Child and adolescent mental disorders: the magnitude of the problem across the globe

How often do German children and adolescents show signs of common mental health problems? Results from different methodological approaches--a cross-sectional study

BACKGROUND

Child and adolescent mental health problems are ubiquitous and burdensome. Their impact on functional disability, the high rates of accompanying medical illnesses and the potential to last until adulthood make them a major public health issue. While methodological factors cause variability of the results from epidemiological studies, there is a lack of prevalence rates of mental health problems in children and adolescents according to ICD-10 criteria from nationally representative samples. International findings suggest only a small proportion of children with function impairing mental health problems receive treatment, but information about the health care situation of children and adolescents is scarce. The aim of this epidemiological study was a) to classify symptoms of common mental health problems according to ICD-10 criteria in order to compare the statistical and clinical case definition strategies using a single set of data and b) to report ICD-10 codes from health insurance claims data.

METHODS

a) Based on a clinical expert rating, questionnaire items were mapped on ICD-10 criteria; data from the Mental Health Module (BELLA study) were analyzed for relevant ICD-10 and cut-off criteria; b) Claims data were analyzed for relevant ICD-10 codes.

RESULTS

According to parent report 7.5% (n=208) met the ICD-10 criteria of a mild depressive episode and 11% (n=305) showed symptoms of depression according to cut-off score; Anxiety is reported in 5.6% (n=156) and 11.6% (n=323), conduct disorder in 15.2% (n=373) and 14.6% (n=357). Self-reported symptoms in 11 to 17 year olds resulted in 15% (n=279) reporting signs of a mild depression according to ICD-10 criteria (vs. 16.7% (n=307) based on cut-off) and 10.9% (n=201) reported symptoms of anxiety (vs. 15.4% (n=283)). Results from routine data identify 0.9% (n=1,196) with a depression diagnosis, 3.1% (n=6,729) with anxiety and 1.4% (n=3,100) with conduct disorder in outpatient health care.

CONCLUSIONS

Statistical and clinical case definition strategies show moderate concordance in depression and conduct disorder in a German national sample. Comparatively, lower rates of children and adolescents with diagnosed mental health problems in the outpatient health care setting support the assumptions that a small number of children and adolescents in need of treatment receive it.

Early life programming as a target for prevention of child and adolescent mental disorders

This paper concerns future policy development and programs of research for the prevention of mental disorders based on research emerging from fetal and early life programming. The current review offers an overview of findings on pregnancy exposures such as maternal mental health, lifestyle factors, and potential teratogenic and neurotoxic exposures on child outcomes. Outcomes of interest are common child and adolescent mental disorders including hyperactive, behavioral and emotional disorders. This literature suggests that the preconception and perinatal periods offer important opportunities for the prevention of deleterious fetal exposures. As such, the perinatal period is a critical period where future mental health prevention efforts should be focused and prevention models developed. Interventions grounded in evidence-based recommendations for the perinatal period could take the form of public health, universal and more targeted interventions. If successful, such interventions are likely to have lifelong effects on (mental) health.

Adolescents' multiple, recurrent subjective health complaints: investigating associations with emotional/behavioural difficulties in a cross-sectional, school-based study

BACKGROUND

Adolescence has been documented as the peak age of onset for mental health perturbations, clinical disorders and unsubstantiated health complaints. The present study attempted to investigate associations between multiple, recurrent subjective health complaints (SHC) with emotional/behavioural difficulties, as measured by the Strengths and Difficulties Questionnaire scale (SDQ), among Greek adolescents.

METHODS

Questionnaires were administered in a large, nation-wide, random, school-based sample of Greek adolescents, aged 12-18 years. Data from 1170 participants were analyzed. Adolescents with multiple, recurrent SHC were compared in terms of their emotional/behavioural difficulties to their peers with lower levels of health complaints. SDQ scales were separately investigated for their associations with multiple, recurrent SHC, after adjustment for gender, age and socioeconomic status (ses). Further analysis included multiple logistic regression models with multiple, recurrent SHC as the dependent variable and gender, age, ses and SDQ Total difficulties score as independent factors. Potential gender and age interactions were also explored.

RESULTS

Almost half of the study participants reported multiple, recurrent SHC. Adolescents with multiple, recurrent SHC had higher scores on all SDQ scales, except from the Prosocial behavior scale, compared to their peers with lower levels of health complaints. Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention and Peer Problems were associated with greater likelihood of having multiple, recurrent SHC, after adjustment for gender, age and ses. The multiple logistic regression models revealed that older adolescents and girls, as well as those with increased Total difficulties score had an increased risk for multiple, recurrent SHC reporting. No significant interaction between SDQ scales and gender or age was found.

CONCLUSIONS

Our study highlights the magnitude of psychological burden among adolescents experiencing multiple, recurrent SHC. Professionals in school and clinical settings should be cautious for impaired emotional/behavioural functioning when assessing adolescents with multiple, recurrent SHC, so as early identification of at-risk individuals and timely, appropriate referrals are facilitated.

Predictors of mental health competence in a population cohort of Australian children

BACKGROUND

The child mental health epidemiology literature focuses almost exclusively on reporting the prevalence and predictors of child mental disorders. However, there is growing recognition of positive mental health or mental health competence as an independent outcome that cannot be inferred from the absence of problems, and requires epidemiological investigation in its own right.

METHODS

We developed a novel measure of child mental health competence within the framework of the Australian Early Development Index, a three-yearly national census of early child development. Predictors of this outcome were investigated by linking these census data at individual level to detailed background information collected by a large longitudinal cohort study.

RESULTS

Predictors of competence were consistent with previously described theoretical and empirical models. Overall, boys were significantly less likely than girls to demonstrate a high level of competence (OR 0.60, 95% CI 0.39 to 0.91). Other strong predictors of competence were parent education and a relative absence of maternal psychological distress; these factors also appeared to attenuate the negative effect of family hardship on child competence.

