Clinical research updates

Anastasia Kouklidou

European University of Cyprus, Nicosia, Cyprus

Early-onset psychosis (EOP) is defined by its onset before the age of 18 years. Negative symptoms, including decreased motivation, interest, and expressive functions such as alogia and blunted affect, are commonly present in EOP. Earlier onset of such symptoms is associated with a greater number of them at follow-up, and their severity is associated with poor outcomes. They also occasionally predominate in children and adolescents who are at clinical high risk for psychosis (CHR-P). The identification of negative symptoms in children and adolescents with psychosis or at CHR-P can be challenging, their prevalence is unclear, and there is little evidence for their treatment.

Gonzalo Salazar de Pablo et al. (2022) conducted a systematic review and meta-analysis which aimed at providing meta-analytical evidence and a comprehensive review of the status and advances in the diagnosis, prognosis, and treatment of negative symptoms in children and adolescents with EOP and at CHR-P. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used. Eligible studies were original studies, abstracts, conference proceedings, cross-sectional studies, longitudinal studies, randomized clinical trials, and other intervention studies providing information regarding negative symptoms in children and adolescents (mean age < 18 years) with EOP or at CHR-P. Publication bias and heterogeneity among studies were assessed. A total of 133 studies with 9055 children and adolescents (mean age 15.5 years; 54.1% males) were included in the systematic review. The prevalence of negative symptoms in EOP was 61% and in CHR-P was 80%. A total of 20 studies (N = 1799 individuals) were further included in the meta-analysis. Negative symptoms were associated with poorer prognostic, functional, neurobiological, cognitive, and intervention outcomes in EOP and CHR-P. Sample prevalence of schizophrenia was not associated with high prevalence of negative symptoms. Obesity in EOP was associated with less severe negative symptoms. An improvement of negative symptoms was found at 12-month follow-up but not at 24 or ≥36 months compared with baseline in CHR-P. Clozapine may be more efficacious in reducing negative symptoms in treatment-resistant EOP compared to other antipsychotics. There is no consistent evidence in relation to comparative efficacy of other second-generation antipsychotics and no data on the efficacy of antidepressants in relation to negative symptoms in EOP. There is limited evidence favoring psychosocial interventions for negative symptoms. Early intervention services contribute to a reduction of negative symptom severity after 6–24 months compared with treatment as usual.

This is the first systematic review and meta-analysis on the prevalence of negative symptoms in children and adolescents with EOP and at CHR-P. Negative symptoms are commonly present in CHR-P and are associated with poor clinical, functional, and intervention outcomes in EOP and CHR-P. Limitations of this study include characteristics of individual studies related to sample size, limited number of articles for some outcomes, heterogeneity of samples, design, methodology and quality of most studies, varied threshold for the presence and absence of negative symptoms, variability of mean age of participants, and possible differences regarding the expression of negative symptoms on the background of neurodevelopmental differences.

Salazar de Pablo, G., Catalan, A., Vaquerizo Serrano, J., Pedruzo, B., Alameda, L., Sandroni, V., … & Correll, C.U. (2023). Negative symptoms in children and adolescents with early-onset psychosis and at clinical high-risk for psychosis: Systematic review and meta-analysis. British Journal of Psychiatry, 17, 1–13.

Sofia Leopoulou

Penteli Children's Hospital, Athens, Greece

Emotional dysregulation has been recognized as a risk factor linked to disordered eating and self-harm in young people. However, only a few prospective studies have explored this long-term, or considered potential mediators. Social cognition, emotional recognition, and bullying may underlie the association of emotional dysregulation with these adverse outcomes. By understanding potential mediating mechanisms, appropriate interventions addressing these can be developed.

Warne et al. (2023) used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) in the UK in order to explore mediating pathways between emotional dysregulation in childhood, and disordered eating and self-harm in adolescence. The study sample included a total of 6934 children who had emotional dysregulation measured through the Strengths and Difficulties Questionnaire-Dysregulation Profile filled out by their mothers at mean age of 6 years 9 months. The outcomes, self-harm and disordered eating, were assessed during adolescence, at mean age of 16 years 8 months, through self-report questionnaires. Social cognition (at mean age of 7 years 8 months), emotion recognition (at mean age of 8 years 8 months), and bullying victimization (at mean age of 12 years 10 months) were studied as possible mediators. Potential confounding variables, including sex, socioeconomic disadvantage, maternal mental health, child general cognitive ability, and body mass index at mean age of 12 years 10 months were taken into account in the analysis.

