NADD Bulletin Volume X Number 3 Article 1

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Psychopathology in Children and Adolescents with Intellectual Disability: Is Prevention/Amelioration Possible?

Ann R. Poindexter, M.D., F.A.A.P.

Mental illness contributes a substantial burden of disease worldwide, with about 450 million people having mental disorders. At least one fourth of the world’s population will develop a mental or behavioral disorder at some point during their lives. Mental disorders account for about 25% of disability in North America and western Europe. An estimated one in ten children in the U.S. has a mental disorder that causes some level of impairment, and the effects of mental illness are evident across the life span, among all ethnic, racial, and cultural groups, as well as among people of every socioeconomic level. Mental illness costs the U.S. an estimated $150 billion dollars every year, excluding the costs of research (Centers for Disease Control and Prevention [CDC], 2005a).

The needs of children with emotional, behavioral, and developmental problems are a national concern in the United States. In order to assess the health care and well-being of these children with problems serious enough to require treatment or counseling, researchers from Oregon Health and Science University and the CDC analyzed parent reported data from a 2001 national survey. They found that children with chronic emotional, behavioral, and developmental problems, when compared with children with other special health care needs, were more likely to have diminished health and quality of life and to have problems accessing and receiving needed care (CDC, 2005b). Not surprisingly, children from families of lower socioeconomic status have  disproportionately higher rates of unmet needs (Ganz & Tendulkar, 2006).

A research group in Finland studied the rate of and factors associated with recognition of psychiatric disorders and self-perceived problems among 2,347 18-year-old boys (Sourander et al., 2005). The group was assessed at age eight by parents and teachers on Rutter scales, and self-reports using the Child Depression Inventory. At military call-up 10 years later, the boys filled in the Young Adult Self-Report, and information about recognized psychiatric disorders was obtained from the national military register. About 4.6% of boys were recognized as having a psychiatric disorder at the military call-up medical exam, and 23.1% of boys reported emotional, behavioral, or relational difficulties but not to the degree that a diagnosis could be made. All informant sources, parents, teachers, and the children themselves at age eight, independently predicted recognition of psychiatric disorders and perceived difficulties 10 years later (Sourander et al., 2005).

In a study of community-dwelling children with disabilities, Witt, Kasper, and Riley (2003) examined the use of mental health services and correlates of receiving services. The study sample included 4,939 children with disabilities, ages 6 to 17 years, representing an estimated eight million children with disabilities nationwide. Parents of these children reported on the health, emotional and behavioral problems; mental health services use; and who, if anyone, coordinated the child’s health care. Among the 11.5% of disabled children with poor psychosocial adjustment, only 11.8% of these children had received mental health services in the previous year. Younger children and African American children with disabilities 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 those with no one or family only. Services were even more apt to be used if care was jointly coordinated by a family member and a health professional. While inequalities to access of mental health services do exist, the school setting may be one in which some barriers to mental health services for disabled children are reduced.

This is particularly troubling in view of the high cost of mental health disorders, both personally and fiscally, since recent research indicates that mental health disorders are generally not of single-factor origin—both “nature and nurture” are involved. Pennington (2002) points out that all DSM-IV-TR (American Psychiatric Association, 2000) diagnoses are described in behavioral terms, and that the etiology of all behaviorally-defined disorders includes both genetic and environmental influences. While the genetic influences probably cannot be controlled, environmental influences, when discovered, may be addressed to improve outcomes, either to prevent disorders or improve eventual outcomes of disorders. Also, early recognition and treatment may be particularly beneficial, since every year of development without illness allows time for the child to develop ego skills to deal with his/her inherited risk factors (Wamboldt & Reiss, 2006).

Genetic-environmental interaction in the genesis of aggressive and conduct disorders was studied by Cadoret and colleagues (1995). The authors studied an adoption group in which children who were separated at birth from their biological parents with documented antisocial personality disorder and/or alcohol abuse or dependence were followed up as adults. The control group was made up of adoptees whose biological background was negative for documented psychopathologic behavior. The group included 95 males and 102 females and their adoptive parents. Multiple regression analysis showed a biologic background of antisocial personality disorder predicted increased adolescent aggressivity, conduct disorder, and adult antisocial behaviors. An adverse adoptive home environment (defined as adoptive parents who had marital problems, were divorced, were separated, and/or had anxiety conditions, depression, substance abuse and/or dependence, or legal problems) independently predicted increased adult antisocial behaviors. Adverse adoptive home environment interacted with biologic background of antisocial personality disorder to result in significantly increased aggressivity and conduct disorder in the presence of but not in the absence of a biological background of antisocial personality disorder.

