Prediction of children's referral to mental health and special education services from earlier adjustment

Reactive, Proactive, Relational, and Slow Dissipation of Aggression in Children

Objective

This study investigated the associations between aggression subtypes (reactive, proactive, relational, and slow dissipation of aggression), callous-unemotional traits (CU), irritability (IRR), and sex among children.

Method

The sample included 508 children 5 to 12 years of age, rated by their mothers.

Results

A 4-factor model of aggression subtypes (reactive, proactive, relational, slow dissipation) provided a good fit to the data. Correlations between aggression subtypes and demographic variables were generally nonsignificant, except for a unique association between relational aggression and sex, with girls exhibiting higher scores, and proactive aggression was associated with younger age. Both CU and IRR correlated positively with all types of aggression. Slow dissipation of aggression showed a unique association with IRR, whereas reactive aggression was uniquely associated with both CU and IRR. Regressions showed an interaction between CU, IRR, and sex for slow dissipation and relational aggression. Interactions showed that boys with high levels of both CU and IRR demonstrated slower dissipation of aggression, indicating a tendency to hold grudges, and that sex differences in relational aggression depended on the co-occurrence of CU and IRR.

Conclusion

This study sheds light on the interplay among aggression subtypes, CU, IRR, and sex in children. Findings emphasize the need for psychiatrists and other mental health professionals to consider the multifaceted nature of aggressive behavior and the role of CU and IRR when assessing aggressive children or developing treatment plans for them. Further research is warranted to examine these relationships longitudinally and across diverse populations.

Clinical guidance

•Recognize the different types of aggression: Look beyond angry outbursts and consider reactive, proactive, relational, and slow dissipation of aggression to target intervention.•Emotional traits matter: Assess for callous-unemotional traits and irritability alongside aggression. High levels of both, especially in boys, may indicate greater difficulty managing anger and holding grudges.•Gender differences exist: Girls may be more prone to relational aggression compared to boys.•Proactive aggression might be more common in younger than in older children. Tailor interventions accordingly.

Association of mental health problems in childhood with prenatal and postnatal physical growth

Aims

The present study was conducted to examine (i) prenatal and postnatal patterns of growth in relation to the risk of later mental health problems in children and (ii) the possible mediating effect of these patterns of growth in the association between parental socioeconomic status (SES) and children’s mental health.

Subjects and methods

The present study is part of a blinded, matched case control study, involving a retrospective analysis of prospectively collected data from routine examinations at community health services for children and adolescents. The sample comprised 80 patients, referred between the age of 6–13 years to the Community Mental Health Centre in Maastricht, and 320 matched population controls.

Results

Children coming from unemployed families weighed less at birth, but postnatal growth was not associated with this or other indicators of SES. Although children using mental health care were somewhat smaller at birth, there was no evidence that leanness during childhood was a risk factor for the development of mental health problems.

Conclusions

The present results showed some evidence for the impact of intrauterine development on children’s mental health problems. In addition, neither prenatal nor postnatal physical growth were on the pathway between parental SES and children’s mental health problems.

The association of maternal polyunsaturated fatty acids during pregnancy with social competence and problem behaviours at 7 years of age: The MEFAB cohort

BACKGROUND

The prenatal exposure to maternal n-6 and n-3 polyunsaturated fatty acids (PUFAs) might influence the development of social competence and internalizing and externalizing behaviours of the child, because of the numerous functions of PUFAs within the nervous system.

METHODS

To analyse the association of selected maternal PUFAs (i.e., AA, EPA, DHA, total n-6, total n-3, and the n-6:n-3 ratio) measured during gestation with childhood social competence and problem behaviours, we examined 311 mother-child pairs from the Maastricht Essential Fatty Acid Birth (MEFAB) cohort. For each woman, PUFA-specific changes in relative concentrations were calculated by identifying the best-fitting curve of PUFA concentration by linear splines of gestational age. The associations of changes in maternal PUFAs in early and late pregnancy with childhood social competence, total problems, internalizing and externalizing behaviours, measured with the Child Behaviour Checklist 4/18 at age 7, were investigated with linear regression analyses adjusted for maternal and children's socio-demographic characteristics.

RESULTS

In late gestation (i.e., from gestational week 30), an increase in AA was associated with higher social competence, while a decrease in total n-6 was associated with lower externalizing behaviours. No other significant associations were found.

DISCUSSION

In this prospective study, increasing maternal AA and decreasing total n-6 were associated with improved social competence and externalizing behaviours, respectively, in 7-year old children. Nonetheless, the clinical significance of the identified associations is modest and further investigations are warranted to clarify the relationship between maternal AA and total n-6 during pregnancy and childhood social and behavioural development.

Individual characteristics of students with autism spectrum disorders and school refusal behavior

This study compared social, executive, emotional, and behavioral characteristics of students with autism spectrum disorder who did and did not display school refusal behavior. The participants were 62 students with autism spectrum disorder without intellectual disability aged 9-16 years attending inclusive schools. Parents first completed questionnaires assessing social and executive functioning as well as emotional and behavioral problems. They then documented their child's school refusal behavior for a period of 20 days. Compared to students without school refusal behavior (n = 29), students with school refusal behavior (n = 33) were significantly less socially motivated; displayed more deficits in initiating tasks or activities, in generating ideas, responses, or problem-solving strategies; and displayed more withdrawn and depressive symptoms. Assessing social and executive functioning, as well as emotional problems, may help professionals provide tailored interventions for students with autism spectrum disorder and school refusal behavior, which will further be valuable in recognizing characteristics associated with school refusal behavior.

