Precursors of mental health problems for low birth weight children: the salience of family environment during the first year of life

Maternal depressive symptoms, poverty, and young motherhood increase the odds of early depressive and anxiety disorders for children born prematurely

Children born preterm, compared to term, are at risk for behavioral problems. However, the prevalence and predictors of internalizing disorders among children born preterm are unclear. The purpose of this study was to identify the prevalence of depressive and anxiety disorders at 2 years of age among children born preterm and determine the extent to which poverty, maternal depressive symptoms, or young motherhood increase the likelihood of these disorders. Mothers and their infants (N = 105) were recruited from two neonatal intensive care units affiliated with a major U.S. university. A sociodemographic questionnaire, the Patient Health Questionnaire‐9, and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition scale scores from the Preschool Child Behavior Checklist were used to measure primary variables. We examined mothers’ family satisfaction and quality of caregiving as well as children's degree of prematurity, morbidity, gender, cognitive functioning, and motor function as covariates. Fifteen percent of children met criteria for an anxiety disorder and another 15% for depression. Maternal depressive symptoms increased the odds of children developing both anxiety and depression, whereas young motherhood was associated with child anxiety and poverty with child depression. Results indicate the need for mental health assessment of children born preterm during their first 2 years of life and the importance of early therapeutic and tangible support to vulnerable mothers and children.

Preventive strategies for mental health

Available treatment methods have shown little effect on the burden associated with mental health disorders. We review promising universal, selective, and indicated preventive mental health strategies that might reduce the incidence of mental health disorders, or shift expected trajectories to less debilitating outcomes. Some of these interventions also seem to be cost-effective. In the transition to mental illness, the cumulative lifetime effect of multiple small effect size risk factors progressively increases vulnerability to mental health disorders. This process might inform different levels and stages of tailored interventions to lessen risk, or increase protective factors and resilience, especially during sensitive developmental periods. Gaps between knowledge, policy, and practice need to be bridged. Future steps should emphasise mental health promotion, and improvement of early detection and interventions in clinical settings, schools, and the community, with essential support from society and policy makers.

Behavioral outcomes at corrected age 2.5 years in children born extremely preterm

OBJECTIVE

This study examined a national cohort of 2.5-year-old children born extremely preterm with respect to behavioral problems from the perspective of parents and whether developmental variables mediated the effects of extreme prematurity on behavioral problems.

METHODS

As a part of the Extremely Preterm Infants in Sweden Study (EXPRESS), 344 children born before 27 weeks of gestation and 338 control children were given the Cognitive, Language, and Motor Scales of the Bayley-III and the Parent report Child Behavior Checklist/1½-5 (CBCL/1½-5). CBCL/1½-5 assigns 7 syndrome scores, further classified into composite scores for internalizing and externalizing behavior as well as total problems. Group differences in behavioral difficulties and prevalence of clinical problems were calculated. Bayley-III scores were used in regression models to determine if developmental factors mediated the effects of extreme prematurity on behavioral problems, after controlling for sociodemographic factors.

RESULTS

Preterm children had significantly higher mean T-scores on internalizing, externalizing, and total problems, as compared with the control subjects, but these were still within the average range. However, the proportion of subjects showing behavioral problems within the clinical range was significantly higher in the preterm group. Levels of cognitive, language, and motor development mediated the between-group differences in behavioral problems.

CONCLUSION

Our findings encourage behavioral assessments during preschool years and emphasize the importance of considering multifactorial pathways of prediction when examining prematurity outcome.

The significance of insecure and disorganized attachment for children's internalizing symptoms: a meta-analytic study

This meta-analytic review examines the association between attachment and internalizing symptomatology during childhood, and compares the strength of this association with that for externalizing symptomatology. Based on 42 independent samples (N = 4,614), the association between insecurity and internalizing symptoms was small, yet significant (d = 0.15, CI 0.06~0.25) and not moderated by assessment age of internalizing problems. Avoidance, but not resistance (d = 0.03, CI -0.11~0.17) or disorganization (d = 0.08, CI -0.06~0.22), was significantly associated with internalizing symptoms (d = 0.17, CI 0.03~0.31). Insecurity and disorganization were more strongly associated with externalizing than internalizing symptoms. Discussion focuses on the significance of attachment for the development of internalizing versus externalizing symptomatology.

Factors Affecting Attachment in International Adoptees at 6 Months Post Adoption

This pilot study examined the effect of five child and maternal factors on the attachment security of international adoptees at six months post adoption. Results from the sample of 22 adoptive mother-infant dyads showed that age at adoption, developmental status, length and quality of preadoption care, and maternal attachment representations were not significant predictors of child attachment status. The number of preadoption placements and the child's stress level did significantly predict attachment status, accounting for approximately 40% of the variance in attachment security. Number of preadoption placements uniquely contributed 14% of that variance (p=.007) while stress level uniquely contributed 12% (p=.01). Children who had fewer preadoption placements had higher attachment security; similarly, children who had lower stress levels had higher attachment security. Results suggest that consistency of preadoption care was more important than its length or quality. Further, the relationship between stress level and attachment security raises the possibility that a lower stress level functions as a protective factor for the developing attachment with the adoptive mother.

Attachment Behavior of Children Adopted Internationally at Six Months Post Adoption

The purpose of this pilot study was to describe attachment behavior in children adopted internationally at 6 months post adoption. Twenty-two children and their adoptive mothers were observed at home for completion of an attachment measure. Mothers also completed a questionnaire on their child's preadoption care. Comparisons of children low and high in attachment security suggested that low secure children showed predominantly ambivalent attachment behavior or that they were still in the process of forming an attachment. Children having foster versus orphanage care prior to adoption differed in quality of preadoption care and in certain attachment behaviors, but not in overall attachment security.