CONCLUSIONS

This measure of mental health competence shows promise as a population-level indicator with the potential benefit of informing and evaluating evidence-based public health intervention strategies that promote positive mental health.

Prevalence and comorbidity of psychiatric disorders among 6-year-old children: 2004 Pelotas Birth Cohort

PURPOSE

Most studies published on the prevalence of psychiatric disorders in children were conducted in high-income countries despite the fact that nearly 90 % of the world's population aged under 18 live in low- and middle-income countries. The study aimed to assess the prevalence of psychiatric disorders among children of 6 years of age, to examine the distribution of psychiatric disorders by gender and socioeconomic status and to evaluate the occurrence of psychiatric comorbidities.

METHODS

The 2004 Pelotas Birth Cohort originally comprised 4,231 live births from Pelotas, southern Brazil. A total of 3,585 (84.7 % of 4,231 births) children aged 6 years were assessed using the Development and Well-Being Assessment (DAWBA).

RESULTS

Nearly 13 % of the children presented a psychiatric diagnosis according to DSM-IV, being more prevalent among males than females (14.7 and 11.7 %, respectively, p = 0.009). Anxiety disorders were the most prevalent of all disorders (8.8 %) and specific phobias (5.4 %) and separation anxiety disorder (3.2 %) were the most common subtypes. Attention deficit hyperactivity disorder (2.6 %), oppositional defiant disorder/conduct disorder (2.6 %), and depression (1.3 %) were also diagnosed. More than one psychiatric disorder was presented by 17 % of children. Socioeconomically disadvantaged children had a higher prevalence of psychiatric disorders.

CONCLUSION

Our findings underline the early onset of psychiatric disorders among children and the frequent occurrence of psychiatric comorbidity. Early prevention is needed in the field of mental health in Brazil and should start during infancy.

One size does not fit all: psychometric properties of the Shona Symptom Questionnaire (SSQ) among adolescents and young adults in Zimbabwe

BACKGROUND

Depression is a major contributor to the global burden of disease. Onset commonly occurs during the adolescent period. Understanding how depression tools are functioning among adolescents has been relatively overlooked.

METHODS

Using cross-sectional survey data among a sample of 2768 adolescents (aged 15-19) and 2027 young adults (aged 20-24) living in Zimbabwe this paper calibrated the Shona Symptom Questionnaire (SSQ) against the Self Report Questionnaire (SRQ-20) and examined the performance indices of the SSQ based on various cut points for classification. Using a multivariate logistic regression model we isolated particular characteristics to test their association with the odds of being misclassified as non-depressed by the SSQ.

RESULTS

A modified cut point of five or more substantially increases the depression estimates for both age groups. The prevalence of depression increased from 3.5% to 13.2% among adolescents and from 5.1% to 16.2% among young adults based on these revisions. Adolescents who were orphaned or ever had sex had significantly a greater odd of being misclassified. When retested using the modified cut point of five or greater, associations with misclassification disappeared.

LIMITATIONS

Scales were not administered separately or in their entirety but rather overlapping items were only asked once, utilizing exclusively SRQ-20 phrasing rather than the culturally-emic language in the SSQ.

CONCLUSIONS

Not all depression scales are appropriate for use among adolescents given their unique developmental stage. An alternative cut point for depression classification could improve detection of depression among Zimbabwean adolescents.

Behavioural/emotional problems in Brazilian children: findings from parents' reports on the Child Behavior Checklist

Background. To compare Child Behavior Checklist (CBCL) findings for a large Brazilian general population sample with those for US children considering: (a) mean problem item ratings; (b) fit of the US-derived CBCL 8-syndrome model; (c) scale internal consistency measured by Cronbach's alphas; (d) effects of society, age, gender on CBCL problem scores; and (e) ability to discriminate referred from non-referred children. Methods. Parents of 1228 non-referred 6-to-11-year-olds from three different regions of Brazil and 247 referred 6-to-11-year-olds from one clinic rated their children's behavioural and emotional problems using the CBCL/6-18. Results. Results for mean item ratings and scale internal consistencies were very similar to those found in the US and in Uruguay. Confirmatory factor analysis indicated that Brazilian data showed the best fit to the US 8-syndrome model of all countries studied to date. Gender patterns were comparable to those reported in other societies, but mean problem scores for non-referred Brazilian children were higher than those for US children. Therefore, the CBCL discriminated less well between non-referred and referred children in Brazil than in the US. Conclusions. Overall, our findings replicated those reported in international comparisons of CBCL scores for 31 societies, thereby providing support for the multicultural robustness of the CBCL in Brazil.

Adolescents with a history of specific language impairment (SLI): strengths and difficulties in social, emotional and behavioral functioning

Adolescents with specific language impairment (SLI) are at a greater risk of emotional and behavioral problems compared to their typically developing (TD) peers, but little is known about their self-perceived strengths and difficulties. In this study, the self-reported social, emotional and behavioral functioning of 139 adolescents with a history of SLI and 124 TD individuals at age 16 was examined. The self-report version of the Strengths and Difficulties Questionnaire (SDQ) was used to assess their prosocial behavior and levels of peer, emotional and behavioral difficulties. Associations of these areas of functioning with gender, verbal and non-verbal skills were also investigated. Adolescents with a history of SLI were more likely than their TD peers to report higher levels of peer problems, emotional symptoms, hyperactivity and conduct problems. The majority of adolescents in both groups (87% SLI and 96% TD), however, reported prosocial behavior within the typical range. Difficulty with peer relations was the strongest differentiator between the groups, with the odds of reporting borderline or abnormally high levels of peer problems being 12 times higher for individuals with a history of SLI. Adolescents with poorer receptive language skills were also more likely to report higher levels of emotional and behavioral difficulties. The findings of this study identify likely traits that may lead to referral to services.

