Rating child psychiatric caseness from detailed case histories

Associations between prenatal stress with offspring inflammation, depression and anxiety

PURPOSE

Few longitudinal studies have investigated the mediating role of inflammation during childhood in associations between prenatal maternal stress and adolescent mental health. The objective of this study was to examine the associations between prenatal maternal stress, concentrations of immune markers at age 9, and symptoms of generalized anxiety disorder (GAD) and depression during adolescence.

METHODS

This study included 3723 mother-child pairs from the Avon Longitudinal Study of Parents and Children (ALSPAC). Prenatal maternal stress was examined using 55 items measured during pregnancy. Inflammation was assessed using serum concentrations of interleukin-6 (IL-6) and C-reactive protein (CRP) when children were 9 years old. GAD and depression were assessed when children were 16 and 18 years of age, respectively. Analyses comprised of structural equation models.

RESULTS

Prenatal maternal stress was associated with higher concentrations of IL-6 in childhood, and with greater symptoms of depression and GAD in adolescence. However, we did not observe associations between prenatal maternal stress and CRP; also, CRP and IL-6 were not associated with depression and GAD. There was no evidence that CRP and IL-6 mediated the associations between prenatal maternal stress and either GAD or depression.

CONCLUSIONS

Prenatal maternal stress is associated with IL-6 levels in childhood, and with GAD and depression during adolescence. Future studies should examine immune activity at multiple points during development in relation to mental health into adulthood to determine whether inflammation at different points during development could increase risk for mental health problems among children whose mothers experienced significant stressors during pregnancy.

Longitudinal Associations between Peer and Family Relationships, Emotional Symptoms, and Regional Brain Volume across Adolescence

The period of adolescence brings with it a dynamic interaction between social context and behaviour, structural brain development, and anxiety and depressive symptoms. The rate of volumetric change in the ventromedial prefrontal cortex (vmPFC) and amygdala have been implicated in socioemotional development in adolescence; typically, there is thinning of grey matter volume (GMV) in the vmPFC and growth in the amygdala during this time. The directionality of the associations between social, emotional, and neuroanatomical factors has yet to be untangled, such as the degree to which social variables impact regional brain development, and vice versa. To add, the differences between sexes are still up for debate. In this study, longitudinal associations between peer problems, family support, socioeconomic stress, emotional symptoms, amygdala volume, and vmPFC GMV were investigated for both sexes using latent change score models. Data from a multi-site European study at baseline (mean (SD) age = 14.40 (0.38) years; % female = 53.19) and follow-up 2 (mean (SD) age = 18.90 (0.69) years, % female = 53.19) were used. Results revealed that peer problems did not predict emotional symptoms, rather they changed together over time. For males only, there was positive correlated change between vmPFC GMV, peer problems and emotional symptoms, indicating that slower vmPFC GMV thinning was associated with poorer social and emotional functioning. Additionally, greater family support at age 14 years was associated with slower growth of amygdala volume between ages 14 and 19 years for males; previous research has related slower amygdala growth to resilience to mental health disorders. The findings have extended understanding of mutual social, emotional and brain development, and avenues to protect mental health.

Socioeconomic Associations with ADHD: Findings from a Mediation Analysis

BACKGROUND

Children from disadvantaged socioeconomic backgrounds are at greater risk of a range of negative outcomes throughout their life course than their peers; however the specific mechanisms by which socioeconomic status relates to different health outcomes in childhood are as yet unclear.

AIMS

The current study investigates the relationship between socioeconomic disadvantage in childhood and attention deficit/hyperactivity disorder (ADHD), and investigates putative mediators of this association in a longitudinal population-based birth cohort in the UK.

METHODS

Data from the Avon Longitudinal Study of Parents and Children was used (n = 8,132) to explore the relationship between different measures of socioeconomic status at birth-3 years and their association with a diagnosis of ADHD at age 7. A multiple mediation model was utilised to examine factors occurring between these ages that may mediate the association.

RESULTS

Financial difficulties, housing tenure, maternal age at birth of child and marital status were significantly associated with an outcome of ADHD, such that families either living in financial difficulty, living in council housing, with younger or single mothers' were more likely to have a child with a research diagnosis of ADHD at age 7. Financial difficulties was the strongest predictor of ADHD (OR 2.23 95% CI 1.57-3.16). In the multiple mediation model, involvement in parenting at age 6 and presence of adversity at age 2-4 mediated 27.8% of the association.