Many women with depression have a history of antisocial behavior, but research into maternal depression in the past did not ascertain if this had implications for their children. Kim-Cohen, Caspi, Rutter, Tomas, and Moffitt (2006) in the Environmental Risk Longitudinal Twin Study looked at a nationally representative group of 1,106 families in which mothers were administered the Diagnostic Interview Schedule for Major Depressive Disorder and interviewed about their lifetime history of antisocial personality disorder symptoms. Mothers and teachers provided information regarding the children’s behavior problems at five and seven years of age, and the authors assessed the quality of the caregiving environment through maternal reports and interviewer observations. They found that, when compared with children of mothers with depression only, the children of depressed and antisocial mothers had significantly higher levels of antisocial behavior and rates of DSM-IV conduct disorder, even after control for numbers of symptoms and chronicity of maternal major depressive disorder. The children of depressed and antisocial mothers were at an elevated risk of experiencing multiple caregiving abuses, including physical maltreatment, high levels of maternal hostility, and exposure to domestic violence.

For many years, childhood maltreatment has been known to be an important psychiatric risk factor, said to be the single most important contributor to later psychiatric morbidity and mortality (Walsh, 2006), but earlier research has focused primarily on the effects of physical abuse, sexual abuse, or witnessing domestic violence. Teicher and colleagues (2006) developed a study designed to define the impact of parental verbal aggression, witnessing domestic violence, physical abuse, and sexual abuse, by themselves and in combination, on psychiatric symptoms. Verbal aggression was found to be associated with moderate to large effects, comparable to those associated with witnessing domestic violence or nonfamilial sexual abuse, and larger than those associated with familial physical abuse. Exposure to multiple forms of maltreatment had an effect size that was often greater than the component sum. Combined exposure to verbal abuse and witnessing domestic violence had a greater negative effect on some measures than exposure to familial sexual abuse.

Resilience in children is especially important to help them overcome adversity—and this seems to be another factor associated with both nature (genetics) and nurture (Hampton, 2006). A new resource published by the American Academy of Pediatrics, A parent’s guide to building resilience in children and teens: Giving your child roots and wings (Ginsburg, 2006), appears to show great promise in helping both families and professionals assist children in this area.

Assessment methodology currently exists to routinely screen very young children for social-emotional and behavior problems as well as for delays in the acquisition of competencies, to be used in primary health care settings as well as in early intervention programs. Unfortunately, despite the likely long-term benefits and cost-saving potential of early identification and intervention services, short-term cost and knowledge barriers currently limit widespread implementation (Carter, Briggs-Gowan, & Davis, 2004). The National Center for Education in Maternal and Child Health of Georgetown University published a practice guide and tool kit in 2002 (Jellinek, Patel, & Froehle, a & b), both of which contain a wealth of information for clinicians and materials for families and others dealing with children with mental health problems. These are quite applicable to children with developmental disabilities, but unfortunately this group may be automatically “screened out” by clinicians when initial tests show developmental disabilities/delays.

While routine assessment for psychopathology is not widespread, a number of interesting pilot programs have been reported in recent years. Researchers in Australia developed an early intervention program aimed at preventing the development of anxiety in preschool children (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005). Children were chosen if they exhibited a high number of withdrawn/inhibited behaviors, one of the best-identified risk factors for later anxiety disorders, and were randomly assigned to either a six-session parent-education program or no intervention. While there were no significant effects demonstrated on measures of inhibition/withdrawal, children whose parents were allocated to the education condition showed a significantly greater decrease in anxiety diagnoses 12 months later relative to those whose parents received no intervention. The authors felt that their results demonstrate the value of even brief, very early intervention for anxiety disorders even though temperament does not seem to be altered.

Since depression in parents is common and children of depressed parents are at risk for psychopathology and other difficulties, Beardslee, Gladstone, Wright, and Cooper (2003) studied a family-based approach to the prevention of depressive symptoms in these children. They adopted a developmental perspective and intervened with families when children were entering adolescence, the age of highest risk for depression onset. They sought to reduce risk factors and enhance protective factors by increasing positive interactions between parents and children, and by increasing understanding of the illness for everyone in the family. They enrolled families with relatively healthy children, administered carefully designed preventive interventions that are manual-based and relatively brief, and found that the programs had long-standing positive effects in how families problem solve around parental illness.

