Cumulative comorbidity between neurodevelopmental, internalising, and externalising disorders in childhood: a network approach

Cumulative comorbidity of mental disorders is common, but the extent and patterns of comorbid psychopathology in childhood are not well established. The current study aimed to elucidate the emergent patterns of cumulative mental disorder comorbidity in children using network analysis of diagnoses recorded between birth and age 12 years. Participants were 90,269 children (mean age 12.7 years; 51.8% male) within the New South Wales Child Development Study (NSW-CDS)-a longitudinal record-linkage cohort study of Australian children born in NSW between 2002 and 2005. Binary indicators for eight types of mental disorder were derived from administrative health records. Patterns of conditional association between mental disorders were assessed utilising network analysis. Of 90,269 children, 2268 (2.5%) had at least one mental disorder by age 12 years; of the 2268 children who had at least one mental disorder by age 12 years, 461 (20.3%) were diagnosed with two or more different disorders out of the eight disorder types included in analyses. All disorders were either directly or indirectly interconnected, with childhood affective and emotional disorders and developmental disorders being most central to the network overall. Mental disorder nodes aggregated weakly (modularity = 0.185) into two communities, representative of internalising and externalising disorders, and neurodevelopmental and sleep disorders. Considerable sex differences in the structure of the mental disorder comorbidity networks were also observed. Developmental and childhood affective and emotional disorders appear to be key to mental disorder comorbidity in childhood, potentially reflecting that these disorders share symptoms in common with many other disorders.

Patterns of health service use for children with mental disorders in an Australian state population cohort

OBJECTIVES

The rate of mental health services provided to children and young people is increasing worldwide, including in Australia. The aim of this study was to describe patterns of hospital and ambulatory mental health service use among a large population cohort of adolescents followed from birth, with consideration of variation by age, sex and diagnosis.

METHODS

Characteristics of services provided for children with mental disorder diagnoses between birth and age 17.5 years were ascertained for a population cohort of 85,642 children (52.0% male) born between 2002 and 2005, from 'Admitted Patients', 'Emergency Department' and 'Mental Health Ambulatory' records provided by the New South Wales and Australian Capital Territory Health Departments.

RESULTS

A total of 11,205 (~13.1%) children received at least one hospital or ambulatory health occasion of service for a mental health condition in the observation period. More than two-fifths of children with mental disorders had diagnoses spanning multiple categories of disorder over time. Ambulatory services were the most heavily used and the most common point of first contact. The rate of mental health service contact increased with age across all services, and for most categories of mental disorder. Girls were more likely to receive services for mental disorders than boys, but boys generally had an earlier age of first service contact. Finally, 3.1% of children presenting to mental health services experienced involuntary psychiatric inpatient admission.

CONCLUSIONS

The extent of hospital and ambulatory-based mental healthcare service among children emphasises the need for primary prevention and early intervention.

Levels of Involvement with Child Protection Services Associated with Early Adolescent Police Contact as a Victim and Person of Interest

The relationship between childhood maltreatment and subsequent offending/victimization is well established. However, the magnitude of this relationship for different levels of child protection services (CPS) involvement is poorly understood, due to measurement issues, lack of longitudinal data, and reliance on reports of substantiated maltreatment, which can underestimate the impact of maltreatment. This study examined associations between CPS involvement during childhood (ages 0 to <11 years) and police services contact (as a victim and/or a person of interest) for criminal incidents in early adolescence (11 to ~14 years), differentiated according to levels of CPS involvement (i.e., no risk of significant harm [non-ROSH], unsubstantiated ROSH, substantiated ROSH, and out-of-home care; each examined relative to no CPS contact). Data for 71,465 children were drawn from the New South Wales Child Development Study, an intergenerational, longitudinal investigation that uses administrative records from CPS and police alongside other health, justice, and education data. Multinomial regression analyses were conducted to determine associations between increasing levels of CPS involvement and police contact as a victim only, a person of interest only, and as both victim and person of interest while accounting for covariates (i.e., child's sex, Aboriginal, and/or Torres Strait Islander background, socioeconomic status, maternal age at child's birth, and parental offending history). Children exposed to any of the four levels of CPS involvement had higher odds of police contact, relative to children with no CPS involvement. Odds ratios were higher for contact with police as both a victim and a person of interest, compared to police contact as a victim or a person of interest only. These findings highlight that children with even unsubstantiated CPS reports (i.e., non-ROSH and unsubstantiated ROSH reports) are at heightened risk of police contact compared to children who are unknown to CPS, underlining the need to support all families in contact with CPS.

Early life exposure to air pollution and psychotic-like experiences, emotional symptoms, and conduct problems in middle childhood

BACKGROUND

Air pollution has been linked to a variety of childhood mental health problems, but results are inconsistent across studies and the effect of exposure timing is unclear. We examined the associations between air pollution exposure at two time-points in early development and psychotic-like experiences (PLEs), and emotional and conduct symptoms, assessed in middle childhood (mean age 11.5 years).

METHODS

Participants were 19,932 children selected from the NSW Child Development Study (NSW-CDS) with available linked multi-agency data from birth, and self-reported psychotic-like experiences (PLEs) and psychopathology at age 11-12 years (middle childhood). We used binomial logistic regression to examine associations between exposure to nitrogen dioxide (NO2) and particulate matter less than 2.5 μm (PM2.5) at two time-points (birth and middle childhood) and middle childhood PLEs, and emotional and conduct symptoms, with consideration of socioeconomic status and other potential confounding factors in adjusted models.

RESULTS

In fully adjusted models, NO2 exposure in middle childhood was associated with concurrent PLEs (OR = 1.10, 95% CI = 1.02-1.20). Similar associations with PLEs were found for middle childhood exposure to PM2.5 (OR = 1.05, 95% CI = 1.01-1.09). Neither NO2 nor PM2.5 exposure was associated with emotional symptoms or conduct problems in this study.

CONCLUSIONS

This study highlights the need for a better understanding of potential mechanisms of action of NO2 in the brain during childhood.