CONCLUSIONS

Socioeconomic disadvantage, conceptualised as reported difficulty in affording basic necessities (e.g. heating, food) has both direct and indirect impacts on a child's risk of ADHD. Lower levels of parent involvement mediates this association, as does presence of adversity; with children exposed to adversity and those with less involved parents being at an increased risk of having ADHD. This study highlights the importance of home and environmental factors as small but important contributors toward the aetiology of ADHD.

Association between parent-infant interactions in infancy and disruptive behaviour disorders at age seven: a nested, case-control ALSPAC study

BACKGROUND

Effective early intervention to prevent oppositional/conduct disorders requires early identification of children at risk. Patterns of parent-child interaction may predict oppositional/conduct disorders but large community-based prospective studies are needed to evaluate this possibility.

METHODS

We sought to examine whether the Mellow Parenting Observational System (MPOS) used to assess parent-infant interactions at one year was associated with psychopathology at age 7. The MPOS assesses positive and negative interactions between parent and child. It examines six dimensions: anticipation of child's needs, responsiveness, autonomy, cooperation, containment of child distress, and control/conflict; these are summed to produce measures of total positive and negative interactions. We examined videos from the Avon Longitudinal Study of Parents and Children (ALSPAC) sub-cohort who attended the 'Children in Focus' clinic at one year of age. Our sample comprised 180 videos of parent-infant interaction: 60 from infants who received a psychiatric diagnostic categorisation at seven years and 120 randomly selected controls who were group-matched on sex.

RESULTS

A negative association between positive interactions and oppositional/conduct disorders was found. With the exception of pervasive developmental disorders (autism), an increase of one positive interaction per minute predicted a 15% (95% CI: 4% to 26%) reduction in the odds of the infant being case diagnosed. There was no statistically significant relationship between negative parenting interactions and oppositional/conduct disorders, although negative interactions were rarely observed in this setting.

CONCLUSIONS

The Mellow Parenting Observation System, specifically low scores for positive parenting interactions (such as Responsiveness which encompasses parental warmth towards the infant), predicted later psychiatric diagnostic categorisation of oppositional/conduct disorders.

Prevalence, correlates, and comorbidities of DSM-IV psychiatric disorders in children in Seoul, Korea

The present study reports past-year prevalence of and comorbidities associated with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders in 1645 children aged 6 to 12 years in Seoul, Korea. The diagnosis was based on the parental version of the Diagnostic Interview Schedule for Children (DISC-IV). Our participants completed the Children's Depression Inventory (CDI). The estimated prevalence of any full-syndrome and subthreshold DSM-IV disorders were 16.2% and 28.1%, respectively. The most prevalent disorders were specific phobia (9.6%), attention-deficit hyperactivity disorder (ADHD; 5.9%), and oppositional defiant disorder (ODD; 4.9%). The estimated prevalence of depressive disorder was 0.1% according to the DISC-IV and1.9% according to the CDI. ADHD, ODD, and anxiety disorders were highly comorbid. Our study highlights the importance of obtaining children's self-report data in addition to the parents' interview, particularly for depression, and the importance of early detection of subthreshold conditions and considering comorbid diagnoses.

Is severity of motor coordination difficulties related to co-morbidity in children at risk for developmental coordination disorder?

Aim of the study was to investigate whether 7-9 year old children with severe motor difficulties are more at risk of additional difficulties in activities in daily living, academic skills, attention and social skills than children with moderate motor difficulties. Children (N=6959) from a population based cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC), were divided into three groups based on their scores on the ALSPAC Coordination Test at age 7: control children (scores above 15th centile; N=5719 [82.1%]); children with moderate (between 5th and 15th centile; N=951 [13.7%]); and children with severe motor difficulties (below 5th centile N=289 [4.2%]). Children with neurological disorders or an IQ<70 were excluded. Logistic regression was used to compare children with moderate and severe motor coordination difficulties with each other and with control children regarding their risk of co-morbidity defined as significant (<10th centile) difficulties with activities of daily living (ADL); academic skills (reading, spelling and handwriting); attention; social skills (social cognition and nonverbal skills). Children with severe motor difficulties demonstrated a higher risk of difficulties in ADL, handwriting, attention, reading, and social cognition than children with moderate motor difficulties, who in turn had a higher risk of difficulties than control children in five out of seven domains. Screening and intervention of co-morbid problems is recommended for children with both moderate and severe motor difficulties.