Behavioral Risk Assessment From Newborn to Preschool: The Value of Older Siblings

OBJECTIVES

The aim of this study was to examine the plausibility of a risk prediction tool in infancy for school-entry emotional and behavioral problems. Familial aggregation has been operationalized previously as maternal psychopathology. The hypothesis was tested that older sibling (OS) psychopathology, as an indicator of familial aggregation, would enable a fair level of risk prediction compared with previous research, when combined with traditional risk factors.

METHODS

By using a longitudinal design, data on child and family risk factors were collected on 323 infants (M = 2.00 months), all of whom had OSs. Infants were followed up 4.5 years later when both parents provided ratings of emotional and behavioral problems. Multiple regression and receiver operating characteristic curve analyses were conducted for emotional, conduct, and attention problems separately.

RESULTS

The emotional and behavioral problems of OSs at infancy were the strongest predictors of the same problems in target children 4.5 years later. Other risk factors, including maternal depression and socioeconomic status provided extra, but weak, significant prediction. The area under the receiver operating characteristic curve for emotional and conduct problems yielded a fair prediction.

CONCLUSIONS

This study is the first to offer a fair degree of prediction from risk factors at birth to school-entry emotional and behavioral problems. This degree of prediction was achieved with the inclusion of the emotional and behavioral problems of OSs (thus limiting generalizability to children with OSs). The inclusion of OS psychopathology raises risk prediction to a fair level.

The gap between a mother seeking psychological help for her child and for a friend’s child

More children need psychological help than those who get it (‘‘service gap’’). Since parents are those who refer children for help, they are responsible for this gap. This study examined the difference between the reported willingness of schoolchildren’s mothers to seek help from a psychologist and from natural support systems for their own child and to refer another mother for such help. Participants were 321 mothers of 3rd- to 5th-grade children. Participants’ reported intentions to seek help for their own child or to refer another’s child were evaluated regarding a hypothetical externalisation or internalisation problem behaviour. Mothers were more willing to refer another’s child than their own for psychological help. Mothers of boys were more willing to refer their own or another’s child for psychological help than mothers of girls. Mothers tended to prefer natural support systems over professional help. Some relations were found between emotional responses and socialisation strategies, and help-seeking intentions.

Mental Health Service Use in Schools and Non-School-Based Outpatient Settings: Comparing Predictors of Service Use

Researchers have consistently documented a gap between the large number of US youth meeting criteria for a mental health disorder with significant associated impairment, and the comparatively few youth receiving services. School-based mental health care may address the need-services gap by offering services more equitably to youth in need, irrespective of family economic resources, availability of transportation, and other factors that can impede access to community clinics. However, diagnoses alone do not fully capture the severity of an individual's mental health status and need for services. Studying service use only in relation to diagnoses may restrict our understanding of the degree to which service use is reflective of service need, and inhibit our ability to compare school and non-school-based outpatient settings on their responsiveness to service need. The present study evaluated predictors of mental health service use in school- and community-based settings for youth who had had an active case in one of two public sectors of care, comparing empirically-derived dimensional measurements of youth mental health service need and impairment ratings against non-need variables (e.g., ethnicity, income). Three dimensions of youth mental health service need were identified. Mental health service need and non-need variables each played a significant predictive role. Parent-rated impairment was the strongest need-based predictor of service use across settings. The impact of non-need variables varied by service setting, with parental income having a particularly noticeable effect on school-based services. Across time, preceding service use and impairment each significantly predicted future service use.

Secure base representations in middle childhood across two Western cultures: Associations with parental attachment representations and maternal reports of behavior problems

Recent work examining the content and organization of attachment representations suggests that 1 way in which we represent the attachment relationship is in the form of a cognitive script. This work has largely focused on early childhood or adolescence/adulthood, leaving a large gap in our understanding of script-like attachment representations in the middle childhood period. We present 2 studies and provide 3 critical pieces of evidence regarding the presence of a script-like representation of the attachment relationship in middle childhood. We present evidence that a middle childhood attachment script assessment tapped a stable underlying script using samples drawn from 2 western cultures, the United States (Study 1) and Belgium (Study 2). We also found evidence suggestive of the intergenerational transmission of secure base script knowledge (Study 1) and relations between secure base script knowledge and symptoms of psychopathology in middle childhood (Study 2). The results from this investigation represent an important downward extension of the secure base script construct.

Does neighborhood social capital buffer the effects of maternal depression on adolescent behavior problems?

Neighborhood characteristics have been shown to impact child well-being. However, it remains unclear how these factors combine with family characteristics to influence child development. The current study helps develop that understanding by investigating how neighborhoods directly impact child and adolescent behavior problems as well as moderate the influence of family characteristics on behavior. Using multilevel linear models, we examined the relationship among neighborhood conditions (poverty and social capital) and maternal depression on child and adolescent behavior problems. The sample included 741 children, age 5–11, and 564 adolescents, age 12–17. Outcomes were internalizing (e.g. anxious/depressed) and externalizing (e.g. aggressive/hyperactive) behavior problems. Neighborhood poverty and maternal depression were both positively associated with behavior problems for children and adolescents. However, while neighborhood social capital was not directly associated with behavior problems, the interaction of social capital and maternal depression was significantly related to behavior problems for adolescents. This interaction showed that living in neighborhoods with higher levels of social capital attenuated the relationship between maternal depression and adolescent behavior problems and confirmed the expectation that raising healthy well-adjusted children depends not only on the family, but also the context in which the family lives.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour

BACKGROUND

Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems.