Childhood Schizotypy and Adolescent Mental Disorder

BACKGROUND AND HYPOTHESIS

Schizotypy provides a framework for understanding the developmental nature of psychotic disorders and a means of identifying "at-risk" individuals early in the lifespan. However, there is a lack of prospective longitudinal research examining the relationship between schizotypy in childhood and later psychotic and other mental disorders. We hypothesized that distinct profiles of schizotypy in childhood would be differentially associated with psychotic and other mental disorders emerging later in adolescence.

STUDY DESIGN

In a large population cohort of Australian young people (n = 26 837), we prospectively examined the relationship between person-centered profiles of schizotypy identified in middle childhood (age ~11 years) and adolescent diagnoses (age ~13-18 years) across 7 types of mental disorders using multinomial logistic regression.

RESULTS

Membership in any of 3 childhood schizotypy profiles (true schizotypy, affective schizotypy, or introverted schizotypy) was associated with an increased likelihood of being diagnosed with any type of mental disorder in adolescence; effects were strongest for the true schizotypy group (aOR = 3.07, 95% CI = 2.64, 3.57), followed by the introverted (aOR = 1.94, 95% CI = 1.75, 2.15) and affective (aOR = 1.29, 95% CI = 1.13, 1.47) schizotypy groups. Six of the 7 types of mental disorders measured (including psychotic disorders) were associated with at least 1 schizotypy group.

CONCLUSIONS

Schizotypy in middle childhood is an important correlate of mental disorders in adolescence; however, it does not appear to be specifically associated with psychotic disorders in this age group.

Self-harm and suicidal ideation among young people is more often recorded by child protection than health services in an Australian population cohort

OBJECTIVE

We investigated patterns of service contact for self-harm and suicidal ideation recorded by a range of human service agencies - including health, police and child protection - with specific focus on overlap and sequences of contacts, age of first contact and demographic and intergenerational characteristics associated with different service responses to self-harm.

METHODS

Participants were 91,597 adolescents for whom multi-agency linked data were available in a longitudinal study of a population cohort in New South Wales, Australia. Self-harm and suicide-related incidents from birth to 18 years of age were derived from emergency department, inpatient hospital admission, mental health ambulatory, child protection and police administrative records. Descriptive statistics and binomial logistic regression were used to examine patterns of service contacts.

RESULTS

Child protection services recorded the largest proportion of youth with reported self-harm and suicidal ideation, in which the age of first contact for self-harm was younger relative to other incidents of self-harm recorded by other agencies. Nearly 40% of youth with a health service contact for self-harm also had contact with child protection and/or police services for self-harm. Girls were more likely to access health services for self-harm than boys, but not child protection or police services.

CONCLUSION

Suicide prevention is not solely the responsibility of health services; police and child protection services also respond to a significant proportion of self-harm and suicide-related incidents. High rates of overlap among different services responding to self-harm suggest the need for cross-agency strategies to prevent suicide in young people.

Parental mental disorders and offspring schizotypy in middle childhood: an intergenerational record linkage study

PURPOSE

To investigate relationships between distinct schizotypy risk profiles in childhood and the full spectrum of parental mental disorders.

METHODS

Participants were 22,137 children drawn from the New South Wales Child Development Study, for whom profiles of risk for schizophrenia-spectrum disorders in middle childhood (age ~ 11 years) were derived in a previous study. A series of multinomial logistic regression analyses examined the likelihood of child membership in one of three schizotypy profiles (true schizotypy, introverted schizotypy, and affective schizotypy) relative to the children showing no risk, according to maternal and paternal diagnoses of seven types of mental disorders.

RESULTS

All types of parental mental disorders were associated with membership in all childhood schizotypy profiles. Children in the true schizotypy group were more than twice as likely as children in the no risk group to have a parent with any type of mental disorder (unadjusted odds ratio [OR] = 2.27, 95% confidence intervals [CI] = 2.01-2.56); those in the affective (OR = 1.54, 95% CI = 1.42-1.67) and introverted schizotypy profiles (OR = 1.39, 95% CI = 1.29-1.51) were also more likely to have been exposed to any parental mental disorder, relative to children showing no risk.

CONCLUSION

Childhood schizotypy risk profiles appear not to be related specifically to familial liability for schizophrenia-spectrum disorders; this is consistent with a model where liability for psychopathology is largely general rather than specific to particular diagnostic categories.

Cumulative environmental risk in early life is associated with mental disorders in childhood

BACKGROUND

No single environmental factor is a necessary or sufficient cause of mental disorder; multifactorial and transdiagnostic approaches are needed to understand the impact of the environment on the development of mental disorders across the life course.

METHOD

Using linked multi-agency administrative data for 71 932 children from the New South Wales Child Developmental Study, using logistic regression, we examined associations between 16 environmental risk factors in early life (prenatal period to <6 years of age) and later diagnoses of mental disorder recorded in health service data (from age 6 to 13 years), both individually and summed as an environmental risk score (ERS).

RESULTS

The ERS was associated with all types of mental disorder diagnoses in a dose-response fashion, such that 2.8% of children with no exposure to any of the environmental factors (ERS = 0), compared to 18.3% of children with an ERS of 8 or more indicating exposure to 8 or more environmental factors (ERS ⩾ 8), had been diagnosed with any type of mental disorder up to age 13-14 years. Thirteen of the 16 environmental factors measured (including prenatal factors, neighbourhood characteristics and more proximal experiences of trauma or neglect) were positively associated with at least one category of mental disorder.

CONCLUSION

Exposure to cumulative environmental risk factors in early life is associated with an increased likelihood of presenting to health services in childhood for any kind of mental disorder. In many instances, these factors are preventable or capable of mitigation by appropriate public policy settings.

Conditions of Birth and Early Childhood Developmental Risk for Mental Disorders

Distinct classes of children in the general population are at increased odds of later mental illness and other adverse outcomes according to patterns of early childhood developmental vulnerability. If certain risk factors known at the time of birth are reliably associated with membership in early childhood risk classes, then preventative interventions could be initiated in the earliest years of life. Associations between 14 factors known at the time of birth and membership in early childhood risk classes were examined in 66,464 children. Risk class membership was associated with maternal mental illness, parental criminal charges and being male; distinct patterns of association were shown for some conditions, for example, prenatal child protection notification was uniquely associated with misconduct risk'. These findings suggest that risk factors known at the time of birth could assist in very early detection of children who may benefit from early intervention in the first 2000 days.