Breast feeding and early adolescent behaviour, self-esteem and depression: Hong Kong's 'Children of 1997' birth cohort

OBJECTIVE

Breast feeding may contribute to neurological development and hence mental health. However, associations from Western populations are unclear, and most likely confounded by socioeconomic position (SEP), making evidence from other sociocultural settings valuable. We examined whether breast feeding was associated with early adolescent emotional and behavioural problems, self-esteem and depressive symptoms in a non-Western developed setting, where socioeconomic patterning of breast feeding differs from but other postnatal characteristics are similar to Western settings.

DESIGN

The adjusted associations of breast feeding with emotional and behavioural problems assessed from parent-reported Rutter z-score at ~11 years (n=5598, 67% follow-up), self-reported self-esteem z-score at ~11 years (n=6937, 84%) and depressive symptoms assessed from self-reported Patient Health Questionnaire-9 z-score at ~13 years (n=5797, 70%) were examined using multivariable linear regression in a population-representative Hong Kong Chinese birth cohort, 'Children of 1997'.

RESULTS

Mothers from families with higher education tended to start but not sustain breast feeding, whereas migrant mothers tended to start and sustain breast feeding. Breast feeding for 3+ months had mostly null associations with Rutter score, self-esteem or depressive symptoms adjusted for sex, age, survey mode, SEP, parents' age, birth weight-for-gestational age, birth order and secondhand smoke exposure, although partial breast feeding for any length of time or exclusive breast feeding for <3 months was associated with poorer behaviour (higher Rutter z-score (0.10, 95% CI 0.05 to 0.16)) and lower self-esteem (-0.09, 95% CI -0.14 to -0.04).

CONCLUSIONS

In a non-Western developed setting, breast feeding was inconsistently associated with several early adolescent mental health measures suggesting a reflection of setting specific unmeasured confounding.

Eating patterns and mental health problems in early adolescence--a cross-sectional study of 12-13-year-old Norwegian schoolchildren

OBJECTIVE

To investigate the association between eating patterns and mental health problems in young Norwegian adolescents (12-13 years of age).

DESIGN

Cross-sectional study. Dietary information was reported by parents using a retrospective FFQ. Eating patterns were identified using principal component analysis. The Strengths and Difficulties Questionnaire was used to measure mental health problems. The association between eating patterns and mental health problems was examined using multiple logistic regression analysis.

SETTING

Primary schools, Telemark County, Norway.

SUBJECTS

Children (n 1095) aged 12-13 years and their parents.

RESULTS

Children with high scores on a 'varied Norwegian' eating pattern were less likely to have indications of any psychiatric disorders (adjusted OR = 0·5; 95 % CI 0·3, 1·0) and hyperactivity-inattention disorders (adjusted OR = 0·4; 95 % CI 0·2, 0·8) than children with low scores on this pattern. Children with high scores on a 'junk/convenient' eating pattern were more likely to have indications of hyperactivity-inattention disorders (adjusted OR = 3·4; 95 % CI 1·3, 8·6) than children with low scores on this pattern. Children with high scores on a 'snacking' eating pattern were more likely to have indications of conduct/oppositional disorders (adjusted OR = 3·8; 95 % CI 1·2, 11·5) than those with low scores on this eating pattern.

CONCLUSIONS

We identified a significant association between eating patterns and mental health problems in young adolescents, independently of physical activity, sedentary activity and background variables. A diverse diet rich in unrefined plant foods, fish and regular meals was associated with better mental health, while energy-dense, nutrient-poor diets and irregular meals were associated with poorer mental health.

The moderating role of emotional competence in suicidal ideation among Chinese university students

AIMS

To explore the relationship among perceived family functioning, emotional competence and suicidal ideation and to examine the moderating role of emotional competence in suicidal ideation.

BACKGROUND

Previous studies have highlighted that poor family relationships and emotional symptoms are significant predictors of suicidal ideation. However, the roles of perceived family functioning and emotional competence in predicting suicidal ideation have not been given adequate attention.

DESIGN

A cross-sectional survey using convenience sampling.

METHOD

A questionnaire was administered to 302 university students from February-April in 2011 in Hong Kong. The means, standard deviations and Cronbach's alphas of the variables were computed. Pearson correlation analyses and hierarchical regression analyses were performed.

RESULTS

Hierarchical regression analyses showed that perceived high family functioning and emotional competence were significant negative predictors of suicidal ideation. Further analyses showed that parental concern, parental control and creative use of emotions were significant predictors of suicidal ideation. Emotional competence, specifically creative use of emotions, was found to moderate the relationship between perceived family functioning and suicidal ideation.

CONCLUSION

The findings support the family ecological framework and provide evidence for emotional competence as a resilience factor that buffers low family functioning on suicidal ideation. Suggested measures to decrease suicidal ideation include enhancing parental concern, lessening parental control, developing students' awareness, regulation and management of their own emotions, fostering empathy towards others' emotional expression, enhancing social skills in sharing and influencing others' emotions and increasing the positive use of emotions for the evaluation and generation of new ideas.

Depressão materna e riscos para o comportamento e a saúde mental das crianças: uma revisão

A depressão materna tem sido considerada um fator de risco para a saúde mental das crianças. Objetivou-se identificar e analisar na literatura indexada artigos empíricos recentes (2005 a 2012), que abordaram as associações da depressão materna ao comportamento e à saúde mental de crianças, escolares. Procedeu-se a uma busca sistemática nas bases PubMed, PsycInfo e LILACS, por meio das palavras-chave "Maternal Depression or Depression" e "Risk Factors". Foram selecionados e analisados 68 artigos, 23 transversais e 45 longitudinais. Independentemente dos delineamentos adotados, a depressão materna mostrou-se associada à presença de dificuldades emocionais e comportamentais em geral, de manifestações depressivas e de ansiedade. Além da depressão materna, outras variáveis contextuais mostraram-se associadas às dificuldades das crianças. O reconhecimento da ação de múltiplas variáveis permitiu a verificação de indicadores diversos, o que pode favorecer o planejamento de intervenções.

Child mental health and service needs in Iraq: beliefs and attitudes of primary school teachers

OBJECTIVE

To survey Iraqi primary school teachers' beliefs and attitudes about mental health and behavioural problems of children.