METHODS

Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008–2009 were linked to psychiatric case register data over the years 2010–2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems.

RESULTS

During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01–2.46).

CONCLUSIONS

Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

Contributions of attachment theory and research: a framework for future research, translation, and policy

Attachment theory has been generating creative and impactful research for almost half a century. In this article we focus on the documented antecedents and consequences of individual differences in infant attachment patterns, suggesting topics for further theoretical clarification, research, clinical interventions, and policy applications. We pay particular attention to the concept of cognitive "working models" and to neural and physiological mechanisms through which early attachment experiences contribute to later functioning. We consider adult caregiving behavior that predicts infant attachment patterns, and the still-mysterious "transmission gap" between parental Adult Attachment Interview classifications and infant Strange Situation classifications. We also review connections between attachment and (a) child psychopathology; (b) neurobiology; (c) health and immune function; (d) empathy, compassion, and altruism; (e) school readiness; and (f) culture. We conclude with clinical-translational and public policy applications of attachment research that could reduce the occurrence and maintenance of insecure attachment during infancy and beyond. Our goal is to inspire researchers to continue advancing the field by finding new ways to tackle long-standing questions and by generating and testing novel hypotheses.

Language and internalizing and externalizing behavioral adjustment: developmental pathways from childhood to adolescence

Two independent prospective longitudinal studies that cumulatively spanned the age interval from 4 years to 14 years used multiwave designs to investigate developmental associations between language and behavioral adjustment (internalizing and externalizing behavior problems). Altogether 224 children, their mothers, and teachers provided data. Series of nested path analysis models were used to determine the most parsimonious and plausible paths among the three constructs over and above stability in each across age and their covariation at each age. In both studies, children with poorer language skills in early childhood had more internalizing behavior problems in later childhood and in early adolescence. These developmental paths between language and behavioral adjustment held after taking into consideration children's nonverbal intellectual functioning, maternal verbal intelligence, education, parenting knowledge, and social desirability bias, as well as family socioeconomic status, and they applied equally to girls and boys.

Behavioral profiles of clinically referred children with intellectual giftedness

It is common that intellectually gifted children--that is, children with an IQ ≥ 130--are referred to paediatric or child neuropsychiatry clinics for socio-emotional problems and/or school underachievement or maladjustment. These clinically-referred children with intellectual giftedness are thought to typically display internalizing problems (i.e., self-focused problems reflecting overcontrol of emotion and behavior), and to be more behaviorally impaired when "highly" gifted (IQ ≥ 145) or displaying developmental asynchrony (i.e., a heterogeneous developmental pattern, reflected in a significant verbal-performance discrepancy on IQ tests). We tested all these assumptions in 143 clinically-referred gifted children aged 8 to 12, using Wechsler's intelligence profile and the Child Behavior Checklist. Compared to a normative sample, gifted children displayed increased behavioral problems in the whole symptomatic range. Internalizing problems did not predominate over externalizing ones (i.e., acted-out problems, reflecting undercontrol of emotion and behavior), revealing a symptomatic nature of behavioral syndromes more severe than expected. "Highly gifted" children did not display more behavioral problems than the "low gifted." Gifted children with a significant verbal-performance discrepancy displayed more externalizing problems and mixed behavioral syndromes than gifted children without such a discrepancy. These results suggest that developmental asynchrony matters when examining emotional and behavioral problems in gifted children.

Disparity of care for children with parent-reported autism spectrum disorders

OBJECTIVE

Although children with autism spectrum disorders (ASDs) are eligible to receive special education services via an individualized education program (IEP), approximately 12% to 20% do not. Our objective was to determine which clinical and demographic characteristics are associated with IEP receipt among a nationally representative sample of children with ASD.

METHODS

Using data from the 2007 National Survey of Children's Health, we determined which clinical and demographic covariates are associated with IEP receipt for children ages 6 to 17 years with a current, parent-reported ASD diagnosis (n = 759). Logistic regression models were used to assess the association of covariates with IEP receipt. Application of weighting techniques made the findings representative of the noninstitutionalized population of US children 6 to 17 years old.

RESULTS

In the weighted model, 90% of children with ASD receive an IEP. Maternal education level above high school (adjusted odds ratio [aOR] 4.08, P = .01) and presence of perceived need for coordination of care (aOR 3.62, P = .02) were associated with IEP receipt, while Hispanic children were less likely to receive an IEP compared with white children (aOR 0.12, P = .001). The following factors were not associated with IEP receipt: severity of ASD, speech, and behavior problems.

CONCLUSIONS

For children with ASD in the United States, socioeconomic factors, not disability severity, are associated with IEP receipt. Future research should address methods to overcome this disparity in care. Health care providers may help to advocate for appropriate educational services for patients with ASD.