Out-of-home care characteristics associated with childhood educational underachievement, mental disorder, and police contacts in an Australian population sample

BACKGROUND

Children in out-of-home care (OOHC) are generally at increased risk of health and social adversities compared to their peers. However, the experiences of children in OOHC are not uniform and their associated health and social indices may vary in relation to characteristics of OOHC placements and child protection contact.

OBJECTIVE

To examine associations between a range of characteristics of OOHC placements and child protection contact (e.g., number, type, and age of placement) with educational underachievement, mental disorder, and police contact (as a victim, witness, or person of interest) in childhood.

PARTICIPANTS AND SETTING

Participants were Australian children drawn from the New South Wales Child Development Study cohort who had been placed in OOHC at least once between the ages of 0-13 years (n = 2082).

METHODS

Logistic regression was used to examine prospective associations of OOHC placement and child protection contact characteristics (type of carer, placement instability, duration and frequency of maltreatment, and amount of time in care) with educational underachievement, mental disorder diagnosis and any type of police contact.

RESULTS

Placements with foster carers, greater placement instability, longer and more frequent exposure to maltreatment, and longer time spent in care were each associated with greater likelihood of consequences in all domains of functioning.

CONCLUSIONS

Children with certain placement characteristics are at higher risk of adverse consequences and should be prioritised for support services. The magnitude of relationships was not uniform across different health and social indices, highlighting the need for holistic, multiagency approaches to support children placed in care.

Cumulative Environmental Risk in Early Life: Associations With Schizotypy in Childhood

BACKGROUND AND HYPOTHESIS

Psychotic disorders are associated with a growing number of recognized environmental exposures. Cumulative exposure to multiple environmental risk factors in childhood may contribute to the development of different patterns of schizotypy evident in early life. Hypotheses were that distinct profiles of schizotypy would have differential associations with a cumulative score of environmental risk factors.

STUDY DESIGN

We prospectively examined the relationship between 19 environmental exposures (which had demonstrated replicated associations with psychosis) measured from the prenatal period through to age 11 years, and 3 profiles of schizotypy in children (mean age = 11.9 years, n = 20 599) that have been established in population data from the New South Wales-Child Development Study. Multinomial logistic regression was used to examine associations between membership in each of 3 schizotypy profiles (true schizotypy, introverted schizotypy, and affective schizotypy) and exposure to a range of 19 environmental risk factors for psychosis (both individually and summed as a cumulative environmental risk score [ERS]), relative to children showing no risk.

RESULTS

Almost all environmental factors were associated with at least 1 schizotypy profile. The cumulative ERS was most strongly associated with the true schizotypy profile (OR = 1.61, 95% CI = 1.52-1.70), followed by the affective (OR = 1.33, 95% CI = 1.28-1.38), and introverted (OR = 1.32, 95% CI = 1.28-1.37) schizotypy profiles.

CONCLUSIONS

Consistent with the cumulative risk hypothesis, results indicate that an increased number of risk exposures is associated with an increased likelihood of membership in the 3 schizotypy profiles identified in middle childhood, relative to children with no schizotypy profile.

Pathways from developmental vulnerabilities in early childhood to schizotypy in middle childhood

OBJECTIVES

Childhood disturbances in social, emotional, language, motor and cognitive functioning, and schizotypy have each been implicated as precursors of schizophrenia-spectrum disorders. We investigated whether relationships between early childhood developmental vulnerabilities and childhood schizotypy are mediated by educational underachievement in middle childhood.

METHODS

Participants were members of a large Australian (n = 19,216) population cohort followed longitudinally. Path analyses were used to model relationships between developmental vulnerabilities at age ~5 years, educational underachievement from ages ~8 to 10 years and three distinct profiles of schizotypy at age ~11 years (true, introverted and affective schizotypy).

RESULTS

Early childhood developmental vulnerabilities on five broad domains (related to physical, emotional, social, cognitive and communication development) were associated with schizotypy profiles in middle childhood. Educational underachievement in middle childhood was associated with all schizotypy profiles, but most strongly with the true schizotypy profile (OR = 3.92, 95% CI = 3.12, 4.91). The relationships between schizotypy profiles and early childhood developmental vulnerabilities in 'language and cognitive skills (school-based)' and 'communication skills and general knowledge' domains were fully mediated by educational underachievement in middle childhood, and the relationships with early childhood 'physical health and well-being' and 'emotional maturity' domains were partially mediated.

CONCLUSION

Developmental continuity from early childhood developmental vulnerabilities to schizotypy in middle childhood is mediated by educational underachievement in middle childhood. While some domains of early developmental functioning showed differential relationships with distinct schizotypy profiles, these findings support a developmental pathway to schizotypy in which cognitive vulnerability operates from early childhood through to middle childhood.

Relationships between parental mental illness and/or offending and offspring contact with the police in childhood: Findings from a longitudinal record-linkage study

BACKGROUND

Parental offending and mental illness are associated with an increased risk of criminal behaviour in offspring during adolescence and adulthood, but the impact of such problems on younger children, including children's experiences of victimisation, is less well known.

AIM

To investigate the associations between parental offending and mental illness recorded prior to their offspring's age of 5 years and their offspring's contact with police as a 'person of interest', 'victim' or 'witness' between ages 5 and 13 years.

METHODS

Our sample consisted of 72,771 children and their parents drawn from the New South Wales Child Development Study, an Australian longitudinal population-based record linkage study. Logistic regression analyses were conducted to examine associations between parental factors and offspring's police contact. Separate models examined the relationships between maternal or paternal offending and mental illness, as well as the combination among either or both parents, as the independent variables, and their child's police contact as the dependent variable.

RESULTS

Parental offending and mental illness were each individually associated with indices of police contact among offspring. Stronger associations were observed when both offending and mental illness were present together (in either parent, or when one parent had both exposures). Stronger associations were evident for mothers with both factors across all offspring police contact types, relative to fathers with both factors, in fully adjusted models; that is, children of mothers with both factors were over four times as likely to have contact with police as a 'person of interest' (OR = 4.29; 95% CI = 3.75-4.92) and over three times as likely to have contact as a victim (OR = 3.35; 95% CI = 3.01-3.74) or witness (OR = 3.58; 95% CI = 3.03-4.24), than children whose mothers had no history of offending or mental illness.