Online child and adolescent mental health surveys can be good enough

PURPOSE

To assess the value and practicability of online child mental health surveys.

METHODS

Study 1 followed up an existing low-risk sample from the general population. Study 2 recruited a new high-risk sample via a parents' organization for children with a neurological condition. Both studies invited parents of 2-17 year olds to complete the online development and well-being assessment. Pre-existing data on the Study 1 sample made it possible to examine selective participation.

RESULTS

Response rates were low (20 % for Study 1, 8 % for Study 2). Participation in Study 1 was lower for parents who rented rather than owned their home, for non-traditional families, for parents living in more deprived areas, and for Asian families. Nevertheless, studies 1 and 2 generally replicated the findings of previous interviewer-based surveys with higher response rates.

CONCLUSIONS

Online surveys can be quick and easy to carry out and can potentially generate good enough data for service planning and other purposes despite low response rates, selective participation and missing data. Web-based assessments are a useful addition to the researcher's toolbox, but they do not render the other tools redundant.

Cross-national differences in questionnaires do not necessarily reflect comparable differences in disorder prevalence

PURPOSE

To examine whether the widely used Strengths and Difficulties Questionnaire (SDQ) can validly be used to compare the prevalence of child mental health problems cross nationally.

METHODS

We used data on 29,225 5- to 16-year olds in eight population-based studies from seven countries: Bangladesh, Brazil, Britain, India, Norway, Russia and Yemen. Parents completed the SDQ in all eight studies, teachers in seven studies and youth in five studies. We used these SDQ data to calculate three different sorts of "caseness indicators" based on (1) SDQ symptoms, (2) SDQ symptoms plus impact and (3) an overall respondent judgement of 'definite' or 'severe' difficulties. Respondents also completed structured diagnostic interviews including extensive open-ended questions (the Development and Well-Being Assessment, DAWBA). Diagnostic ratings were all carried out or supervised by the DAWBA's creator, working in conjunction with experienced local professionals.

RESULTS

As judged by the DAWBA, the prevalence of any mental disorder ranged from 2.2% in India to 17.1% in Russia. The nine SDQ caseness indicators (three indicators times three informants) explained 8-56% of the cross-national variation in disorder prevalence. This was insufficient to make meaningful prevalence estimates since populations with a similar measured prevalence of disorder on the DAWBA showed large variations across the various SDQ caseness indicators.

CONCLUSIONS

The relationship between SDQ caseness indicators and disorder rates varies substantially between populations: cross-national differences in SDQ indicators do not necessarily reflect comparable differences in disorder rates. More generally, considerable caution is required when interpreting cross-cultural comparisons of mental health, particularly when these rely on brief questionnaires.

Psychopathology in children before and after surgery for extratemporal lobe epilepsy

AIM

To establish the rates and types of psychiatric disorder in children before and after surgery for extratemporal epilepsy. Relationships between psychiatric morbidity and demographic/clinical variables were examined.

METHOD

A retrospective case note review of 71 children undergoing extratemporal focal resection for drug resistant epilepsy in a specialist epilepsy surgery programme between 1997 and 2008. Psychiatric diagnoses were derived from pre- and postoperative assessments according to DSM-IV criteria.

RESULTS

Seventy-one children (38 males, 33 females) were eligible for this study. Mean age (SD) at surgery was 9 (5) years. Frontal resections were performed in 73% of the children, parietal in 17%, and occipital in 10%. Mental health problems were present in 37 of 71 (52%) children pre- and/or postoperatively. A similar proportion of children had psychiatric diagnoses pre- and postoperatively: 31 of 71 (44%) and 32 of 71 (45%) respectively.

