [O]ur study suggests crying behavior and amygdala development are associated.”

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens At High Risk for Suicide.”

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Experts Offer Tips on Talking About Firearms With Adolescents at Risk of Suicide

Mental health professionals who work with adolescents should ask about access to lethal means, including firearms, when assessing their patients who are at risk of suicide, according to the authors of a clinical perspectives piece in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Many adolescent suicide attempts are impulsive; completed suicides may be prevented if access to firearms is limited during periods of crisis,” wrote Apurva Bhatt, M.D., of the University of California, Davis, and colleagues. “However, many clinicians do not talk about firearms with patients even when clinically relevant. This may be due to assumptions that adolescents do not have access to firearms, or to lack of comfort with this topic.”

The authors offered several tips to help child and adolescent mental health professionals approach the topic of firearms with their patients:

Be informed and respectful. Conversations about reducing the risk of firearm suicide are more effective if they are approached with knowledge and respect for the various reasons for ownership.

Establish context, assess risk, and ask about firearms. This should be a nonjudgmental conversation wherein the mental health professional asks about whether the adolescent has access to firearms not only at home, but at the homes of friends or family members where the adolescent spends time.

Provide tailored recommendations. Once an adolescent has been identified as at risk for suicide, mental health professionals should discuss their concerns with the adolescent’s caregiver and work collaboratively to reduce the youth’s access to firearms. They can use a harm reduction approach with shared decision-making and emphasize that the goal is to keep the person at risk as safe as possible.

Follow up with continued discussions. Follow-up discussions can foster a trusting relationship about the health and safety of all family members.

“By being informed and respectful, establishing context, and providing tailored recommendations for each clinical situation, clinicians can provide this important suicide prevention intervention in their clinical practice,” the authors concluded.

For related information, see the Psychiatric Services article “Promoting Firearm Safety as a Suicide Prevention Strategy Within Health Care Systems: Challenges and Recommendations.”

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