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<p class="ltrs-br-ltr-br-title"><span class="bold">Five-Year Follow-Up for Adolescents With Conduct Disorder Referred to an Urgent Psychiatric Consult Clinic: A Descriptive Study</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> The publication<span class="htm-cite"><a href="#ref1">1</a></span> on the incidence rates of treated mental disorders in children and adolescents inspired us to revisit the idea of clinical trajectories in individuals with conduct disorder.</p>
<p class="ltrs-br-ltr-br-body-text">Conduct disorder (CD) is diagnosed in children or adolescents displaying persistent patterns of behavior violating the basic rights of others.<span class="htm-cite"><a href="#ref2">2</a></span> Prevalence estimates of CD vary widely from 0.2% to 8.7%.<span class="htm-cite"><a href="#ref3">3</a></span> CD is increasingly viewed as a neurobiological syndrome involving antisocial behaviors and callous unemotional traits.<span class="htm-cite"><a href="#ref4">4</a></span> Genetic studies<span class="htm-cite"><a href="#ref5">5</a>,<a href="#ref6">6</a></span> have identified patterns of heritability. Autonomic hypoarousal,<span class="htm-cite"><a href="#ref7">7</a></span> depressed serotonergic and opioid neurotransmission,<span class="htm-cite"><a href="#ref7">7</a>,<a href="#ref8">8</a></span> reduced brain glucose metabolism,<span class="htm-cite"><a href="#ref9">9</a></span> and white matter alterations in the corpus collosum<span class="htm-cite"><a href="#ref10">10</a></span> may underpin abnormal emotion processing, behavioral control, and reward-related learning associated with CD.</p>
<p class="ltrs-br-ltr-br-body-text">As there are no evidence-based treatments for CD, pharmacologic<span class="htm-cite"><a href="#ref11">11</a></span> and psychosocial interventions<span class="htm-cite"><a href="#ref12">12</a></span> are largely applied to treatable comorbidities. Recently, urgent psychiatric consultation services for high-risk adolescents have emerged as potential harm-reduction venues.<span class="htm-cite"><a href="#ref13">13</a>,<a href="#ref14">14</a></span> This study aimed to describe the adult clinical trajectories of a cohort of adolescents diagnosed with CD after referral to an urgent psychiatry service using a retrospective record-linkage approach.</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Methods.</span> After seeking ethics approval, we retrospectively identified a cohort of all adults (≥<span class="thinspace"> </span>18 years old) diagnosed with CD after assessment at a university-affiliated child and adolescent mental health urgent consult clinic (CAMHUCC). Details of the study were published previously.<span class="htm-cite"><a href="#ref13">13–15</a></span> After linking CAMHUCC records with several regional databases, we extracted relevant characteristics at baseline and 5-year follow-up to establish a clinical trajectory. We used SPSS<span class="htm-cite"><a href="#ref16">16</a></span> to conduct basic descriptive and inferential analyses (using a significance threshold of .05).</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Results.</span> Our cohort consisted of 32 individuals (characteristics are described in <span class="callout"><a href="#" onclick="createFigure('T1'); return false;" title="">Table 1</a></span>). At initial presentation, the mean age was 15.3 years (SD<span class="thinspace"> </span>=<span class="thinspace"> </span>1.05), 69.1% were male, 91.1% reported a family history of CD, 81.3% reported substance use, 43.8% reported abuse, and 37.5% were registered with children’s aid. Suicidal ideation (71.9%) and aggression/anger (25.0%) were the most common reasons for referral. Attention-deficit/hyperactivity disorder (ADHD) (59.4%) and substance use disorders (SUDs) (18.8%) were the most commonly diagnosed comorbidities.</p>
<div id="figure" class="right">
<a href="#" onclick="createFigure('T1'); return false;"><img src="19l02489T1.gif" alt="Table 1" id="T1" border="0"></a>
<p class="click-to-enlarge">Click figure to enlarge</p>
</div>