CONCLUSIONS

Children with a parental history of offending and mental illness in early life are at an increased likelihood of early police contact as young as 5-13 years of age; it is vital that this is taken as a signal to help them and their affected families according to need.

Self-reported mental health of children known to child protection services: an Australian population-based record linkage study

Maltreated children are vulnerable to adverse mental health outcomes. Information about how children's mental health needs vary according to different levels of child protection contact (potentially culminating in out-of-home care [OOHC]) is valuable for the effective provision of services. This study aimed to examine associations between different levels of contact with child protection services before the age of 10 years and self-reported mental health difficulties at age 11 years. Participants (n = 26,960) were drawn from the New South Wales Child Development Study, a multiagency, multigenerational, longitudinal record linkage study that combines administrative records with cross-sectional survey data. We examined associations between four levels of child protection response (non-threshold reports, unsubstantiated reports, substantiated reports, OOHC; each relative to no report) and six domains of self-reported mental health difficulties (including internalising and externalising symptoms, and psychotic-like experiences). All levels of contact with child protection services were associated with increased odds of mental health difficulties in all domains. Children who had been placed in OOHC and children with substantiated reports had the highest odds of reporting clinical levels of mental health difficulties; 48.1% of children with an OOHC placement and 45.6% of those with substantiated child protection reports showed clinical levels of mental health difficulties in at least one domain. Children with child protection reports that were unsubstantiated, or determined not to meet the threshold for risk-of-significant harm, were also at increased risk of mental health difficulties in middle childhood. These findings underscore the importance of early detection and intervention for all children at risk of maltreatment.

Regional mapping of early childhood risk for mental disorders in an Australian population sample

AIM

Population-level profiles of risk for later childhood mental disorders have been identified in patterns of early developmental vulnerabilities using Australian Early Developmental Census. We sought to demonstrate the geographical distribution of these early childhood risk profiles for mental illness, to inform policy decisions for place-sensitive provision of health and allied services.

METHODS

Using geographic information system techniques, we mapped the regional percentage of children at highest risk for mental disorders across the state of New South Wales (NSW), according to Local Government Areas, for 82 891 children in the NSW Child Development Study.

RESULTS

A high proportion (>10%) of children at risk of later mental disorders were located in regional and socioeconomically disadvantaged areas, with a few metropolitan regions showing similarly high proportions of the population at risk.

CONCLUSIONS

These findings highlight the potential to identify place-sensitive needs for early intervention and prevention programs for emerging mental health problems in children.

Early developmental vulnerabilities following exposure to domestic violence and abuse: Findings from an Australian population cohort record linkage study

Early life exposure to Domestic Violence and Abuse (DVA) is associated with poor psychosocial and cognitive development in childhood. However, most prior research uses mother-reported involvement in DVA as a proxy indicator of child exposure; studies using direct measures of child exposure to DVA are scarce, especially among representative population-based samples. We address this gap by using longitudinal, population-based data from an Australian record linkage study of children to examine the associations between early life exposure to DVA and early childhood developmental vulnerability. Exposure to DVA was measured using police contact records for children involved in a DVA incident either as a victim or witness. Developmental vulnerability at school entry was measured using the Australian Early Development Census, providing indices of five broad domains of function and person-centred classes of developmental risk (referred to as 'mild generalized risk', 'misconduct risk', and 'pervasive risk', each compared to a group showing 'no risk'). Children exposed to DVA showed significantly greater odds of developmental vulnerability on all five domains and were more likely to be members of the three developmental risk classes. Girls who were victims of DVA (OR = 1.65) had significantly poorer developmental outcomes than boys who were victims (OR = 1.26) within the domain of communication skills and general knowledge (d = 0.29 [SE = 0.16], p = .04). No other sex differences were found. These preliminary findings hold important implications for policy regarding the early intervention and implementation of support services for young children exposed to DVA.

Early childhood developmental vulnerability associated with parental mental disorder comorbidity

OBJECTIVES

Parental mental health has a profound influence on the mental health and well-being of their offspring. With comorbid mental disorders generally the rule rather than the exception, increased knowledge of the impact of parental mental disorder comorbidity on early child development may facilitate improved targeting and delivery of early intervention for vulnerable offspring.

METHODS

Participants were 66,154 children and their parents in the New South Wales Child Development Study - a prospective, longitudinal, record-linkage study of a population cohort of children born in NSW between 2002 and 2004. Early childhood developmental vulnerability was assessed at age ~5 years using the Australian Early Development Census, and information on parental mental disorders was obtained from administrative health records. Binomial and multinomial logistic regression were used to assess the relationship between parental mental disorders and early childhood developmental vulnerability on emotional and behavioural domains, as well as membership of latent developmental risk classes reflecting particular classes of vulnerability.

RESULTS

Multiple diagnoses of mental disorders in mothers and fathers were associated with an increased likelihood of early childhood emotional and behavioural developmental vulnerability in offspring, relative to parents without mental disorder. The likelihood of offspring vulnerability increased with the number of parental comorbidities, particularly maternal comorbidities.

CONCLUSION

Early childhood developmental vulnerability was strongly associated with parental mental ill-health, with the strength of associations increasing in line with a greater number of mental disorder diagnoses among mothers and fathers. New and expectant parents diagnosed with multiple mental disorders should be prioritised for intervention, including attention to the developmental well-being of their offspring.

Parental and community risk factors for childhood self-harm thoughts and behaviours

BACKGROUND

Childhood self-harm is rare but increasing in frequency. Little is known about risk factors specifically for self-harm in preteen children.

METHODS

We examined self-harm thoughts and behaviours in children aged 3-14 years in association with parental and community-level risk factors, using a large general population-based record linkage sample (n = 74,479).

RESULTS

Parental factors were strongly associated with childhood self-harm, with over three-quarters of children with self-harm having a parent with a history of mental disorder and/or criminal offending. Community-level factors (socioeconomic deprivation, remote or regional location, and neighbourhood crime rate) were not associated with childhood self-harm after adjustment for confounding factors.