INTERPRETATION

Psychopathology is common in children with extratemporal epilepsy. In this sample, the impact of surgery on psychiatric symptoms was not predictable: some children were unchanged, others improved, and others acquired new psychiatric diagnoses postoperatively. Given the high rates of psychiatric disorder in this group of patients, detection and treatment of mental health needs may be important.

The 'DAWBA bands' as an ordered-categorical measure of child mental health: description and validation in British and Norwegian samples

PURPOSE

To describe and validate the 'DAWBA bands'. These are novel ordered-categorical measures of child mental health, based on the structured sections of the Development and Well-Being Assessment (DAWBA).

METHODS

We developed computer algorithms to generate parent, teacher, child and multi-informant DAWBA bands for individual disorders and for groups of disorder (e.g. 'any emotional disorder'). The top two (out of 6) levels of the DAWBA bands were used as computer-generated DAWBA diagnoses. We validated these DAWBA bands in 7,912 British children (7-19 years) and 1,364 Norwegian children (11-13 years), using clinician-rated DAWBA diagnoses as a gold standard.

RESULTS

In general, the prevalence of clinician-rated diagnosis increased monotonically across all levels of the DAWBA bands, and also showed a dose-response association with service use and risk factors. The prevalence estimates of the computer-generated DAWBA diagnoses were of roughly comparable magnitude to the prevalence estimates from the clinician-generated diagnoses, but the estimates were not always very close. In contrast, the estimated effect sizes, significance levels and substantive conclusions regarding risk factor associations were very similar or identical. The multi-informant and parent DAWBA bands performed especially well in these regards.

CONCLUSION

Computer-generated DAWBA bands avoid the cost and delay occasioned by clinical rating. They may, therefore, sometimes provide a useful alternative to clinician-rated diagnoses, when studying associations with risk factors, generating rough prevalence estimates or implementing routine mental health screening.

Do Unilateral Lesions of the Developing Brain Have Side-specific Psychiatric Consequences in Childhood?

This study used a large epidemiological sample of children with lateralised brain lesions to establish whether damage to the developing human brain has side-specific psychiatric consequences. Parents and teachers completed behaviour questionnaires on 429 hemiplegic children and teenagers, with a subsample of 149 hemiplegic children also being assessed by parent and child interviews. Although childhood hemiplegia was accompanied by a high rate of psychopathology, children with right- and left-sided hemiplegias did not differ significantly on any dimensional or categorical measure of psychopathology. This absence of laterality effects, perhaps reflecting the developing brain's neuroplasticity, casts doubt on theories linking particular types of child or adult psychopathology to side-specific damage to the developing brain.

Prevalence and correlates of psychopathology in a sample of deaf adolescents

AIMS

To examine prevalence and correlates of psychopathology in deaf adolescents using a multi-method multi-informant approach.

METHODS

Data for the study came from checklist assessments by parents (Child Behavior Checklist (CBCL)) and teachers (Teacher's Report Form (TRF)) of 70 deaf adolescents aged 13 to 21 years, from semi-structured clinical interviews of the adolescents (Semi-structured Clinical Interview for Children and Adolescents (SCICA)), and from expert ratings of dossier data.

RESULTS

The percentages of Total Problems scores in the borderline clinical range in this population as found with the CBCL, TRF and SCICA are 28%, 32% and 49-63% respectively. Expert dossier ratings identified psychiatric caseness in 49% and DSM-classifications in 46% of the adolescents (primary classifications: emotional disorder 27%, behavioral disorder 11%, other disorder 7%). Cross-informant agreement between single ratings and expert dossier ratings was better than agreement between single ratings. Logistic regression analyses revealed that low IQ, a signing mode of communication and a history of three or more physical disorders were associated with psychiatric caseness.

CONCLUSIONS

Findings suggest a high prevalence of psychopathology in the population studied and argue for a special focus on the early detection of significant emotional and behavioral problems as well as a multi-informant approach to the assessment of disorder in deaf children and adolescents. The correlational findings support the view that it is not deafness per se that contributes to psychiatric problems.