METHODS

From 10 primary schools in Baghdad, 148 teachers were surveyed using a closed-response questionnaire to assess beliefs and attitudes regarding students' mental health and behavioural problems, needs, resources and limitations to teaching.

RESULTS

Disruptive behaviours were rated as main problems by the largest proportions of teachers. In-service training on 'identifying students with social, emotional, or behavioural problems' and 'effective behaviour management' was rated very important by 70% of teachers. Most teachers received no training on mental health during their teaching career. There was low reported availability of a wide range of school-based mental health resources.

CONCLUSIONS

Teachers in Iraq report substantial mental health and behavioural problems in primary school children and identify high unmet need for school-based mental health programmes and training.

Psychosocial research with children in Iraq: current health practice and policy in a context of armed conflict

There is a need to show how psychosocial issues affect children in conflict areas like Iraq. Raising knowledge and awareness of children's mental health status in Iraq has been difficult and the knowledge base has been limited by the shortage of resources, international sanctions and the isolation of Iraqi scholars. Many obstacles to research in Iraq exist but an agenda should be developed emphasising the need for high-quality contextualised psychosocial research. Health researchers in the country need to clarify basic population parameters and to provide culturally appropriate, evidence-based interventions for practitioners.

Early puberty and childhood social and behavioral adjustment

PURPOSE

Early puberty has been linked to higher rates of mental health problems in adolescence. However, previous studies commencing after the initiation of puberty have been unable to explore whether early puberty is preceded by higher rates of these problems. In a large national study, we aimed to determine whether difficulties in behavior and psychosocial adjustment are evident before as well as during the early pubertal transition.

METHODS

The Longitudinal Study of Australian Children recruited a nationally representative cohort of 4,983 children at age 4-5 years in 2004. This analysis includes 3,491 of these children (70.1%) followed up at ages 6-7, 8-9, and 10-11 years, with a completed parent report of stage of pubertal maturation at age 8-9 years. Parents reported behavior difficulties (Strengths and Difficulties Questionnaire) and psychosocial adjustment (Pediatric Quality of Life Inventory) at all four waves from ages 4-5 to 10-11 years.

RESULTS

Both boys and girls who entered puberty early (i.e., by age 8-9 years) also experienced poorer psychosocial adjustment at this age. These psychosocial differences were already evident at ages 4-5 and 6-7 years, and persisted to at least age 10-11 years. Similar patterns were evident for behavior difficulties, but only for boys; early puberty was not related to behavior difficulties in girls.

CONCLUSIONS

Children with early puberty have different patterns of behavior and social adjustment from the preschool years through early adolescence. At least in part, the association between early-onset puberty and poor mental health appears to result from processes under way well before the onset of puberty.

Adolescent suicide in Australia: rates, risk and resilience

Adolescent suicide rates in Australia have fallen significantly during recent years. The incidence, however, clearly remains a serious concern for young people, parents, professionals and policy makers. Some groups of Australian youth appear to be at heightened risk. Adolescents within the welfare system, indigenous, rural and refugee youth, along with same sex attracted young people often need very careful monitoring and support. Young men continue to take their lives more frequently than young women. Prevention programmes in Australia aim to develop resilience in young people, families and communities that can serve as protection against self harm and suicide. The improvement of mental health literacy, a fostering of adolescent self-efficacy and better access to early intervention strategies are currently privileged in national and state policies related to young people in Australia. More work is needed, however, to achieve a well integrated mental health framework capable of effectively addressing adolescent suicide prevention into the twenty-first century.

Childhood psychological problems in school settings in rural Southern Africa

Background

Many children can be exposed to multiple adversities in low and middle-income countries (LMICs) placing them at potential risk of psychological problems. However, there is a paucity of research using large representative cohorts examining the psychological adjustment of children in school settings in these countries. Children’s psychological adjustment has been shown to affect educational progress which is critical for their future. This study, based in a rural, socio-economically disadvantaged area of South Africa, aimed to examine the prevalence of children’s psychological problems as well as possible risk and protective factors.

Methods

Rates of psychological problems in 10–12 year olds were examined using teacher- and child-report questionnaires. Data on children from 10 rural primary schools, selected by stratified random sampling, were linked to individual and household data from the Agincourt health and socio-demographic surveillance system collected from households over 15 years.

Results

A total of 1,025 children were assessed. Teachers identified high levels of behavioural and emotional problems (41%). Children reported lower, but substantial rates of anxiety/depression (14%), and significant post-traumatic stress symptoms (24%); almost a quarter felt unsafe in school. Risk factors included being a second-generation former refugee and being from a large household. Protective factors highlight the importance of maternal factors, such as being more educated and in a stable partnership.

Conclusion

The high levels of psychological problems identified by teachers are a serious public health concern, as they are likely to impact negatively on children’s education, particularly given the large class sizes and limited resources in rural LMIC settings. Despite the high levels of risk, a proportion of children were managing well and research to understand resilience could inform interventions.

Psychosocial paediatric training in Iraq: perspectives of trainers and students

There is an absence of education regarding psychosocial issues in Iraqi paediatric training programmes. The aim of this study is to examine current knowledge and perspectives around these topics and to explore potential development in these programmes. 56 paediatric trainers and students at the Child Central Teaching Hospital, a hospital affiliated to the Al-Mustansyria medical college in Baghdad, responded to a questionnaire to evaluate knowledge and perspectives regarding psychosocial approaches to child and adolescent health as delivered presently via academic training and used in professional practice. The majority of the respondents reported having no training in psychosocial interventions. Using a scale from 0 ('not relevant') to 10 ('very important'), psychosocial issues were rated 7.1 in their relevance to everyday paediatric practice. On a scale of 0 ('very poor') to 10 ('totally adequate'), respondents rated formal current psychosocial training at 2.5. It is concluded that incorporating psychosocial approaches in paediatric training will lead to a broader base of knowledge in children's health and contribute to the promotion of multidisciplinary practice in Iraq.