Seeking professional help for mental health problems, among New Zealand secondary school students

OBJECTIVE

Our aim was to investigate whether secondary school students with mental health problems sought help from general practitioners and to investigate whether mental illness type, socio-demographic variables, family, school and community factors were associated with seeking help.

METHOD

A randomly selected sample of 9699 secondary school students from across New Zealand participated in the Youth2000 Health and Wellbeing Survey. Data analysis included uni-variate and regression analyses.

RESULTS

Having symptoms of anxiety (p<0.0001), depression (p<0.0001), and suicidal thoughts (p<0.0001) were associated with help seeking. However, 82%of students who had significant mental health problems had not sought help from a general practitioner. Rates of help seeking increased with age for girls and decreased with age for boys. Seeking help for mental health problems was also associated with living in a single parent family (p<0.0001), living in an over-crowded house (p=0.0006), and being well known by a teacher (p=0.0004).

CONCLUSIONS

The majority of New Zealand secondary school students with mental health problems do not obtain the help they need from general practitioners. Given the prevalence of mental health problems, it is important to find ways of identifying adolescents with difficulties and encouraging them to seek help.

Validation of the Pediatric Symptom Checklist in HIV-infected Batswana

OBJECTIVE: To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. METHOD: Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cut-off scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. RESULTS: The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and child-reported depression symptoms, a cut-off score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. CONCLUSIONS: The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction.

An accurate and efficient identification of children with psychosocial problems by means of computerized adaptive testing

Background

Questionnaires used by health services to identify children with psychosocial problems are often rather short. The psychometric properties of such short questionnaires are mostly less than needed for an accurate distinction between children with and without problems. We aimed to assess whether a short Computerized Adaptive Test (CAT) can overcome the weaknesses of short written questionnaires when identifying children with psychosocial problems.

Method

We used a Dutch national data set obtained from parents of children invited for a routine health examination by Preventive Child Healthcare with 205 items on behavioral and emotional problems (n = 2,041, response 84%). In a random subsample we determined which items met the requirements of an Item Response Theory (IRT) model to a sufficient degree. Using those items, item parameters necessary for a CAT were calculated and a cut-off point was defined. In the remaining subsample we determined the validity and efficiency of a Computerized Adaptive Test using simulation techniques, with current treatment status and a clinical score on the Total Problem Scale (TPS) of the Child Behavior Checklist as criteria.

Results

Out of 205 items available 190 sufficiently met the criteria of the underlying IRT model. For 90% of the children a score above or below cut-off point could be determined with 95% accuracy. The mean number of items needed to achieve this was 12. Sensitivity and specificity with the TPS as a criterion were 0.89 and 0.91, respectively.

Conclusion

An IRT-based CAT is a very promising option for the identification of psychosocial problems in children, as it can lead to an efficient, yet high-quality identification. The results of our simulation study need to be replicated in a real-life administration of this CAT.

Help Seeking Process among Children Attending Psychiatry Clinic in Tirana, Albania

OBJECTIVE

The goal of this study was to investigate all the potential routes to Child/Adolescent Psychiatry Clinic-University Hospital Center (CAPC-UHC) in Tirana. The article provides demographic data, as well as further information on the types and amounts of services children/adolescents received during the process of seeking help related to different diagnoses.

METHOD

The study was conducted in CAPC-UHC in Tirana, during September 2006-September 2007. Data were collected from 162 children and their parents using Strengths and Difficulties Questionnaire (SDQ) and Pathways Encounter Form. The sample consisted of 53.1% (86) males and 46.9% (76) females. The mean age was 9.5+4.4 years.

RESULTS

Out of the total number of cases that sought care to CAPC; 55, 6% were referred by parents themselves, while the rest were referred by others. There was a significant effect of gender to intervals from the onset of problem to the first career (F=10.803, p=0.001), as well as a significant effect of gender to total time intervals from the onset till the specialist of child mental health problem (F=6.742, p=0.01).

CONCLUSIONS

This is the first study investigating the help seeking process to psychiatric care in CAPC Tirana-Albania and may serve as a good start in generating evidence based on child/adolescent mental health service. Further multicentre studies will enhance the values of the findings, since the present study was performed in a single service, and in a setting lacking previous works with similar scope that could have served as references.

Social competence, externalizing, and internalizing behavioral adjustment from early childhood through early adolescence: developmental cascades

This study used a three-wave longitudinal design to investigate developmental cascades among social competence and externalizing and internalizing behavioral adjustment in a normative sample of 117 children seen at 4, 10, and 14 years. Children, mothers, and teachers provided data. A series of nested path analysis models was used to determine the most parsimonious and plausible cascades across the three constructs over and above their covariation at each age and stability across age. Children with lower social competence at age 4 years exhibited more externalizing and internalizing behaviors at age 10 years and more externalizing behaviors at age 14 years. Children with lower social competence at age 4 years also exhibited more internalizing behaviors at age 10 years and more internalizing behaviors at age 14 years. Children who exhibited more internalizing behaviors at age 4 years exhibited more internalizing behaviors at age 10 years and more externalizing behaviors at age 14 years. These cascades among social competence and behavioral adjustment obtained independent of child intelligence and maternal education and social desirability of responding.