The Italian preadolescent mental health project (PrISMA): rationale and methods

The Italian preadolescent mental health project (PrISMA--Progetto Italiano Salute Mentale Adolescenti) is the first Italian study designed to estimate the prevalence of mental disorders in preadolescents (10-14 years old) living in urban areas, and to analyse the demographic and biological correlates of emotional and behavioural problems. This paper describes the rationale, methods and the analysis plan of the project. The design of the study used a two-stage sampling procedure, one screening stage of emotional and behavioural problems in a large sample of subjects attending public and private schools and a second stage of diagnostic assessment in a sample including all high scorers and a proportion of low scorers. In the screening stage, parents of preadolescents were asked to fill in the Child Behavior Checklist (CBCL), whereas in the second stage preadolescents and their parents were administered the Development and Well Being Assessment for the assessment of mental disorders together with the Strengths and Difficulties Questionnaire and two scales (C-GAS and HoNOSCA) designed to evaluate the functioning of the preadolescent in different areas. Genetic samples were collected during the screening stage, after parents gave their informed written consent. The findings of this study are expected to allow an adequate planning of interventions for the prevention and the treatment of mental disorders in preadolescence as well as efficient health services.

The Ilha de Maré study: a survey of child mental health problems in a predominantly African-Brazilian rural community

BACKGROUND

There have been very few Brazilian epidemiological surveys of child mental health problems. The only recent survey to have used internationally recognised measures and diagnostic criteria was carried out in Southeast Brazil in a relatively prosperous setting where the population was predominantly urban and white.

METHODS

The setting was an island community in Northeast Brazil that is rural, relatively poor and has a strong African heritage. In an initial phase, a simple random sample of 519 children aged 5-14 was assessed by screening questionnaires completed by parents, teachers and older children. In a second phase, a sub-sample of 100 children was selected for more detailed diagnostic assessments.

RESULTS

Conduct and hyperactivity problems were commoner in boys; emotional symptoms were commoner in girls; and hyperactivity declined with age. By contrast with previously collected data from Southeast Brazil, there were more reported symptoms, but less resultant impact. Using a variety of indices, the rate of disorder on Ilha de Maré was around half that previously found in Southeast Brazil.

CONCLUSION

The measures and diagnostic criteria that were employed appeared valid for use in Northeast Brazil, though there was evidence for consistent over-reporting of symptoms on the screening questionnaire. Rates of child mental health problems appear to differ substantially between sites, confirming the need for a multi-site Brazilian study of the prevalence of child psychiatric disorders.

Prevalence of child and adolescent psychiatric disorders in southeast Brazil

OBJECTIVE

To describe the prevalence of DSM-IV disorders and the pattern of comorbidity in a population-based sample of 7- to 14-year-old Brazilian schoolchildren.

METHOD

Random sampling of schools (stratified into private, public rural, and public urban) was followed by random sampling of pupils from school lists. In 2000-2001, a total of 1,251 children were assessed for DSM-IV diagnoses using the Development and Well-Being Assessment, a structured multiinformant assessment supplemented by verbatim reports reviewed by clinicians.

RESULTS

The response rate was 83%. The overall prevalence of DSM-IV disorders was 12.7% (95% confidence interval = 9.8%-15.5%), with 3.5% of children being assigned as not otherwise specified rather than operationalized diagnoses. The overall prevalence of psychiatric disorder was significantly higher than in a British study with the same measures and diagnostic procedures (12.7% versus 9.7%, p =.02).

CONCLUSIONS

Approximately one in eight schoolchildren in the study area in the southeast of Brazil have psychiatric disorders involving a level of distress or social impairment likely to warrant treatment. The gulf between need and provision is currently vast.

The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders

OBJECTIVE

To describe the prevalence of DSM-IV disorders and comorbidity in a large population-based sample of British children and adolescents.

METHOD

Using a one-phase design, 10,438 children were assessed using the Development and Well-Being Assessment (DAWBA), a structured interview with verbatim reports reviewed by clinicians so that information from parents, teachers, and children was combined in a manner that emulated the clinical process. The authors' analysis examined comorbidity and the influence of teacher reports.

RESULTS

The overall prevalence of DSM-IV disorders was 9.5% (95% confidence interval 8.8-10.1%), but 2.1% of children were assigned "not otherwise specified" rather than operationalized diagnoses. After adjusting for the presence of a third disorder, there was no longer significant comorbidity between anxiety and conduct disorder or attention-deficit/hyperactivity disorder (ADHD), or between depression and oppositional defiant disorder. A comparison of the disorders in children with and without teacher reports suggested that the prevalence of conduct disorders and ADHD would be underestimated in the absence of teacher information.