The significance of insecure attachment and disorganization in the development of children's externalizing behavior: a meta-analytic study

This study addresses the extent to which insecure and disorganized attachments increase risk for externalizing problems using meta-analysis. From 69 samples (N = 5,947), the association between insecurity and externalizing problems was significant, d = 0.31 (95% CI: 0.23, 0.40). Larger effects were found for boys (d = 0.35), clinical samples (d = 0.49), and from observation-based outcome assessments (d = 0.58). Larger effects were found for attachment assessments other than the Strange Situation. Overall, disorganized children appeared at elevated risk (d = 0.34, 95% CI: 0.18, 0.50), with weaker effects for avoidance (d = 0.12, 95% CI: 0.03, 0.21) and resistance (d = 0.11, 95% CI: -0.04, 0.26). The results are discussed in terms of the potential significance of attachment for mental health.

Health-related quality of life among 3--4-year-old children born with very low birthweight

AIM

This paper reports a study comparing health-related quality of life at 3-4 years of age among children born with very low birthweight (<or=1500 g) to a group of non-very low birthweight controls, and to examine biological, environmental, demographic and health factors associated with quality of life of children born with very low birthweight.

BACKGROUND

Advances in modern medicine have increased the survival of infants with very low birthweight, but its impact on quality of life of children during preschool years has been less studied.

METHODS

The study sample included 118 children born with very low birthweight and 170 non-very low birthweight controls in Taiwan. Primary caregivers of the study children completed structured questionnaires during the period November 2002 to April 2003. Health-related quality of life was measured using the Mandarin version of the TZO-AZL Preschool Children Quality of Life instrument. This tool has four dimensions: physical, emotional, cognitive and social functions. Higher scores indicate better quality of life.

FINDINGS

Children born with very low birthweight had statistically significantly lower mean quality of life scores in all the four dimensions compared with controls. Among the former, those who had current physical health problems scored lower in all dimensions of quality of life. Primary caregivers with higher educational levels and increased ages of the children were associated with improved scores in the emotional and social functions. Birth gestational age was negatively associated with cognitive function. Length of stay in the neonatal intensive care unit was negatively associated with scores for the social function aspect of quality of life.

CONCLUSION

Regular monitoring of the quality of life among very low birthweight children is needed. Nurses need to assess the child's current health state, birth gestational age, and the primary caregiver's educational level in order to identify those who are at risk for low quality of life and intervene early.

Dimensions of behavior of toddlers entering early intervention: Child and family correlates

This study examined the nature and correlates of the behavioral characteristics of a nationally representative sample of 1612 toddlers 18-31 months of age entering Part C early intervention services in the U.S. Factor analysis of 15 items describing child behavior collected as part of an extensive telephone interview of parents yielded four dimensions of behavior: difficult behaviors, lack of persistence, distractible, and withdrawn. Demographic and personal characteristics of the child and family were found to be related to the four behavioral dimensions. Parent reports of behavior of toddlers with fair or poor health or those with communication difficulties were less positive for all behavioral dimensions, suggesting the development of toddler behavioral characteristics is influencing or being influenced by other facets of development.

The contribution of fetal drug exposure to temperament: potential teratogenic effects on neuropsychiatric risk

BACKGROUND

Preliminary evidence indicates that fetal drug exposure may be associated with alterations in temperament. However, studies often do not dissociate the potential effects of drug exposure from other perinatal or environmental factors that could influence temperament phenotypes.

METHODS

High risk children (n = 120) were followed from birth to 6 months of age to determine the effects of fetal drug exposure on temperament, after controlling for the child's gender, gestational age, medical morbidity, ethnicity, and maltreatment as well as the mother's stress, income adequacy, and quality of caregiving. Methods included medical chart review, questionnaires, and videotapes of mother-child interaction.

RESULTS

Preliminary analyses indicated that fetal drug exposure was associated with both distractibility and intensity of children's responses to the environment at 6 months of age. After adjusting for potentially confounding variables, drug exposure accounted for 12% of the variance in distractibility but was not a significant predictor in the regression model for intensity.

CONCLUSIONS

Findings suggest that drug-exposed children may experience difficulty sustaining their focus of attention and be more easily distracted by environmental stimuli than non-drug-exposed children. Results converge with previous research to implicate cortical hyperarousal, stemming from teratogenic effects on the dopaminergic system during fetal development.

National Institute of Nursing Research working group on "Optimizing pregnancy outcomes in minority populations"

The growing complexity of biomedical research requires new methods of discovery; scientists must use an interdisciplinary approach and explore new models of team science, as underscored in the Roadmap of the National Institutes of Health. In March 2003, the National Institute of Nursing Research convened a working group of scientists and clinicians with a wide range of backgrounds to address "Optimizing Pregnancy Outcomes in Minority Populations." The 2-day meeting included a variety of presentations on the current state of research on pregnancy in minority populations. Many participants provided specific insights regarding biobehavioral issues in human-environment interaction, stress and health status relationships to risk, maternal-fetal interactions, and the complications of pregnancy. This supplement presents articles from several participants at this interdisciplinary meeting. The National Institute of Nursing Research looks forward to further collaborations across the National Institutes of Health and other agencies to achieve the vital aims of this working group.