Children who have experienced an accidental injury are at increased risk of developing post-traumatic stress disorder. A self-reporting instrument, the Child Trauma Screening Questionnaire, seems to be a quick, cost-effective, and valid screening tool that can be readily incorporated in a hospital setting to assist in preventing this disorder (Kenardy, Spence, & Macleod, 2006).

Many southeast Asian refugee children have experienced a great deal of violence before coming to the United States, and have high rates of depression and/or post-traumatic stress disorder. Fox, Rossetti, Burns, and Popovich (2005) provided an eight-week school-based program designed to reduce depression symptoms of these refugee children. All the children were screened for depression using the Children’s Depression Inventory. Analysis of data revealed that children’s depression scores had a significant decrease between screening times 1 (about one month before the intervention) and 2 (fourth week of the intervention), 1 and 3 (eighth week of the intervention) and 1 and 4 (one month following the intervention. The authors felt that culturally sensitive mental health school-based programs may be an appropriate intervention to assist immigrant and refugee children to successfully adapt to host countries.

Two to five of every 10,000 individuals have autistic disorder, but as many as 23 of every 10,000 people have conditions that may fall within the autistic-pervasive developmental disorder spectrum (Jellinek et al., 2002a). Early identification and intensive early intervention during early childhood result in improved outcomes for most children with pervasive developmental disorders (PDDs) (Jellinek et al., 2002a). Cox and colleagues (1999) studied the association between, and stability of, clinical diagnosis and diagnosis derived from the Autism Diagnostic Interview-Revised (ADI-R) in a sample of prospectively identified children with childhood autism and other pervasive developmental disorders assessed at the age of 20 months and 42 months. A clinical diagnosis of autism was stable, with all children diagnosed at 20 months receiving a diagnosis of autism or PDD at 42 months. Clinical diagnosis for PDD and Asperger syndrome lacked sensitivity at 20 months, with several children who subsequently received these diagnoses at 42 months receiving diagnoses of language disorder or general developmental delay. Two children were considered clinically normal at the early time point.  The ADI-R was found to have good specificity but poor sensitivity at detecting autism at 20 months, but the stability of diagnosis from 20 to 42 months was good. The ADI-R at age 20 months was not sensitive to the detection of related PDDs or Asperger syndrome.

McConachie, Randle, Hammal, and LeCouteur (2005) evaluated a training course for parents designed to help them understand autism spectrum disorder and to facilitate social communication with their young child. Parents received either immediate intervention or delayed access to the course. Fifty-one children aged 24 to 48 months were involved. Outcome was measured seven months after beginning of the study in parents’ use of facilitative strategies, stress adaptation to the child, children’s vocabulary size, behavior problems, and social skills. The training course was well received by parents and had a measurable positive effect on both parents’ and children’s communication skills.

Very recent (Evans, 2006) growing evidence suggest that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, with applied behavior analysis. Final results from a number of studies in this area are not yet in, but certainly this appears to be a hopeful approach.

Although all psychopathologies have high social costs, those associated with conduct disorder (CD) are exceptionally important, because CD, by definition, involves harm to others. Prevalence depends on the definition utilized and the population studied (Pennington, 2002). Several disorders in parents increase the risk for CD in their children, including antisocial personality disorder (especially in fathers), alcohol dependence, schizophrenia, and depression (especially in mothers) (American Psychiatric Association, 2000). Within the family, both abuse and harsh parenting increase the risk for CD in children. Coercive and inconsistent parenting can start a vicious circle that potentiates the development of CD behaviors in children. Harsh and coercive discipline serves to teach that child that coercion is an acceptable means for reaching goals, and that regard for another’s feelings is not particularly important (Pennington, 2002). Treatment for CD is focused on psychosocial interventions started very early, especially preventive interventions, since no medication has documented efficacy in treatment of the condition.

Future research in these conditions appears very exciting. With new, specific, genetic studies, and new, specific preventive measures as well as new treatments after diagnoses have been made on the horizon. We must remember, however, that, unfortunately, there is no “magic bullet”. These conditions are complex in etiology and treatment.  Hopefully we will not need to wait until serious symptoms develop before we have multi-faceted programs to offer children, their families, and all of us who work with them.

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.