Factors associated with service use among immigrants in the child welfare system

This study investigated child, caregiver, and caseworker factors associated with greater use of family support services by immigrant families in the U.S. child welfare system. Among child factors, higher levels of internalizing behavior problems (Odds Ratio (O.R.)=3.60), externalizing behavior problems (O.R.=2.62) and a history of neglect (O.R.=4.23) were associated with greater family support service use. Among caregiver factors, prior reports of maltreatment (O.R.=6.77), a serious mental health problem of the caregiver (O.R.=6.86), cognitive impairments (O.R.=10.46) in the primary caregiver, the primary caregivers' history of arrests (O.R.=6.47) and domestic violence (O.R.=2.87), were associated with heavy service use. Caseworkers' training on cultural issues (O.R.=61.35), their concerns over bureaucracy (O.R.=25.38) and concern over rules and regulations (O.R.=6.08) were also associated with greater service use among immigrant families. This research suggests that use of family support services may be determined not only by the family's demographic factors and risk level but also by caseworkers' training in cultural competence and their perception of organizational problems.

The nature and predictors of undercontrolled and internalizing problem trajectories across early childhood

Using growth curve modeling, trajectories of undercontrolled (oppositional, irritable, inattentive and overactive behaviors) and internalizing (worried, sad and fearful) problems from 18 months to 4.5 years were studied in a population based sample of 921 Norwegian children. At the population level, undercontrolled problems decreased and internalizing problems increased with increasing age. Child temperament and family factors present at 18 months predicted 43% of the stability and 20% of the linear changes in undercontrolled problems and 30% of the stability and 7% of the linear changes in internalizing problems. Persisting effects of child and family factors from 18 month were found on the two problem dimensions over and above the impact of changes in the same risk factors. Lower initial level of partner support and higher initial level of child emotionality predicted higher slope of undercontrolled problems and higher initial level of family stress predicted higher slope for internalizing problems. As expected, time to time change (t1 to t2 and t2 to t3) in risk factors predicted time to time change in problem scores as well. The study shows the significance of early emerging internalizing and undercontrolled problems, the need to consider their pathways separately from very young ages, lasting effects of early experiences, and the importance of a dynamic approach to the analysis of risk.

Children's and Adolescents' Use of Mental Health Care Is a Family Matter

This article discusses the influence of family structure on children's use of mental health services and explores whether a family's dependency on government assistance compensates for the effect of family income on children's use of services. Children in nontraditional families are at greater risk of using mental health services and have more mental health visits. Family participation in government subsidies programs offsets the influence of family income on the use of mental health services.

Continuity of behavioral and emotional problems from pre-school years to pre-adolescence in a developing country

BACKGROUND

All previous longitudinal community studies assessing the continuity of child behavioral/emotional problems were conducted in developed countries.

METHOD

Six hundred and one children randomly selected from a Brazilian birth cohort were evaluated for behavioral/emotional problems through mother interview at 4 and 12 years with the same standard procedure - Child Behavior Checklist (CBCL).

RESULTS

CBCL Total Problem score presented a medium stability (r = .42) with externalizing problems showing higher stability and more homotypic continuity than internalizing problems. Of the children presenting deviant scores at the age of 4, only 31% remained deviant at the age of 12 (p < .001). A deviant CBCL Total Problem score at 12 years old was predicted by Rule-Breaking Behavior [OR = 7.46, 95% CI 2.76-20.19] and Social Problems [OR = 3.56, 95% CI 1.36-9.30] scores at 4 years of age. Either Rule-Breaking or Aggressive Behavior - externalizing syndromes - were part of the predictors for the three broad-band CBCL scores and six out of the eight CBCL syndromes.

CONCLUSIONS

Behavioral/emotional problems in preschool children persist moderately up to pre-adolescence in a community sample. Externalizing problems at the age of 4 comprise the developmental history of most behavioral/emotional problems at pre-adolescence. Our findings concur with findings from developed countries and are quite similar for continuity, stability and predictability.

Predictors of Service Use for Mental Health Problems Among British Schoolchildren

BACKGROUND

  Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren.

METHOD

  A total of 2461 children aged 5-15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years.

RESULTS

  Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents' and teachers' perceptions that the child had significant difficulties. Other predictors were specific to each service.

CONCLUSIONS

  Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.

The child behavior checklist broad-band scales predict subsequent psychopathology: A 5-year follow-up

OBJECTIVE

To evaluate the utility of the Child Behavior Check list (CBCL) for identifying children of parents with panic disorder or major depression at high-risk for future psychopathology.

METHODS

Baseline Internalizing and Externalizing CBCL T-scores were used to predict subsequent depressive, anxiety, and disruptive behavior disorders at a 5-year follow-up in children of parents with panic disorder, major depression, or neither disorder.

RESULTS

The Internalizing scale predicted subsequent agoraphobia, generalized anxiety disorder, separation anxiety disorder, and social phobia. In contrast, the Externalizing scale predicted subsequent disruptive behavior disorders and major depression.

CONCLUSIONS

The convergence of these results with previous findings based on structured diagnostic interviews suggests that the CBCL broad-band scales can inexpensively and efficiently help identify children at high risk for future psychopathology within a population of children already at risk by virtue of parental psychopathology.