Treatment processes of counseling for children in South Sudan: a multiple n=1 design

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n=1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client's problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

Prevalence of allergic rhinitis in patients with attention-deficit/hyperactivity disorder: a population-based study

Allergic rhinitis (AR) is common in children. Characteristic symptoms of AR may result in daytime inattention, irritability, and hyperactivity, which are also components of ADHD. Conflicting data in previous studies exist regarding the relationship between ADHD and AR. The aim of this study was to examine the prevalence and risk of AR in ADHD patients in Taiwan. We conducted a cross-sectional study using the National Health Insurance Research Database in Taiwan. The study subjects included 469 patients who received psychiatric care for ADHD in 2005 and the general population (n = 220,599). Distributions of age, gender, and living areas as well as allergic diseases in the general population and in the ADHD group were examined by χ2 tests. Multivariate logistic regression models were used to analyze the risk factors of AR. The prevalence of AR in ADHD group and the general population was 28.4 and 15.2%, respectively. The prevalence of asthma was 9.6% in ADHD group and 6.4% in the general population. Both the prevalence of AR (p < 0.001) and asthma (p = 0.008) was significantly higher in ADHD group than the general population. The multivariate logistic regression analysis showed that ADHD patients had an increased rate of AR than general population (OR = 1.83; 95% CI = 1.48-2.27; p < 0.0001), and asthma was strongly associated with AR (OR = 9.28; 95% CI = 8.95-9.63; p < 0.0001). Our data showed that ADHD patients had an increased rate of AR. Therefore, psychiatrists should be more aware of the comorbidity of AR when treating ADHD patients.

Commentary – bridging the research and practice gap in autism: The importance of creating research partnerships with schools

While the last 10 years have seen a significant increase in research published on early intervention and autism, there is a persistent disconnect between educational research and practice. Governments have invested significant funds in autism education, and a range of approaches have been implemented in schools, but there is limited research exploring whether these educational strategies are effective and a lack of involvement of teaching professionals in the research. Given that the majority of children and young people with autism spend most of their time in school and not in early or specialised intervention programmes, there is a compelling need to conduct better educational research and implement educational interventions in schools. We argue that building collaborative partnerships between researchers and school practitioners is central to achieving improved understanding of, and outcomes for, pupils on the autism spectrum. This commentary offers perspectives from teachers about their experiences of, and priorities for, research, and also presents a model of collaboration between autism school practitioners and researchers, which could support a more integrated approach to research. We reflect on the strengths and challenges of this as well as outcomes achieved so far.

[«The child is father of the man» - review of literature on epidemiology in child and adolescent psychiatry]

One of the goals of epidemiological research is to describe the frequency and patterns in the distribution of diseases among certain groups of a statistical population. According to the literature available, mental disorders in children and adolescents are a common phenomenon worldwide. This article provides a review of the most important and recent international studies on the magnitude, on patterns of distribution, on the course and on gender differences of psychiatric disorders in children and adolescents. Additional data from scientific textbooks are added to the original articles.

Asthma and mental health among youth: etiology, current knowledge and future directions

Asthma and mental health problems, such as depression, anxiety and behavior disorders, are common among youth and are significant sources of morbidity. There is a consistent association between asthma and anxiety/depression and a less consistent association between asthma and behavior disorders. Possible biological and psychological mechanisms may include inflammatory processes as well as the stress of having to live with a life-threatening condition. Future studies are warranted with longitudinal designs to establish temporality as well as measures of potential confounds. Biological and psychological measures would complement the longitudinal design to further establish causality. In addition, more information on the degree to which asthma and mental health have reciprocal influences on each other over time - and the mechanisms of these relationships - are needed in order to develop more effective intervention strategies to improve asthma control and mental health among those with both.

Examining changes in substance use and conduct problems among treatment-seeking adolescents

BACKGROUND

Outdoor behavioral healthcare (OBH) treatment offers an alternative to parents of youth who are treatment-resistant or avoidant.

METHOD

The current study evaluated OBH therapeutic outcomes. The sample was 190 adolescents (M_age  = 15.69) presenting for treatment between 2006 and 2008. To be eligible, participants had to be between the ages of 13 and 17 years and be admitted to one of the three OBH programs for mental health intervention. Primary study hypotheses were that OBH treatment would be associated with a reduction in psychiatric symptomatology from baseline to post-treatment and second, that the OBH intervention would be associated with the maintenance of the hypothesized treatment gains.

RESULTS AND CONCLUSIONS

Findings were consistent with hypotheses, suggesting that youth demonstrated significant symptomatic reductions and maintained these improvements over a 12-month follow-up period.

Depressive symptoms among Jordanian youth: results of a national survey

This study examines level of depression and factors associated with depression among female and male youth in Jordan. The study uses data from a cross-sectional survey conducted among a national sample of 14-25 year old youth attending educational institutions in Jordan (N = 8,129). On average, respondents reported frequently experiencing feelings of sadness (66 %), loss of joy (49 %) and loss of hope in living (43 %). Regression models demonstrated that higher levels of depressive symptoms were observed among females and among youth exposed to violence. Better parent-child relationships were associated with lower depression score. Among males depressive symptoms were associated with poor economic status, low assertiveness and a higher likelihood of alcohol use and smoking. There is a need for mental health prevention programs for youth in Jordan that enhance youth's social and emotional skills, strengthen parent-child relationships, and reduce violence in school, home and in the community.

