The development and adjustment of 7-year-old children adopted in infancy

The present study (N = 159) provides evidence of an increased risk for behavior problems of infant-placed 7-year-old internationally, transracially adopted children in the Netherlands. However, parents reported more behavior problems for adopted boys than for adopted girls. Notably, about 30% of the adopted children were classified as clinical on the CBCL scale for total problems, which is a much larger percentage than the 10% found in the normative population. It was suggested that these results could be explained by the operation of multiple risk factors before and after adoption placement, e.g. the child's genetic disposition, pre-natal and pre-adoption care, or the child's cognitive understanding of adoption in middle childhood. Also, results suggest that maternal sensitive responsiveness in adoptive families declines in the transition from early to middle childhood. In contrast to the home setting, the adopted children showed favorable behavioral and socioemotional adjustment at school, while their academic achievement and intelligence were in the normal range or above average. In particular Korean children had high IQs: 31% of these children obtained an intelligence score above 120. It was suggested that adoptive parents seem to offer their children sufficient or even more than average cognitive stimulation. Furthermore, adopted girls scored higher in optimal ego-control, social competence, and peer group popularity than nonadopted girls from the general population: 30% of the adopted girls were rated as popular by their classmates, which compares favorably to the 13% found in the general school population.     

The effect of early deprivation on executive attention in middle childhood

Background: Children reared in deprived environments, such as institutions for the care of orphaned or abandoned children, are at increased risk for attention and behavior regulation difficulties. This study examined the neurobehavioral correlates of executive attention in post institutionalized (PI) children. Methods: The performance and event‐related potentials (ERPs) of 10‐ and 11‐year‐old internationally adopted PI children on two executive attention tasks, Go/No‐go and Flanker, were compared with two groups: children internationally adopted early from foster care (PF) and nonadopted children (NA). Results: Behavioral measures suggested problems with sustained attention, with PIs performing more poorly on Go trials and not on No‐go trials of the Go/No‐go and made more errors on both congruent and incongruent trials on the Flanker. ERPs suggested differences in inhibitory control and error monitoring, as PIs had smaller N2 amplitude on Go/No‐go and smaller error‐related negativity on Flanker. Conclusions: This pattern of results raises questions regarding the nature of attention difficulties for PI children. The behavioral errors are not specific to executive attention and instead likely reflect difficulties in overall sustained attention. The ERP results are consistent with neural activity related to deficits in inhibitory control (N2) and error monitoring (error‐related negativity). Questions emerge regarding the similarity of attention regulatory difficulties in PIs to those experienced by non‐PI children with ADHD.     

Childhood functional status,family stressors,and psychosocial adjustment among school-aged children with disabilities in the United States

BACKGROUND: During the last 30 years, several studies have indicated that children with disabilities are at increased risk for emotional and behavioral morbidity. Population-based studies are needed to understand the relationship between functional status, family stressors, and the psychosocial adjustment of children with disabilities. METHODS: Using data from the 1994 and 1995 National Health Interview Surveys, Disability Supplement, this study examines the associations between children's functional status, family stressors, and the psychosocial adjustment of school-aged children with disabilities. RESULTS: Regression analyses indicate that children's functional impairments in the areas of communication or learning, poor maternal health and mental health, family burden, and poverty are significantly and positively associated with psychosocial maladjustment among children with disabilities. CONCLUSIONS: Children's functional activity limitations and family stressors are significant correlates of psychosocial adjustment among children with disabilities. These data indicate a need for routine screening for mental health problems among children with disabilities, as well as a family-oriented approach to their medical care.     

Parents' evaluation of developmental status: how well do parents' concerns identify children with behavioral and emotional problems?