Factors associated with mental health service utilization among bipolar youth

OBJECTIVES

This study aims to characterize patterns of mental health service utilization within a sample of bipolar youth. Demographic variables, youth bipolar characteristics, youth comorbid conditions, and parental psychopathology were examined as predictors of treatment utilization across different levels of care.

METHODS

A total of 293 bipolar youth (aged 7-17 years) and their parents completed a diagnostic interview, family psychiatric history measures, and an assessment of mental health service utilization. Demographic and clinical variables were measured at baseline and mental health service use was measured at the six-month follow-up.

RESULTS

Approximately 80% of bipolar youth attended psychosocial treatment services over the span of 6 months. Of those who attended treatment, 67% attended only outpatient services, 22% received inpatient/partial hospitalization, and 12% received residential/therapeutic school-based services. Using multinomial logistic regression, older age, female gender, and bipolar characteristics, including greater symptom severity and rapid cycling, were found to predict higher levels of care. Youth suicidal and non-suicidal self-injurious behavior, comorbid conduct disorder, and parental substance use disorders also predicted use of more restrictive treatment settings.

CONCLUSIONS

Results underscore the importance of assessing for and addressing suicidality, comorbid conduct disorder, and parental substance use disorders early in the treatment of bipolar youth to potentially reduce the need for more restrictive levels of care.

Parent-teacher disagreement regarding behavioral and emotional problems in referred children is not a risk factor for poor outcome

OBJECTIVE

To investigate whether parent-teacher disagreement regarding the presence of psychopathology predicts poor outcome in children who have been referred to mental health services

METHODS

A total of 532 6- to 12-year-old children who had been referred to an outpatient department for child and adolescent psychiatry were followed up across an average period of 6.3 years. At initial assessment, standardized parent and teacher ratings of the child's psychopathology were obtained with the Child Behavior Checklist (CBCL) and Teacher's Report form (TRF). At follow-up, indices of poor outcome were assessed.

RESULTS

Several CBCL and TRF scale scores predicted poor outcome. Discrepancies between CBCL and TRF scores were not useful as additional predictors. Some additive effects were found; future police/judicial contacts and disciplinary problems in school were predicted by CBCL and TRF scores.

CONCLUSIONS

The findings underscored the need for information from different informants in clinical practice. However, discrepancies between parent and teacher ratings do not predict outcome, and should not alert clinicians.

Relationship between DHA status at birth and child problem behaviour at 7 years of age

Animal studies have demonstrated behavioural effects of long-chain polyunsaturated fatty acid (LC-PUFA) deficiencies and in humans, several psychiatric disorders have been linked to abnormal essential fatty acid metabolism. The aim of this study was to examine the relationship between LC-PUFA status at birth and the later development of problem behaviour. In a sample of 393 children, higher levels of docosahexaenoic acid (DHA) at birth were associated with lower levels of internalising problem behaviour at age 7 years. The association was markedly present in the infants fed with artificial formula (n=215, Beta=-0.32, P=0.000), but absent in the infants fed with human milk (n=170, Beta=0.11, P=0.325). The associations between arachidonic acid and internalising or externalising behaviour were neither large nor significant. The results suggest that perinatal DHA status may have long-term behavioural consequences. Therefore, we suggest to include measures of problem behaviour in future trials of LC-PUFA supplementation of mothers and/or infants.

Annotation: Pathways to care for children with mental health problems

BACKGROUND

Although many children with mental health problems are in contact with primary health care services, few receive appropriate help.

METHODS

Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services.

RESULTS

Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services.

CONCLUSIONS

As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.

The combination of shared family environment and individual-specific developmental deviance as a cause for treated psychiatric morbidity in children

OBJECTIVE

There is an incomplete understanding of why some children growing up in the same family are in need of treatment for psychiatric morbidity whilst their siblings are not. The present paper examined the possible role of individual-specific developmental risk factors.

METHOD

Three case-control analyses were conducted: i) 80 children referred to the Community Mental Health Centre (cases) and 320 population controls, ii) 68 healthy siblings of cases and 272 population controls, and iii) 80 children and 68 healthy siblings. Measures of development and psychosocial circumstances were obtained from routine, longitudinal, standardized child medical records.

RESULTS

Given shared family environments, additional presence of delays in speech and motor development contributed most to differential sibling mental health outcomes. In addition, cases displayed both earlier expression and more severe levels of developmental behavioural deviance than their healthy siblings, who in turn had higher levels of behavioural deviance than population controls.

CONCLUSION

In siblings sharing a familial risk environment, development of psychiatric morbidity may be canalized through additional individual-specific developmental exposures.

State child mental health efforts to support youth in transition to adulthood

The ability of state child mental health (MH) systems to facilitate the transition to adulthood of adolescents in their systems was studied by interviewing members of the Children, Youth and Families Division of the National Association of State Mental Health Program Directors (NASMHPD). Results demonstrated that transition services within the state child MH systems are sparse, nationally. Continuity of services as youth age into adulthood is hampered because of generally separate child and adult MH systems, each with separate policies defining who accesses those services, lack of clarity about procedures to access adult MH services, and lack of shared client planning between adult and child MH systems. These findings suggest that adolescents in state child MH systems have difficulty accessing services that will help them with the difficult task of learning to function as an adult. Public MH systems should examine their capacity to provide transition supports and make needed improvements.