LIMITATIONS

Measures of self-harm thoughts and behaviours derived from administrative data likely underestimate the prevalence of self-harm in the population.

CONCLUSIONS

Intergenerational transmission of risk factors is likely an important contributor to childhood self-harm.

Familial clustering of birth risk for adverse childhood outcomes

OBJECTIVE

To identify classes of children exposed to distinct clusters of perinatal and familial risk factors at the time of birth, and examine relationships between class membership and a variety of adverse outcomes in childhood.

DESIGN

A prospective longitudinal study of children (and their parents) born between 2002 and 2004 and who have been followed-up until 12-13 years of age. A combination of latent class analysis and logistic regression analyses were used.

RESULTS

Adverse developmental, social, and mental health outcomes in early and middle childhood were greatest for children with 'pervasive familial risk' (i.e., parental mental illness, parental criminality, and perinatal risk factors) at the time of birth; some associations were stronger among girls.

CONCLUSION

Pervasive exposure to multiple risk factors in the pre- and perinatal period increases the risk of adverse outcomes in childhood. Future interventions should tailor strategies to address unique combinations of adverse risk exposures in vulnerable families.

Developmental profiles of schizotypy in the general population: A record linkage study of Australian children aged 11-12 years

Objectives

The detection of young people at high risk for psychotic disorders has been somewhat narrowly focused on overt symptom‐based markers that reflect mild reality distortion (e.g., psychotic‐like experiences), or prodromal syndromes that are proximal to psychosis onset. The concept of schizotypy represents a broader framework for investigating risk for schizophrenia (and other disorders) in childhood, before the onset of prodromal or overt symptoms. We sought to detect profiles of risk for psychosis (schizotypy) in a general population sample of 22,137 Australian children aged 11–12 years, and to determine early life risk factors associated with these profiles from data available in linked records (registers).

Methods

Fifty‐nine self‐reported items were used as indicators of schizotypy across six broad domains; z‐scores for each domain were subjected to latent profile analyses (LPA). A series of multinomial logistic regressions was used to examine the association between resulting profile (class) membership and several childhood and parental risk factors, and the proportion of children with mental disorders among each schizotypy profile was examined.

Results

The LPA revealed three person‐centred profiles referred to as True Schizotypy (n = 1,323; 6.0%), Introverted Schizotypy (n = 4,473; 20.2%), and Affective Schizotypy (n = 4,261; 19.2%), as well as a group of children showing no risk (n = 12,080; 54.6%). Prior exposure to perinatal and familial adversities including childhood maltreatment, as well as poor early childhood development and academic functioning, was variously associated with all risk groups. There was a higher proportion of childhood mental disorder diagnoses among children in the True Schizotypy group, relative to other profiles.

Conclusion

Subtle differences in the pattern of exposures and antecedents among schizophrenia liability profiles in childhood may reflect distinct pathogenic pathways to psychotic or other mental illness.

Practitioner points

Children aged 11–12 years report characteristics of schizotypy which can be classified into three distinct profiles that may represent different pathological processes towards later mental ill‐health.

Early life exposure to perinatal and familial adversities including childhood maltreatment, early childhood developmental vulnerability, and poor academic functioning predict membership in all three childhood schizotypy profiles.

Latent liability for schizophrenia (and potentially other mental disorders) may be represented by different profiles of functioning observable in childhood.

Forecasting childhood adversities from conditions of birth

BACKGROUND

Childbirth presents an optimal time for identifying high-risk families to commence intervention that could avert various childhood health and social adversities.

OBJECTIVE

We sought to establish the minimum set of exposures required to accurately predict a range of adverse childhood outcomes up to the age of 13 years, from a set of 14 individual and familial risk exposures evident at the time of birth.

METHODS

Participants were 72,059 Australian children and their parents drawn from a multi-register population cohort study (data spanning 1994-2018). Risk exposures included male sex, young mother (aged ≤21 years), no (or late first; >16 weeks) antenatal visit, maternal smoking during pregnancy, small for gestational age, preterm birth, pregnancy complications (any of hypertension, diabetes mellitus, gestational diabetes or pre-eclampsia), >2 previous pregnancies of ≥20 weeks, socio-economic disadvantage, prenatal child protection notification, and maternal or paternal mental disorder or criminal offending history. Individual outcomes included early childhood developmental vulnerability (age 5 years), sustained educational underachievement (age 8 and 10 years), mental disorder diagnoses, substantiated childhood maltreatment, and contact with the police as a victim or person-of-interest up to age 13-14 years.

RESULTS

Risk exposures at birth predicted individual childhood outcomes with fair to excellent accuracy: the area under the receiver operating characteristic curves ranged between 0.60 (95% CI 0.58, 0.62) for childhood mental disorder and 0.83 (95% CI 0.82, 0.85) for substantiated child maltreatment. The presence of five or more exposures characterised 12-25% of children with one or more adverse outcomes and showed high predictive certainty for models predicting multiple outcomes, which were apparent in 9% of the population.

CONCLUSIONS

Up to a quarter of the neonatal population at risk of multiple adverse outcomes can be detected at birth, with implications for population health screening. However, cautious implementation of these models is warranted, given their relatively low positive predictive values.

Increased incidence of childhood mental disorders following exposure to early life infection

Early life exposure to infectious diseases confers risk for adult psychiatric disorders but relatively few human population studies have examined associations with childhood mental disorder. Here we examined the effects of exposure to maternal infection during pregnancy, and child infectious diseases in early childhood (birth to age 4 years), in relation to first mental disorder diagnosis (age 5-13 years). The study sample comprised 71,841 children represented in a population cohort of children in New South Wales, Australia, followed from birth to early adolescence via linkage of administrative registers. Childhood exposure to infectious disease was determined during the prenatal period (i.e., maternal infection during gestation), and in early childhood (between birth and age 4 years) using the NSW Ministry of Health Admitted Patients data collection. Days to first diagnosis with a mental disorder was determined from recorded diagnoses between age 5-13 years in the NSW Ministry of Health's Admitted Patients, Emergency Department and Mental Health Ambulatory data collections. While crude hazard ratios for both prenatal infection and childhood infection exposures indicated significantly earlier diagnosis with mental disorders associated with both of these risk factors, only childhood infection exposure was associated with higher adjusted hazard ratios (aHR) for any diagnoses (aHR = 1.21, 95% CI = 1.11-1.32), externalising disorders (aHR = 1.45, 95% CI 1.18-1.79) and developmental disorders (aHR = 1.82, 95% CI 1.49-2.22) when the effects of maternal and early childhood (age < 5 years) mental disorders were taken into account. Exposure to infectious diseases during early childhood, but not prenatal infection exposure, appears to be associated with earlier diagnosis of mental disorders in childhood.