CONCLUSIONS

Roughly 1 in 10 children have at least one DSM-IV disorder, involving a level of distress or social impairment likely to warrant treatment. Comorbidity reported between some childhood diagnoses may be due to the association of both disorders with a third. Diagnoses of conduct disorder and ADHD may be missed if information is not sought from teachers about children's functioning in school.

Schizophrenia with onset before the age of eleven: clinical characteristics of onset and course

This study reports on the long-term course of 11 patients (6 girls, 5 boys) with childhood onset schizophrenia (COS, age at onset < 10 years). Patients were examined twice (mean follow-up period 38 years after onset). The premorbid development is assessed in terms of the Modified Premorbid Adjustment Scale (M-PAS) and additionally described by distinct psychopathological categories. The psychopathology at the onset of psychosis and at the second follow-up examination was assessed by categorical application of the Positive and Negative Syndrome Scale (PANSS). The outcome was rated with the Disability Assessment Score (DAS). The course of psychotic episodes and intervals between them is presented according to DSM-IV subtype classifications. Ten of 11 patients presented premorbid developmental peculiarities that were not adequately covered by the M-PAS subscales. Whereas in the 4 patients with acute onset of psychosis the positive PANSS-type was predominant, in the 7 patients with an insidious onset the negative PANSS-type prevailed. The nature of the diagnostic subtypes varied markedly across the course of the illness. In case of a continuous predominant catatonic symptomatology the outcome was poor. Detailed case descriptions help to illuminate the heterogeneous psychopathology of COS. Various temporary premorbid behavioral peculiarities were precursors of COS. A differentiation between premorbid and prodromal signs proved to be arbitrary. Our results contradict the assumption that COS is characterized only by a negative symptomatology.

Identifying thresholds for classifying childhood psychiatric disorder: issues and prospects

OBJECTIVE

To evaluate empirically the implications of choosing different thresholds to classify conduct disorder and attention-deficit hyperactivity disorder for estimating prevalence, test-retest reliability of measurement, and informant (parent/teacher) agreement and for evaluating comorbidity and associated features of disorder.

METHOD

Data for the study came from problem checklist assessments done by parents and teachers of children aged 6 to 16 years (N = 1,229) selected with known probability from a general population sample and from structured interviews obtained in a stratified, random subsample (n = 251).

RESULTS

Estimates varied widely depending on the rationale used to set thresholds. Percent prevalence went from 0.1 to 39.2; kappa estimates of test-retest reliability went from .19 to .82. Parent-teacher agreement based on kappa went from .0 to .38. Relative odds between disorder and associated features varied twofold.

CONCLUSION

Use of different rationales to set thresholds for classifying childhood psychiatric disorder in the general population has profound implications for what we learn about the epidemiology of childhood disorder.

Psychiatric problems in children with hemiplegia: cross sectional epidemiological survey

OBJECTIVE

To examine the prevalence and predictors of psychiatric problems in children with hemiplegia.

DESIGN

Cross sectional questionnaire survey of an epidemiological sample with individual assessments of a representative subgroup. The questionnaire survey was repeated on school age subjects four years later.

SUBJECTS

428 hemiplegic children age 2 1/2-16 years, of whom 149 (aged 6-10 years) were individually assessed.

MAIN OUTCOME MEASURES

Psychiatric symptom scores and the occurrence of psychiatric disorder.

RESULTS

Psychiatric disorders affected 61% (95% confidence interval 53% to 69%) of subjects as judged by individual assessments and 54% (49% to 59%) and 42% (37% to 47%) as judged from parent and teacher questionnaires, respectively. Few affected children had been in contact with child mental health services. The strongest consistent predictor of psychiatric problems was intelligence quotient (IQ), which was highly correlated with an index of neurological severity; age, sex, and laterality of lesion had little or no predictive power.

CONCLUSION

Though most hemiplegic children have considerable emotional or behavioural difficulties, these psychological complications commonly go unrecognised or untreated. Comprehensive health provision for children with chronic neurodevelopmental disorders such as hemiplegia should be psychologically as well as physically oriented.