The role of parental burden in child mental health service use: longitudinal study

OBJECTIVE

To examine the relative contributions of symptom severity, functional impairment, and parental burden in predicting the use of specialist child mental health services over a 4-year period.

METHOD

Between 1999 and 2000, parental Strengths and Difficulties Questionnaires were completed on a community-based sample of 1,168 (40% response rate) 5- to 11-year-olds in the United Kingdom. Using a prospective longitudinal design, these data were related to subsequent referral records (until 2003). Children who were and were not referred to specialist mental health services were compared. Changes in the association between predictor variables (symptoms, impairment, and burden) and referral over time were also examined.

RESULTS

Over 4 years, 5.1% of children were referred. After controlling for all other predictors, only severity of symptoms predicted future referrals (for each 1-point increase on the total symptoms score, odds ratio 1.15; 95% confidence interval=1.09-1.21). Burden was only associated with referrals made during the first year, whereas conduct and emotional problems predicted subsequent referrals.

CONCLUSIONS

In contrast to cross-sectional studies that have highlighted the roles of functional impairment and parental burden in predicting specialist service use, this longitudinal study indicates that symptom severity best predicts future referrals. For children with mental health problems, there is considerable delay in accessing specialist services.

Predictors of outpatient mental health service use--the role of foster care placement change

This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health.

Outpatient mental health services for children in foster care: a national perspective

OBJECTIVE

To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States.

METHOD

As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use.

RESULTS

Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children.

CONCLUSIONS

This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.

Mental health services use among school-aged children with disabilities: the role of sociodemographics, functional limitations, family burdens, and care coordination

OBJECTIVE

To examine the use of mental health services and correlates of receiving services among community-dwelling children with disabilities, ages 6 to 17 years.

STUDY DESIGN

Data are from the 1994 and 1995 National Health Interview Survey Disability Supplements (NHIS-D), conducted by the National Center for Health Statistics. The study sample is 4,939 children with disabilities, representing an estimated eight million children with disabilities nationwide. Parents of children under 16 years of age reported (17-year-olds self-reported) on health, emotional and behavioral problems, mental health services use, and who, if anyone, coordinated the child's health care.

PRINCIPAL FINDINGS

Among disabled children with poor psychosocial adjustment (11.5 percent), only 11.8 percent received mental health services in the past year. Multivariate logistic regression analysis showed service use was associated with poor psychosocial adjustment; communication, social, and learning-related functional impairments; public health insurance; and financial family burdens. Younger and black disabled children were less likely to receive mental health services. The odds of service use were greater with the involvement of a health professional in coordinating care, in contrast to no one or family only. Moreover, children with disabilities were more likely to use outpatient mental health services if their care was jointly coordinated by a family member and a health professional, compared to a health professional working alone. In contrast to inpatient and outpatient care, race and family burden were not associated with the likelihood of mental health counseling in special education school settings.

CONCLUSIONS

Findings indicate that only two in five disabled children with poor psychosocial adjustment receive mental health services. Differences by age, race, and insurance coverage suggest that inequalities to access exist. However, the school setting may be one in which some barriers to mental health services for disabled children are reduced. The study also shows that the involvement of health professionals in care coordination is associated with greater access to mental health care for disabled children. These findings underscore the importance of engaging both health care professionals and the family in the care process.

DSM-IV disorders in children with borderline to moderate intellectual disability. I: prevalence and impact

OBJECTIVE

To assess the prevalence, comorbidity, and impact of DSM-IV disorders in 7- to 20-year-olds with intellectual disability.

METHOD

A total of 474 children (response 86.8%) were randomly selected from a sample of students from Dutch schools for the intellectually disabled. Parents completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children.

RESULTS

A total of 21.9% of the children met the DSM-IV symptom criteria for anxiety disorder, 4.4% for mood disorder, and 25.1% for disruptive disorder. Similar prevalence rates were found for children who screened positive or negative for pervasive developmental disorder. More than half of the children meeting the criteria for a DSM-IV disorder were severely impaired in everyday functioning, and about 37% had a comorbid disorder. Children with multiple disorders were more likely to be impaired across various areas of everyday functioning. Almost 27% of the diagnosed children received mental health care in the last year. Comorbidity and impairment in everyday functioning increased the likelihood of referral.

CONCLUSIONS

Most disorders can be observed in intellectually disabled children. Impairment and comorbidity are high. The finding that less than one third of the children with a psychiatric disorder receive mental health care deserves attention.

Family predictors of antisocial behavior in adolescence

The goal of the present study was to examine the combined and unique ability of different aspects of family functioning to predict involvement in antisocial behavior in a large nonclinical (community) sample of adolescents. Distinction was made between global (e.g., family socioeconomic status), distal (dispositional characteristics of parents), contextual (family characteristics), and proximal (parent-child interaction) factors that operate within families. Results show that proximal factors were significant predictors of antisocial behavior, independent of their shared variance with other factors. Consistent with the hypothesized mediational model, the effects of distal and contextual factors appear to be mostly indirect: after their association with proximal factors was taken into account, these factors were no longer significantly related to antisocial behavior. The implications of these findings for planning of developmentally appropriate interventions for adolescents and their families are discussed.