Burden of psychiatric disorders in the pediatric population

In order to estimate the burden of mental disorders in a representative Italian pediatric population, an epidemiological study was performed using three administrative databases: a drug prescription, a hospital discharge form, and an outpatient ambulatory visit database. The population target was 1,616,268 children and adolescents under 18 years living in the Lombardy Region, Italy. A youth was defined as a case if during 2008 he/she received at least one psychotropic drug prescription or was hospitalized for a psychiatric disorder (International Classification of Disease codes 290-319), or attended a child neuropsychiatric outpatient unit for a visit and/or a psychological intervention or rehabilitation at least once. Epileptic children were excluded. In all, 63,550 youths (39.3 per 1000; 95%CI 39.1-39.7‰) were identified as users of health care resources for a putative mental disorder. The prevalence was higher in boys than in girls (47.0‰ versus 31.3‰) and the highest value was recorded in children 8 years old (60.2‰). A total of 59,987 youths (37.1‰) attended a child and adolescent neuropsychiatry service at least once, 3605 (2.2‰) were admitted to hospital, and 2761 (1.7‰) received at least one psychotropic drug prescription, 57% of which did not attend a child neuropsychiatry service. In all, 14,741 youths (23.1% of users) had a disorder that required a high intensity of care (e.g. recurrent prescriptions for drugs and/or ambulatory care). The proportion of youths who received care for mental disorders in the Lombardy Region seems lower than in other countries. However, the fact that many children were prescribed psychotropic drugs without the supervision of a child psychiatrist is a reason for concern.

Promoting healthy outcomes among youth with multiple risks: innovative approaches

Adolescent behavior problems such as substance use, antisocial behavior problems, and mental health problems have extremely high social costs and lead to overburdened mental health and juvenile justice systems in the United States and Europe. The prevalence of these problems is substantial, and at-risk youth often present with a combination of concerns. An understanding of risk and protective factors at multiple levels, including the child, family, peer, school, and community, has influenced intervention development. At the individual and family levels, the most effective and cost-effective programs work intensively with youth and their families or use individual and group cognitive-behavioral approaches. However, there is a paucity of careful studies of effective policies and programs in the juvenile justice system. Research is needed that focuses on adoption, financing, implementation, and sustainable use of evidence-based programs in public service systems. In addition, the field needs to understand better for whom current programs are most effective to create the next generation of more effective and efficient programs.

Parents' experience of their child's first psychiatric breakdown: "welcome to hell"

Clinicians and researchers have emphasized the importance of helping the primary caregivers of persons going through the first outbreak of psychiatric illness in order to mitigate the negative consequences of the illness on the patient and the caregivers. The aim of the current qualitative, retrospective study is to examine the experiences, challenges, and difficulties faced by Israeli parents during the outbreak of psychiatric illness in their children. In-depth, semi-structured interviews were conducted with 10 parents who participated in a psycho-educational group in a family mental health center. Several themes regarding parents' experience of the first outbreak of their children's psychiatric illness emerge from the content analysis of the interviews--the perception of sudden onset of the illness, feelings of being mired in distress, intense pain stemming from guilt and helplessness with concomitant anger, and isolation. The themes are then discussed in light of the concept of ambiguous loss and the existential approach. The findings indicate psycho-social services in the Israeli mental health system provide only a partial response to the needs of parents during this critical period.

Disease burden and mental health system capacity: WHO Atlas study of 117 low- and middle-income countries

BACKGROUND

Treatment coverage for mental disorders ranges from less than 10% to more than 90% across low- and middle-income (LAMI) countries. Studies have yet to examine whether the capacity of mental health systems might be adversely affected by the burdens of unrelated conditions such as HIV/AIDS.

AIMS

To examine whether the magnitude of disease burden from communicable, perinatal, maternal and nutritional conditions - commonly referred to as Group 1 diseases - is inversely associated with mental health system capacity in LAMI countries.

METHOD

Multiple regression analyses were undertaken using data from 117 LAMI countries included in the 2011 World Health Organization (WHO) Mental Health Atlas. Capacity was defined in terms of human resources and infrastructure. Regressions controlled for effects of political stability, government health expenditures, income inequality and neuropsychiatric disease burden.

RESULTS

Higher Group 1 disease burden was associated with fewer psychiatrists, psychologists and nurses in the mental health sector, as well as reduced numbers of out-patient facilities and psychiatric beds in mental hospitals and general hospitals (t = -2.06 to -7.68, P<0.05).

CONCLUSIONS

Evidence suggests that mental health system capacity in LAMI countries may be adversely affected by the magnitude of their Group 1 disease burden.

Low intake of B-vitamins is associated with poor adolescent mental health and behaviour

OBJECTIVE

The current prevalence of mental health problems in Western populations is approximately 20% and half of all adult mental health disorders are estimated to originate in adolescence. Diet plays an important role in modulating psychological wellbeing and B-vitamins are vital for the synthesis of neurotransmitters such as serotonin. We aimed to examine the relationship between B-group vitamins and adolescent mental health and behaviour.

METHODS

This is a cross-sectional analysis of the West Australian Pregnancy Cohort (Raine) Study. The 17-year follow-up included collection of a food frequency questionnaire allowing B-vitamin intake calculation. Mental health was assessed using the Youth Self Report (YSR) which measures total, internalising (withdrawn/depressed) and externalising (aggressive/delinquent) behaviour scores. Multiple linear regression was used to analyse associations between B-vitamins and mental health with adjustment for relevant confounders (n=709).

RESULTS

Lower intake of vitamins B1, B2, B3, B5, B6, and folate was associated with higher externalising behaviour scores (p ≤ 0.05). Reduced intake of vitamin B6 and folate was associated with higher internalising behaviour scores (p ≤ 0.05).

CONCLUSIONS

Poor nutrition may contribute to the pathogenesis of mental health problems in adolescence. The role of B-vitamins requires further investigation in randomised controlled trials.

Behavioral risk factors and mental health: single and cluster associations in Spanish adolescents

OBJECTIVE

The risk factors associated with mental health in adolescents are not well known in the general population of Mediterranean countries. Therefore, this study aimed to identify individual and clustered behavioral risk factors for psychological distress.

METHODS

Cross-sectional study conducted between 2008 and 2009 among 4054 students representative of those in the fourth year of secondary education in the region of Madrid (Spain). Mental health was assessed using the General Health Questionnaire, with psychological distress defined as a score ≥3. The analyses were performed with logistic regression and adjusted for the main confounders.