Beardslee, W. R., Gladstone, T. R., Wright, E. J., & Cooper, A. B. (2003). A family-based approach to the prevention of depressive symptoms in children at Risk: Evidence of parental and child change. Pediatrics, 112, 119-131.

Cadoret, R. J., Yates, W. R., Troughton, E., Woodworth, G., & Stewart, M. A. (1995). Genetic-environmental interaction in the genesis of aggressivity and conduct disorders. Archives of General Psychiatry, 52, 916-924.

Carter, A. S., Briggs-Gowan, M. J., & Davis, N. O. (2004). Assessment of young children’s social-emotional development and psychopathology: Recent advances and recommendations for practice. Journal of Child Psychology and Psychiatry, 45, 109-134.

Centers for Disease Control & Prevention. (2005a). The role of public health in mental health promotion. Morbidity & Mortality Weekly Report, 54, 841-842.

Centers for Disease Control & Prevention. (2005b). Mental health in the United States: Health care and well being of children with chronic emotional, behavioral, or developmental problems—United States, 2001. Morbidity & Mortality Weekly Report, 54, 985-989.

Cox, A., Klein, K., Charman, T., Baird, G., Baron-Cohen, S., & Swettenham, J. (1999). Autism spectrum disorders at 20 and 42 months of age: Stability of clinical and ADI-R diagnosis. Journal of Child Psychology & Psychiatry, 40, 719-732.

Evans, J. (2006, May 15). Some do recover from autistic spectrum disorder. Family Practice News, p. 41.

Fox, P. G., Rossetti, J., Burns, K. R., & Popovich, J. (2005). Southeast Asian refugee children: A school-based mental health intervention. International Journal of Psychiatric Nursing Research, 11, 1227-1236.

Ganz, M. L. & Tendulkar, S. A. (2006). Mental health care services for children with special health care needs and their family members: Prevalence and correlates of unmet needs. Pediatrics, 117, 2138-2148.

Ginsburg, K. R. (2006). A parent’s guide to building resilience in children and teens: Giving your child roots and wings. Chicago, IL: American Academy of Pediatrics.

Hampton, T. (2006). Researchers seek roots of resilience in children. Journal of the American Medical Association, 295, 1756-1760.

Jellinek, M., Patel, B. P., & Froehle, M. C. (Eds.). (2002a). Bright futures in practice: Mental health (Vol. I). Arlington, VA: National Center for Education in Maternal & Child Health.

Jellinek, M., Patel, B. P., & Froehle, M. C. (Eds.). (2002b). Bright futures in practice: Mental health (Vol. II). Arlington, VA: National Center for Education in Maternal & Child Health.

Kenardy, J. A., Spence, S. H., & Macleod, A. C. (2006). Screening for posttraumatic stress disorder in children after accidental injury. Pediatrics, 118, 1002-1009.

Kim-Cohen, J., Caspi, A., Rutter, M., Tomas, M. P., & Moffitt, T. E. (2006). The caregiving environments provided to children by depressed mothers with or without an antisocial history. American Journal of Psychiatry, 163, 1009-1018.

McConachie, H., Randle, V., Hammal, D., & LeCouteur, A. (2005). A controlled trial of a training course for parents of children with suspected autism spectrum disorder. Journal of Pediatrics, 147, 283-284.

Pennington, B. F. (2002). The development of psychopathology: Nature and nurture. New York: Guilford Press.

Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting & Clinical Psychology, 73, 488-497.

Sourander, A., Haavisto, A. Ronning, J. A., Multimaki, P., Parkkola, K., & Santalahti, P. (2005). Recognition of psychiatric disorders, and self-perceived problems: A follow-up study from age 8 to age 18. Journal of Child Psychology & Psychiatry, 46, 1124-1134.

Teicher, M. H., Simson, J. A., Polcari, A., & McGreenery, C. E. (2006). Sticks, stones, and hurtful words: Relative effects of various forms of childhood maltreatment. American Journal of Psychiatry, 163, 993-2000.

Walsh, N. (2006, Nov. 15). Early trauma tied to adult mental, physical health. Family Practice News, p.34.

Wamboldt, M. Z. & Reiss, D. (2006). Editorial: Explorations of parenting environments in the evolution of psychiatric problems in children. American Journal of Psychiatry, 163, 951-953.

Witt, W. P., Kasper, J. D., & Riley, A. W. (2003). Mental health services use among school-aged children with disabilities: The role of sociodemographics, functional limitations, family burdens, and care coordination. Health Services Research, 38, 1441-1466.