Risk behaviors in maltreated youth placed in foster care: a longitudinal study of protective and vulnerability factors

OBJECTIVE

Few studies have examined the impact of placement in foster care prospectively to determine what early responses might predict later functioning. The current study examined protective and vulnerability factors in a longitudinal study of youth placed in foster care.

METHODOLOGY

A cohort of 214 ethnically-diverse youth, ages 7-12, who entered foster care between May 1990 and October 1991 were recruited for the Time 1 study if they remained in foster care for at least 5 months. For the Time 1 study, youth and their caregivers were interviewed and assessed approximately 6 months following their initial placement. Six years later, as adolescents, the youth were re-interviewed regarding their involvement in four domains of risk behavior.

RESULTS

Bivariate analyses indicated that several Time 1 control variables (e.g., age, ethnicity, type of maltreatment, behavior problems) and Time 1 psychosocial predictor variables (i.e., dimensions of social support and self-perception) were related to the Time 2 risk behavior outcomes. Regression analyses with all variables accounted for between 33 and 46% of the variance, with the psychosocial predictor variables, as a group, significant over and above the control variables.

CONCLUSIONS

The results suggest that there are some modifiable protective and vulnerability factors present shortly after maltreated youth are placed in foster care that predict their engagement in adolescent risk behaviors 6 years later.

Neurologic outcome of choreoathetoid encephalopathy after cardiac surgery

Postoperative encephalopathy with choreoathetosis is a serious neurologic complication of childhood cardiac surgery. An inadequate understanding of the long-term outcome has limited family counseling and the institution of intervention strategies. Our objective was to define the long-term neurologic, cognitive, and behavioral outcome in this group of patients. By retrospective review we identified all cases of choreoathetosis in our cardiac intensive care unit from 1986 through 1995. During this decade we described a sudden transient increase in postoperative choreoathetosis that disappeared as we modified treatment strategies in perioperative care. These children underwent a comprehensive battery of neurologic, cognitive, and behavioral tests to determine in detail their long-term outcome. Of the 36 cases identified of which three were deceased, four were abroad, and eight were lost to follow-up, 21 families were approached, and 15 of the 21 (71%) consented to testing. We found pervasive deficits in memory, attention, and language, with a median full-scale IQ of 67 (range = 40-122), as well as in motor function, including persistent dyskinesia in seven of 15 (47%). The pervasive and enduring cognitive and motor deficits in survivors of postoperative choreoathetosis caution for guarded predictions of outcome and highlight the need for careful neurologic and cognitive evaluation in all children with choreoathetosis after open heart surgery.

Cultural and contextual influences in mental health help seeking: a focus on ethnic minority youth

In this article, a mental health help-seeking model is offered as a framework for understanding cultural and contextual factors that affect ethnic minority adolescents' pathways into mental health services. The effects of culture and context are profound across the entire help-seeking pathway, from problem identification to choice of treatment providers. The authors argue that an understanding of these help-seeking pathways provides insights into ethnic group differences in mental health care utilization and that further research in this area is needed.

Use of the pediatric symptom checklist in strategies to improve preventive behavioral health care

OBJECTIVE

The purpose of this study was to examine the utility of the Pediatric Symptom Checklist (PSC) in identifying youth at risk of behavioral health problems and to develop strategies to meet their mental health needs.

METHODS

The PSC was completed by the parents of 570 children aged two to 18 years at three urban health centers in Massachusetts. Follow-up interviews were conducted with the parents of 95 of the children. Multidisciplinary teams held case conferences to review the cases of 43 of the 95 children who were interviewed and who were determined to have moderate to severe behavioral health problems.

RESULTS

Of the 570 children in the screening sample, 144 (25 percent) had moderate to severe behavioral health problems, as indicated by a positive score on the PSC, and 2 percent had a serious emotional disturbance. Of the 297 pre-school-aged children (younger than six years), 67 (23 percent) received a positive score. Of the 283 school-aged children (age six and older) from both English- and Spanish-speaking families, 77 (27 percent) received a positive score. About one-third of the severely emotionally disturbed youth were receiving some mental health treatment, but only 20 percent were rated by the multidisciplinary team as receiving adequate treatment.

CONCLUSIONS

The study provided further support for the validity and reliability of the PSC and confirmed the results of earlier studies that found a high level of unmet needs for mental health services among this population. Use of the PSC in this study promoted an increase in referrals for children in need.

Utility of psychosocial screening at a school-based health center

School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents' mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.

Help-seeking steps and service use for children in foster care

This study describes help-seeking steps and service-use patterns for school-age children in foster care. It also examines how these access indices are moderated by sociodemographic, enabling, and child disorder factors. Two home interviews and a telephone teacher interview were conducted using a sample of 302 randomly selected children (age 6-12 years) in foster care. The majority of children (80%) were given a psychiatric diagnosis, and 43% of the foster parents perceived a need for mental health services for the child. In the past year, about one-half of the children had received mental health (51%) and special education services (52%). Age and ethnicity, foster parent education, placement history, level of monthly benefits, number of caseworker visits, and disorder characteristics were related to help-seeking steps and mental health service use. Strategies to improve access to mental health services for children in foster care should include interventions at the caregiver and system levels.

Children in foster care: factors influencing outpatient mental health service use

OBJECTIVE

To determine factors influencing outpatient mental health service use by children in foster care.

METHOD

Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL).

RESULTS

Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60.

CONCLUSIONS

Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.