RESULTS

Psychological distress was more frequent in those who did insufficient physical activity (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.03-1.47), smokers (OR, 1.30; 95% CI, 1.07-1.59), and users of illegal drugs (OR, 1.46; 95% CI, 1.21-1.76). Psychological distress also showed a positive dose-response relationship with the number of risk behaviors for eating disorders (p for linear trend <0.001). Moreover, it was associated with both thin (OR, 1.37; 95% CI, 1.16-1.62) or very thin body image (OR, 2.15; 95% CI, 1.39-3.32) and perceived overweight (OR, 1.74; 95% CI, 1.40-2.15) or obesity (OR, 3.12; 95% CI, 2.23-4.37). Compared with individuals without classic risk behaviors (low physical activity, low consumption of fruits/vegetables, smoking, high-risk alcohol consumption), frequency of psychological distress was higher in those with 2 risk behaviors (OR, 1.47; 95% CI, 1.19-1.82) and was even greater in those with 3 or 4 risk behaviors (OR, 1.56; 95% CI, 1.21-2.01).

CONCLUSIONS

During adolescence, psychological distress is associated with lifestyles, body image, and eating behaviors. Clustering of classic risk behaviors increases the likelihood of poor mental health.

Schizophrenia in women and children: a selective review of literature from developing countries

Women and children with psychotic disorders in developing countries may be vulnerable and have considerable social disadvantages. Gender disadvantage has implications for all health outcomes including mental illnesses. In the more relevant gender-related context we discuss several important issues which affect women with schizophrenia, namely stigma, caregiver burden, functional outcome, marriage, victimization and help-seeking. The findings indicate that there are variations in clinical and functional outcomes and age of onset of illness between different regions. Drug side effects, such as metabolic syndrome appear to be quite common, adding to disease burden in women from developing countries. Victimization and coercion may contribute to poor quality of life and health concerns such as STIs and HIV. Stigma among women with schizophrenia appears to play a major role in help-seeking, caregiver burden and issues such as marriage and parenting. Gender-sensitive care and practices are few and not well documented. Research in the area of psychoses in children and adolescents from LAMI countries is sparse and is mainly restricted to a few clinic-based studies. More research is needed on organic and medical factors contributing to childhood psychoses, pathways to care, help-seeking, and impact of early detection and community care.

Major health-care providers and the 10 leading reasons for adolescent ambulatory visits

BACKGROUND

Epidemiological research underpins the importance of effective health-care strategies for adolescents. This descriptive study compares the 10 most common diseases among Taiwanese adolescents for 2000 and 2009.

METHODS

Data for a total of 69,594 visits in 2000 and 65,802 visits in 2009 by adolescents aged between 10 and 20 years were collected from the National Health Insurance Research Database. A maximum of three outpatient diagnostic codes (International Classification of Disease, ninth revision) could be listed for every visit. The data categories were: principal diagnosis, patient age, and physician specialty.

RESULTS

  The middle adolescent age group utilized the least amount of medical services. Respiratory (46.2% in 2000, 40.5% in 2009) and digestive (16.5% in 2000 and 16.9% in 2009) tracts were the leading two diagnostic categories for adolescent ambulatory visits. Teeth (6.8%, 6.1%) and eye (4.0%, 3.1%) problems were also among the top 10 diseases. Family practitioners, ear-nose-throat specialists, and traditional Chinese medicine physicians were the major health-care providers for Taiwanese adolescents, especially in the middle and late groups. Although noted as the first option for consultation in the early group, the role of pediatricians with regard to adolescent health care declined in importance with age.

CONCLUSIONS

Nearly 99% of the population in Taiwan is covered under the national health insurance system. The different disease patterns and major health-care providers between Taiwan and other countries are compared.

Second-hand smoke exposure and psychological distress in adolescents. A population-based study

OBJECTIVES

To examine the association between duration and place of second-hand smoke (SHS) exposure and psychological distress in adolescents.

METHODS

A cross-sectional study conducted in 2008 and 2009 in a representative sample of 4th-year students of secondary education (mean age 15.7 years) in the region of Madrid, Spain. The 2215 students who were not smokers were selected for the analysis. Duration of SHS exposure within and outside the home was obtained by self-report. Psychological distress was defined as a score ≥ 3 points in the General Health Questionnaire (GHQ-12). The analyses were made using logistic regression adjusted for demographic variables, lifestyles and family characteristics.

RESULTS

Among non-smoking adolescents, 27.8% (95% CI 25.5 to 30.0) were exposed to SHS in the home, and 33.6% (95% CI 31.3 to 36.0) outside the home. Compared with those with no SHS exposure in the home, the multivariate OR for psychological distress was 1.23 (95% CI 0.92 to 1.64) in individuals with SHS exposure <1 h/day, 2.07 (95% CI 1.30 to 3.28) for exposure 1-3 h/day, and 2.24 (95% CI 1.45 to 3.47) for exposure >3 h/day (p for linear trend <0.001). No association was observed between SHS exposure outside the home and psychological distress.

CONCLUSIONS

In non-smoking adolescents, duration of exposure to SHS in the home had a positive dose-response relationship with the frequency of psychological distress. However SHS exposure outside the home did not show an association with mental health.

Perceptions of parental support buffer against depression for Brazilian youth with interpersonal difficulties

This study examines whether perceptions of parent support buffer against concurrent adolescent depression for youth with interpersonal difficulties. Participants included 398 youth (225 females, 173 males) from public (63.3%) and private (36.7%) schools in Brazil. Adolescents ranged in age from 11 to 14 years ( M = 12.81). Perceptions of parent support moderated concurrent associations between youth reports of peer victimization and depressive symptoms such that youth with high levels of support reported less depression when victimized than youth with low levels of support. Perceptions of parent support also moderated concurrent nonlinear associations between youth reports of family conflict and depressive symptoms. Moderate levels of family conflict were associated with heightened depressive symptoms in youth who reported low levels of support from parents, whereas youth who perceived high levels of support from parents reported heightened depressive symptoms only in conjunction with elevated family conflict.