Profiles of Resilience from Early to Middle Childhood among Children Known to Child Protection Services

OBJECTIVE

The processes facilitating resilience are likely to be influenced by individual, familial and contextual factors that are dynamic across the life-course. These factors have been less studied in relation to resilience profiles evident in the developmental period between early to middle childhood, relative to later periods of adolescence or adulthood.

METHOD

This study examined factors associated with resilience in a cohort of 4,716 children known to child protection services by age 13 years, in the Australian State of New South Wales. Latent profile and transition analyses were used to identify multi-dimensional profiles of resilience as evident in social, emotional and cognitive functioning when assessed in early childhood (time 1 [T1], age 5-6 years) and middle childhood (time 2 [T2], age 10-11 years). Logistic regression models were used to investigate factors associated with two types of resilience identified: a transition profile of stress-resistance (i.e., represented by a typically developing profile at both T1 and T2) delineated in the largest subgroup (54%) of children, and a smaller subgroup (13%) with a profile of emergent resilience (i.e., typically developing at T2 following a vulnerable profile at T1).

RESULTS

Factors associated with resilience profiles included being female, and personality characteristics of openness and extraversion; other factors associated with stress-resistance, specifically, included higher socioeconomic status, non-Indigenous background, higher perceived port at home and at school, and not having a parent with a history of criminal offending.

CONCLUSIONS

Resilience processes appear to involve a complex interplay between individual, family, and community characteristics requiring interagency support.

Incidence of Early Police Contact Among Children With Emerging Mental Health Problems in Australia

IMPORTANCE

In adulthood and adolescence, mental health vulnerability is known to be associated with risk of criminal justice system contact as both a perpetrator and survivor of crime, but whether this association is apparent early in child development is unknown. Prevention of poor outcomes, including repeated contact with the criminal justice system, relies on the identification of vulnerability early in life and at the start of such contact.

OBJECTIVE

To ascertain whether children with emotional or behavioral problems and general developmental vulnerabilities are at an increased risk of subsequent contact with police as a person of interest, a survivor of crime, or a witness.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used routinely collected data from the New South Wales Child Development Study in Australia. The cohort was composed of children who entered full-time schooling in New South Wales in 2009, had complete data for the emotional maturity domain of the Australian Early Development Census, and had no police contact before January 1, 2009. The children in the cohort were followed up until the age of 13 years. Data were analyzed from October 17, 2019, to May 13, 2020.

EXPOSURES

Emotional or behavioral problems and developmental risk profiles derived from the teacher-rated Australian Early Development Census.

MAIN OUTCOMES AND MEASURES

Incidence rates of police contact (as a person of interest, survivor of crime, or witness) were derived from the New South Wales Police Force Computerised Operational Policing System.

RESULTS

A total of 79 801 children (40 584 boys [50.9%]; 2009 mean [SD] age, 5.2 [0.37] years) were included. Children with teacher-identified emotional or behavioral problems at school entry had an incidence rate of police contact (for any reason) that was twice that of children without such problems (unadjusted hazard ratio [HR], 2.14; 95% CI, 1.94-2.37). Contact with police as a survivor of crime was most commonly recorded (7350 [9.2%]), but the strength of the association was greatest between emotional or behavioral problems and police contact as a person of interest (unadjusted HR, 4.75; 95% CI, 3.64-6.19). Incidence of police contact as a person of interest was high for children with a pervasive developmental risk profile (unadjusted HR, 13.80; 95% CI, 9.79-19.45).

CONCLUSIONS AND RELEVANCE

This study found an association of emerging emotional or behavioral problems and developmental vulnerabilities with increased risk of police contact for any reason among young children, suggesting that this well-known association in adults and adolescents can be identified at an earlier developmental stage. These findings support primary and secondary interventions to prevent police contact early in life and to target the earliest contacts with the criminal justice and educational systems.

Transitions between socio-emotional and cognitive vulnerability profiles from early to middle childhood: a population study using multi-agency administrative records

Adult psychosocial difficulties, including psychiatric disorders, are often preceded by childhood psychosocial vulnerabilities, presenting critical windows of opportunity for preventative intervention. The present study aimed to identify longitudinal patterns (representing transitions between profiles) of childhood socio-emotional and cognitive vulnerability in the general population from early to middle childhood, in relation to key risk factors (e.g. parental mental illness and offending). Data were drawn from the New South Wales Child Development Study, which combines intergenerational multi-agency administrative records with cross-sectional assessments using data linkage methods. We analysed data from childhood assessments of socio-emotional and cognitive functioning at two time points (ages 5-6 and 10-11 years) that were linked with administrative data from government departments of health, child protection, and education for 19,087 children and their parents. Latent profile analyses were used to identify socio-emotional and cognitive profiles at each time point, and latent transition analyses were used to determine the probability and potential moderators of transition between profiles at each age. Three developmental profiles were identified in early childhood, reflecting typically developing, emotionally vulnerable, and cognitively vulnerable children, respectively; two profiles were identified in middle childhood, reflecting typically developing and vulnerable children. Child's sex, child protection services contact, parental mental illness, and parental offending influenced children's transitions between different vulnerability profiles, with the strongest effects for parental mental illness and child protection contact. Early detection of vulnerable children and factors promoting resilience are important steps in directing future health and social policy, and service planning for vulnerable children.

Chronic Physical Health Conditions, Mental Health, and Sources of Support in a Longitudinal Australian Child Population Cohort

OBJECTIVE

This study examined associations between chronic physical health conditions (identified from hospital records) that are subject to school health care plans, and children's emotional, behavioral, and social functioning during early (∼5 years of age) and middle childhood (∼11 years).