The study identified emotional dysregulation in childhood being positively linked to disordered eating and self-harm in adolescence, with stronger associations observed after accounting for sex. The primary mediator between emotional dysregulation and these outcomes was social cognition. Bullying victimization was an important pathway to disordered eating in both males and females, and to self-harm in females. Indirect effects were stronger for disordered eating than self-harm. The study findings raise the possibility that interventions on improving emotional regulation and social cognition skills, and addressing bullying may prevent and contribute to the treatment of disordered eating and self-harm in adolescence.

This study has a few limitations that are related to the inclusion of any disordered eating rather than diagnosed eating disorders, the inability to differentiate self-harm with and without suicidal intent, and the inclusion of white and less socioeconomically disadvantaged children and young people. In addition, social cognition was measured close in time to the exposure and by using the same informant and bullying related to appearance or weight was not specifically measured. Finally, emotion regulation, social cognition, and emotion recognition may all be parameters of underlying neurodevelopment rather than causal of each other. As the authors did not statistically examine the difference in proportion mediated for males and females, any differences should be interpreted with caution.

Warne, N., Heron, J., Mars, B., Solmi, F., Biddle, L., Gunnell, D., … & Bould, H. (2022). Emotional dysregulation in childhood and disordered eating and self-harm in adolescence: Prospective associations and mediating pathways. Journal of Child Psychology and Psychiatry, 64, 797–806.

Kyriaki Stavrou

National and Kapodistrian University of Athens, Athens, Greece

Children on the autism spectrum frequently display emotional and behavioral issues, which can be helped by behavioral parenting interventions. The COVID-19 pandemic and the associated lockdowns could offer grounds for a natural experiment to examine the long-term effects of such interventions.

Palmer et al. (2023) reported on the opportunistic follow-up of an existing cohort during COVID-19-related restrictions. The researchers examined the possibility of later effects of behavioral parenting interventions, while these did not have any major effect at primary study endpoint. Participants in the Autism Spectrum Treatment and Resilience (ASTAR) study, a parallel two-group, two-site pilot randomized controlled trial comparing predictive parenting to psychoeducational attention control were contacted again between June and September 2020, 2 years after the original randomization, and completed the same study endpoint measures of parent-reported child irritability and parenting stress. A small intervention effect was identified from baseline to COVID-19 follow-up favoring predictive parenting on parent-reported child irritability and parenting stress. Interview feedback on both interventions was positive, and parents reported using strategies from predictive parenting during COVID-19-related restrictions. They reported that the participation in those groups had led to a change in their daily experiences of parenthood.

Techniques from predictive parenting may have helped parents assist children with ASD cope with stressful and unpredictable situations like those arising during COVID-19, the parents spending more time with their children may have given them additional opportunities to apply these strategies, and the longer follow-up may have provided more time for parents to put recommendations into practice at home. It is also possible that predictive parenting techniques may have acted as a buffer against declining child mental health in the context of the COVID-19 pandemic.

Limitations of the study included the fact that outcome measures were all parent-reported, and parents were not blinded to intervention arm. Follow-up questionnaires were not specifically sent with the aim of assessing the effects of the intervention but rather as part of questionnaires to assess the effect of the pandemic. This study highlighted the potential importance of the timing and the context when measuring the effects of parenting interventions in ASD.

Palmer, M., Carter Leno, V., Hallett, V., Mueller, J.M., Breese, L., Pickles, A., … & Simonoff, E. (2023). Effects of a parenting intervention for emotional and behavioral problems in young autistic children under conditions of enhanced uncertainty: Two-year follow-up of a pilot randomized controlled trial cohort (ASTAR) during the United Kingdom COVID-19 pandemic. Journal of the American Academy of Child and Adolescent Psychiatry, 62, 558–567.

No ethical approval was required for these updates.