Perspectives on the Incredible Years programme: psychological management of conduct disorder

Two out of three children diagnosed with conduct disorder will not outgrow it without treatment. It is costly to the individual in terms of negative life outcomes and to society in terms of increased health, social and education service use. Psychosocial interventions are effective in psychologically managing and preventing the onset of conduct disorder.

Reducing child conduct problems and promoting social skills in a middle-income country: cluster randomised controlled trial

BACKGROUND

There is an urgent need for effective, affordable interventions to prevent child mental health problems in low- and middle-income countries.

AIMS

To determine the effects of a universal pre-school-based intervention on child conduct problems and social skills at school and at home.

METHOD

In a cluster randomised design, 24 community pre-schools in inner-city areas of Kingston, Jamaica, were randomly assigned to receive the Incredible Years Teacher Training intervention (n = 12) or to a control group (n = 12). Three children from each class with the highest levels of teacher-reported conduct problems were selected for evaluation, giving 225 children aged 3-6 years. The primary outcome was observed child behaviour at school. Secondary outcomes were child behaviour by parent and teacher report, child attendance and parents' attitude to school. The study is registered as ISRCTN35476268.

RESULTS

Children in intervention schools showed significantly reduced conduct problems (effect size (ES) = 0.42) and increased friendship skills (ES = 0.74) through observation, significant reductions to teacher-reported (ES = 0.47) and parent-reported (ES = 0.22) behaviour difficulties and increases in teacher-reported social skills (ES = 0.59) and child attendance (ES = 0.30). Benefits to parents' attitude to school were not significant.

CONCLUSIONS

A low-cost, school-based intervention in a middle-income country substantially reduces child conduct problems and increases child social skills at home and at school.

Prevalence of child and adolescent psychiatric disorders in Santiago, Chile: a community epidemiological study

PURPOSE

To determine the prevalence of DSM-IV psychiatric disorders in a representative sample of children and adolescents living in Santiago, Chile, as part of a national sample.

METHOD

Subjects aged 4-18 were selected using a stratified multistage design. First, ten municipalities/comunas of Santiago were selected; then the blocks, homes, and child or adolescent to be interviewed were chosen. Psychology graduate students administered the Spanish-language, computer-assisted version of DISC-IV that estimated DSM-IV 12-month prevalence.

RESULTS

A total of 792 children and adolescents were evaluated, with a participation rate of 76.7%. The most stringent impairment DSM-IV DISC algorithm for psychiatric disorders revealed a prevalence of 25.4% (20.7% for boys and 30.3% for girls). The majority of the diagnoses corresponded to anxiety and affective disorders. Prevalence was higher in children aged 4-11 (31.9%) than in adolescents aged 12-18 (18.2%). This difference was mainly accounted for by disruptive disorders in the younger age group. Anxiety disorders had the highest prevalence, although impairment was low. In contrast, most children and adolescents with affective disorders were impaired.

CONCLUSIONS

In Santiago, the prevalence of psychiatric disorders in children and adolescents was high. This study helps raise awareness of child and adolescent mental health issues in Spanish-speaking Latin America and serves as a basis for improving mental health services.

Prevalence of externalizing behavior problems in Sri Lankan preschool children: birth, childhood, and sociodemographic risk factors

PURPOSE

There is dearth of epidemiological data on externalizing behavior problems among preschool children in many developing countries. The aim of this study was to examine the prevalence and associated birth, childhood, and sociodemographic factors of externalizing behavior problems among a community sample of preschool children in Sri Lanka.

METHODS

Maternal ratings of child behavior were obtained from a community-based sample of 1,117 in the age group of 4-6 years using the Child Behaviour Assessment Instrument, which was developed and validated to assess externalizing behavior problems of preschool children. In addition, mothers responded to a questionnaire on birth and childhood related factors of the index child and sociodemographic status of the family.

RESULTS

The prevalence of externalizing behavior problems was estimated as 19.2% (95% CI 17.5-20.9%) with the proportion being significantly higher among boys (p < 0.0001). Breast-feeding less than 3 months, low socioeconomic status, and child living with only one parent were identified as independent predictors of externalizing problems of preschool children.

CONCLUSIONS

The study suggests the need for implementation of strategies and policies focusing at population and family level to reduce the burden associated with externalizing behavior problems in preschool children in Sri Lanka and similar developing countries.

Indoor factors and behavioural problems in children: the GINIplus and LISAplus birth cohort studies

Indoor microbial agents exposure is associated to depressive symptoms in adults and persistent exposure to indoor mould is associated to poorer cognitive function in children. In our study, we aimed to assess the effects of the exposure to indoor factors associated with increased microbial exposure (mould, dampness and pets) on behavioural problems in children aged 10 years, participating in two German birth cohorts. A total of 4860 children were followed until the age of 10 years, and the strengths and difficulties questionnaire (SDQ) was administered to the parents. Indoor factors were assessed through parental reported questionnaires in periodical surveys. Logistic and multinomial regressions adjusting for potential confounders were performed. Prevalences of borderline/abnormal total scores in the SDQ at 10 years of age were higher in children exposed to mould (aOR=1.23, 95%CI=1.00-1.56), dampness (aOR=1.51, 95%CI=1.10-2.07), and pets (aOR=1.48, 95%CI=1.20-1.94). The dimension "emotional symptoms" showed statistically significant risk estimates for mould and pets, meanwhile "conduct problems" and "hyperactivity/inattention" dimensions only did for pets. No significant associations were found for the "peer relationship problems" dimension. We found a significant strong interaction between dampness and pet, the risk of borderline/abnormal scores in the "total difficulties" scale and the "emotional symptoms" dimension for pets' was at least twice the risk in children with reported dampness than in children without. Our findings point to a potential effect of microbial exposure on children's behavioural problems, especially on emotional disorders, probably mediated through neurotoxicity and immune system activation.