METHODS

Participants were 21,304 Australian children from a representative longitudinal population cohort derived by multi-agency record linkage. Hospital presentations (admitted patients and emergency department) identified children with asthma (n = 1,573), allergies and anaphylaxis (n = 738), type 1 diabetes (n = 59), epilepsy (n = 87), and any of these conditions (n = 2,275), relative to 19,029 children without these presentations. Logistic regression analyses determined associations between these exposures and (i) emotional, behavioral, social, and overall vulnerabilities reported by teachers (early childhood) and children (middle childhood), and (ii) self-reported lack of sources of support (middle childhood).

RESULTS

Prevalence of any condition in hospital records was 7.5% by early childhood, and 10.7% by middle childhood. Relative to peers without these presentations, small increases in risk of overall problems, and selected emotional, behavioral, and social problems, were apparent for children with any condition, and asthma specifically, in early and middle childhood. Large and pervasive effects were apparent for epilepsy, limited small effects in middle childhood only for allergies and anaphylaxis, and no increases in risk associated with type 1 diabetes examined in middle childhood. No condition was associated with increased risk of lacking supports.

CONCLUSIONS

Children with hospital records of chronic conditions, particularly epilepsy and asthma, might benefit from school-based care plans that integrate their physical and mental health support needs.

Reading and numeracy attainment of children reported to child protection services: A population record linkage study controlling for other adversities

BACKGROUND

Maltreated children are at risk of poor educational outcomes, but also experience greater individual, family, and neighbourhood adversities that may obscure an understanding of relationships between child protection involvement and educational attainment.

OBJECTIVE

To examine associations between child protection involvement and 3rd- and 5th-grade reading and numeracy attainment, while controlling multiple other adversities.

PARTICIPANTS AND SETTING

Participants were 56,860 Australian children and their parents from the New South Wales Child Development Study with linked multi-agency records.

METHODS

Multinomial logistic regressions examined associations between level of child protection involvement (Out-Of-Home Care [OOHC] placement; substantiated Risk Of Significant Harm [ROSH]; unsubstantiated ROSH; non-ROSH; and no child protection report) and standardised tests of 3rd- and 5th-grade reading and numeracy. Fully adjusted models controlled demographic, pregnancy, birth, and parental factors, and early (kindergarten) developmental vulnerabilities on literacy and numeracy, and other developmental domains (social, emotional, physical, communication).

RESULTS

All children with child protection reports were more likely to attain below average, and less likely to attain above average, 3rd- and 5th-grade reading and numeracy, including children with reports below the ROSH threshold. Children with substantiated ROSH reports who were not removed into care demonstrated the worst educational attainment, with some evidence of protective effects for children in OOHC.

CONCLUSIONS

A cross-agency response to supporting educational attainment for all children reported to child protection services is required, including targeted services for children in OOHC or with substantiated ROSH reports, and referral of vulnerable families (unsubstantiated and non-ROSH cases) to secondary service organisations (intermediate intervention).

Costs for physical and mental health hospitalizations in the first 13 years of life among children engaged with Child Protection Services

BACKGROUND

Longitudinal data on health costs associated with physical and mental conditions are not available for children reported to child protection services.

OBJECTIVE

To estimate the costs of hospitalization for physical and mental health conditions by child protection status, including out-of-home-care (OOHC) placement, from birth until 13-years, and to assess the excess costs associated with child protection contact over this period.

PARTICIPANTS AND SETTING

Australian population cohort of 79,285 children in a multi-agency linkage study.

METHODS

Costs of hospitalization were estimated from birth (if available) using Round 17, National Hospital Cost Data Collection (2012-13; deflated to 2015-16 AUD). Records of the state child protection authority determined contact status. Data were reported separately for children in OOHC. Hospital separations were classified as mental disorder-related if the primary diagnosis was recorded in ICD-10 Chapter V (F00-F99).

RESULTS

Hospital separations were more common in children with child protection contact. Physical health care costs per child decreased with age for all children, but were significantly higher for children with contact. Mental health costs per child were always significantly higher for children with contact, with marked increases at 3 ≤ 4 years and 8 ≤ 9 years. Point estimates of annual costs per child were always highest for children with an OOHC placement. The net present value of the excess costs was $3,224 per child until 13- years, discounted at 5 %.

CONCLUSIONS

Children in contact with child protection services show higher rates and costs for physical and mental health hospitalizations in each of their first 13 years of life.

The influence of parental offending on the continuity and discontinuity of children's internalizing and externalizing difficulties from early to middle childhood

PURPOSE

Although parental criminal offending is a recognized risk factor for conduct problems among offspring, its impact on the continuity and discontinuity of children's behavioural and emotional difficulties during the early development is less well known. We used data from a large, population-based record-linkage project to examine the relationship between parental offending and the continuity and discontinuity of children's conduct, attentional, and emotional difficulties from early to middle childhood while also considering the role of timing of the parental offending exposure.

METHOD

Data for 19,208 children and their parents were drawn from the New South Wales Child Development Study. Multinomial regression analyses tested associations between mother's and father's history and timing of any and violent offending, and patterns of continuity or discontinuity in offspring emotional, conduct, and attentional difficulties between ages 5 and 11 years.

RESULTS

Maternal and paternal offending each conferred a significantly increased risk of all the patterns of developmental difficulties, including those limited to age 5 only (remitting problems), to age 11 only (incident problems), and to difficulties present at both ages 5 and 11 years (persisting problems). Greatest odds were observed for persisting conduct problems. Paternal offending that continued through early and middle childhood had the greatest association with child difficulties, while the timing of maternal offending had a less prominent effect on child developmental difficulties.

CONCLUSION

Parental offending is a strong risk factor for early and pervasive behavioural and emotional problems in offspring, and may be a key indicator of high risk for later antisocial behaviour.

Timing of the first report and highest level of child protection response in association with early developmental vulnerabilities in an Australian population cohort

BACKGROUND

Childhood maltreatment is associated with early childhood developmental vulnerabilities. However, the extent to which higher levels of child protection responses confer benefit to developmental competencies, and the impact of earlier timing of first reports in relation to early childhood vulnerability remains unclear.