<p class="ltrs-br-ltr-br-body-text">After transitioning to adult services, there were a mean of 3.41 (SD<span class="thinspace"> </span>=<span class="thinspace"> </span>1.86) emergency psychiatry visits, 0.38 (SD<span class="thinspace"> </span>=<span class="thinspace"> </span>0.98) psychiatric admissions, and 1.22 (SD<span class="thinspace"> </span>=<span class="thinspace"> </span>1.86) outpatient psychiatry appointments. ADHD (65.6%), SUD (34.4%), and antisocial personality disorder (ASPD) (21.9%) were the most commonly diagnosed adult comorbidities, with 81.3% on psychotropic medications and 46.9% in psychotherapy.</p>
<p class="ltrs-br-ltr-br-body-text">Logistic regression—accounting for sex, abuse, comorbidity, and family history—was statistically significant, explaining 38.9% (Nagelkerke <span class="italic">R</span><span class="superscript">2</span>) of the variance in adult ASPD diagnostic status, correctly classifying 78.1% of cases. Males were 18.1 times more likely to develop ASPD than females (95% CI, 1.2–287.0; <span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.039).</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Discussion.</span> Our study indicates that adolescents with CD who were referred to urgent psychiatric services have persistent psychiatric comorbidity and continue to require mental health services in adulthood. Of our sample, 21.9% received a diagnosis of ASPD in adulthood, with male sex the only statistically significant predictor for ASPD diagnosis. While this rate is lower than previous estimates of 40% for males with CD,<span class="htm-cite"><a href="#ref17">17</a></span> we cannot make a causal inference about CAMHUCC’s role.</p>
<p class="ltrs-br-ltr-br-body-text">While our study had minimal attrition, the small sample size and absence of a suitable control group restricted the extent and power of our analysis. As the sample considered by this study comes from an urgent consultation clinic, the severity of the CD presentations considered is likely to be higher than what would typically be seen in other outpatient settings. While our findings may not be generalizable to other CD populations, they do suggest that males with CD are at greater risk of developing ASPD and may benefit from intensive and focused harm-reduction interventions. In a similar vein, future studies comparing the clinical characteristics of adolescents with CD across various settings may be of value to enhance the body of knowledge regarding CD.</p>
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<p class="ltrs-br-ltr-br-author"><span class="bold">Anees Bahji, MD</span><span class="superscript">a,b</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:0ab104@queensu.ca">0ab104@queensu.ca</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Karen Gillis, MSW</span><span class="superscript">c</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Sanjeev Sharma, MD</span><span class="superscript">a,c</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Nasreen Roberts, MD</span><span class="superscript">a,c</span></p>
<p class="front-matter-rule"><span class="superscript">a</span>Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada</p>
<p class="end-matter"><span class="superscript">b</span>Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada</p>
<p class="end-matter"><span class="superscript">c</span>Division of Child and Youth Mental Health, Hotel Dieu Hospital, Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> June 4, 2020.</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Acknowledgments:</span> The authors wish to acknowledge Nicholas Axas, MSW, and Leanne Repetti, MSW, from the Division of Child and Youth Mental Health of the Department of Psychiatry of Queen’s University (Kingston, Ontario, Canada) for maintaining the CAMHUCC database. Mr Axas and Ms Repetti have no conflicts of interest related to the subject of this letter.</p>
<p class="front-matter"><span class="italic">Prim Care Companion CNS Disord</span> 2020;22(3):19l02489</p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Bahji A, Gillis K, Sharma S, et al. Five-year follow-up for adolescents with conduct disorder referred to an urgent psychiatric consult clinic: a descriptive study. <span class="italic">Prim Care Companion CNS Disord. </span>2020;22(3):19l02489.</p>
<p class="doi-line"><span class="bold-italic">To share:</span> https://doi.org/<span class="doi">10.4088/PCC.19l02489</span></p>
<p class="front-matter"><span class="italic">© Copyright 2020 Physicians Postgraduate Press, Inc.</span></p>
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