OBJECTIVE

We examined associations between early developmental vulnerabilities and (1) the highest level of child protection response (where OOHC was deemed the highest response among other types of reports/responses), and (2) the developmental timing of the first child protection report.

PARTICIPANTS AND SETTING

Participants included 67,027 children from the New South Wales Child Development Study, of whom 10,944 were reported to child protection services up to age 5 years.

METHODS

A series of Multinomial Logistic Regressions were conducted to examine focal associations.

RESULTS

Children with substantiated maltreatment reports showed the strongest odds of vulnerability on three or more developmental domains (adjusted OR = 4.90; 95% CI = 4.13-5.80); children placed in OOHC showed slightly better physical, cognitive and communication competencies (adjusted ORs from 1.83 to 2.65) than those with substantiated reports that did not result in OOHC placements (adjusted OR from 2.77 to 3.67), when each group was compared to children with no child protection reports. Children with first maltreatment reports occurring in the first 18 months of life showed the strongest likelihood of developmental vulnerabilities on three or more developmental domains (adjusted OR = 3.56; 95% CI = 3.15-4.01) relative to children with no child protection reports.

CONCLUSION

Earlier reports of maltreatment may signal the need for targeted remediation of early developmental competencies to mitigate early developmental difficulties.

Inter-agency indicators of out-of-home-care placement by age 13-14 years: A population record linkage study

BACKGROUND

Cross-agency administrative data can improve cost-effective triage systems for child protection and other human service delivery.

OBJECTIVE

To determine the minimum set of cross-agency indicators that could accurately classify placement in out-of-home-care (OOHC) before age 13-14 years.

PARTICIPANTS AND SETTING

Participants were 72,079 Australian children (mean age = 13.16 years; SD = 0.37; 51.4% male) and their parents, for whom linked administrative records spanning the years 1994-2016 were available for analysis within the 'New South Wales Child Development Study'.

METHODS

First, a series of logistic regression analyses were conducted to examine associations between cross-agency (health, justice, education) risk indicators and membership of the sub-cohort of 1239 children who had an OOHC placement prior to age 13-14 years, relative to (1) the sub-cohort of 55,473 children who had no previous contact with child protection services, and (2) the sub-cohort of 15,367 children who had been reported to child protection services but had no record of OOHC placement. We then explored the classification characteristics associated with a smaller combination of risk factors, and the utility of specific familial risk factors, for classifying membership of the OOHC subgroup.

RESULTS

A combination of six risk indicators evident before OOHC placement can classify children placed in OOHC with approximately 95% accuracy, and the presence of at least four of these risk indicators provides excellent specificity (99.6%).

CONCLUSIONS

A combination of risk factors observable in administrative datasets held by multiple government agencies may be used to target support services to prevent entry into OOHC for children from vulnerable families.

Parental offending and children's emergency department presentations in New South Wales, Australia

OBJECTIVES

Children whose parents have a history of criminal offending may be at risk of higher rates of emergency department (ED) presentation, along with other adverse health outcomes. We used data from a large, population-based record linkage project to examine the association between maternal and paternal criminal offending and the incidence of ED presentations among child offspring.

METHODS

Data for 72 772 children with linked parental records were drawn from the New South Wales Child Development Study. Information on parental criminal offending (spanning 1994-2016) and child ED presentations (spanning 2005-2016; approximately ages 2-12 years) was obtained from linked administrative records. Cox proportional hazards regression analyses were conducted to examine the association between parental offending and the incidence of children's ED presentations for any reason and for physical injury, while accounting for important covariates.

RESULTS

Child rates of ED presentation, particularly for physical injury, were higher among those with parental history of criminal offending, after adjusting for covariates. The magnitude of the association was higher for paternal criminal offending (ED presentation for any reason: HR=1.44 (95% CI 1.41 to 1.48); physical injury: HR=1.70 (95% CI 1.65 to 1.75)) than maternal criminal offending (any reason: HR=0.99 (95% CI 0.95 to 1.03); physical injury: HR=1.05 (95% CI 1.00 to 1.10)).

CONCLUSION

Children of parents, particularly of fathers, with a history of criminal offending have an increased incidence of ED presentation, including for potentially avoidable physical injury. These findings require replication and further research to understand the mechanisms underlying these associations.

Early developmental risk for subsequent childhood mental disorders in an Australian population cohort

OBJECTIVE

We examined associations between developmental vulnerability profiles determined at the age of 5 years and subsequent childhood mental illness between ages 6 and 13 years in an Australian population cohort.

METHODS

Intergenerational records from New South Wales (NSW) Government Departments of Health and Child Protection spanning pre-birth to 13 years of age were linked with the 2009 Australian Early Development Census records for 86,668 children. Mental illness indices for children were extracted from health records between 2009 and 2016 (child's age of 6-13 years). Associations between mental disorder diagnoses and membership of early childhood risk groups, including those with established 'special needs' (3777, 4.3%) at school entry, or putative risk classes delineated via latent class analysis of Australian Early Development Census subdomains - referred to as 'pervasive risk' ( N = 3479; 4.0%), 'misconduct risk' ( N = 5773; 6.7%) or 'mild generalised risk' ( N = 9542; 11%) - were estimated using multinomial logistic regression, relative to children showing 'no risk' ( N = 64,097; 74%). Poisson regression models estimated the relative risk of a greater number of days recorded with mental health service contacts among children in each Australian Early Development Census risk group. Adjusted models included child's sex, socioeconomic disadvantage, child protection contacts and parental mental illness as covariates.

RESULTS

The crude odds of any mental disorder among children aged 6-13 years was increased approximately threefold in children showing pervasive risk or misconduct risk profiles at the age of 5 years, and approximately sevenfold in children with special needs, relative to children showing no risk; patterns of association largely remained after adjusting for covariates. Children with special needs and the misconduct risk class used mental health services over a greater number of days than the no risk class.

CONCLUSION

Patterns of early childhood developmental vulnerability are associated with subsequent onset of mental disorders and have the potential to inform interventions to mitigate the risk for mental disorders in later childhood and adolescence.