This study was undertaken to determine which parental concerns are most associated with significant behavioral/emotional problems and the extent to which parents' concerns can be depended on in the detection of mental health problems. An additional goal is to view how well a recently published screening test relying on parents' concerns, Parents' Evaluation of Developmental Status (PEDS), detects behavioral and emotional problems. Subjects were a national sample of 472 parents and their children (21 months to 8 years old) who were participants in 1 of 2 test standardization and validation studies. Sites included various pediatric settings, public schools, and Head Start programs in 5 diverse geographic locations. Subjects were representative of U.S. demographics in terms of ethnicity, parental level of education, gender, and socioeconomic status. At each site, psychological examiners, educational diagnosticians, or school psychologists recruited families, and obtained informed consent. Examiners disseminated a demographics questionnaire (in English or Spanish) and a developmental screening test that relies on parents' concerns (PEDS). Examiners were blinded to PEDS' scoring and interpretation administered either by interview or in writing, the Eyberg Child Behavior Inventory (ECBI) or the Possible Problems Checklist (PPC), a subtest of the Child Development Inventory that includes items measuring emotional well-being and behavioral self-control. PEDS was used to sort children into risk for developmental disabilities according to various types of parental concern. Those identified as having high or moderate risk were nominated for diagnostic testing or screening followed by developmental and mental health services when indicated. Because their emotional and behavioral needs would have been identified and addressed, these groups were removed from the analysis (N = 177). Of the 295 children who would not have been nominated for further scrutiny on PEDS due to their low risk of developmental problems, 102 had parents with concerns not predictive of developmental disabilities (e.g., behavior, social skills, self-help skills) and 193 had no concerns at all. Of the 295 children, 12% had scores on either the ECBI or the PPC indicative of mental health problems. Two parental concerns were identified through logistic regression as predictive of mental health status: behavior (OR = 4.74, CI = 1.69-13.30); and social skills (OR = 5.76, CI = 2.46-13.50). If one or more of these concerns was present, children had 8.5 times the risk of mental health problems (CI = 3.69-19.71) In children 434 years of age and older, one or both concerns was 87% sensitive and 79% specific to mental health status, figures keeping with standards for screening test accuracy. In young children, the presence of one or both concerns was 68% sensitive and 66% specific to mental health status. The findings suggest that certain parental concerns, if carefully elicited, can be depended on to detect mental health problems when children are 41 years and older and at low risk of developmental problems. For younger children, clinicians should counsel parents in disciplinary techniques, follow up, and if suggestions were not effective, administer a behavioral-emotional screening test such as the Pediatric Symptoms Checklist or the ECBI before making a referral decision.     

Mental health services utilization by maltreated children: research findings and recommendations

Many maltreated children have, or are at risk for, emotional and behavioral disorders. Some of these children need mental health services but do not receive them because of service delivery and use barriers. Knowledge about the factors related to service utilization is needed to increase access to and use of services. Studies on mental health services utilization by maltreated children in foster care or otherwise monitored by child protective services are reviewed to ascertain service use correlates. Children in foster care had higher use rates than comparison groups of Aid to Families With Dependent Children not in foster care. Need and nonneed variables predicted service use. Race was the most consistent nonneed predictor. Future research needs include the development of conceptual models to guide research on service access and use. More work is needed on the conceptualization and operationalization of mental health services, need for services, and service use.     

A population‐based investigation of behavioural and emotional problems and maternal mental health: associations with autism spectrum disorder and intellectual disability

Background: While research indicates elevated behavioural and emotional problems in children with autism spectrum disorders (ASD) and decreased well‐being in their parents, studies do not typically separate out the contribution of ASD from that of associated intellectual disabilities (ID). We investigated child behavioural and emotional problems, and maternal mental health, among cases with and without ASD and ID in a large population‐representative sample. Methods: Cross‐sectional comparison of child behavioural and emotional problems and maternal mental health measures among 18,415 children (5 to 16 years old), of whom 47 had an ASD, 51 combined ASD with ID, 590 had only ID, and the remainder were the comparison group with no ASD or ID. Results: The prevalence of likely clinical levels of behavioural and emotional problems was highest among children with ASD (with and without ID). After controlling for age, gender, adversity, and maternal mental health, the presence of ASD and ID significantly and independently increased the odds for hyperactivity symptoms, conduct, and emotional problems. Emotional disorder was more prevalent in mothers of children with ASD (with or without ID). The presence of ASD, but not ID, significantly increased the odds for maternal emotional disorder. As has been found in previous research, positive maternal mental health was not affected by the presence of ASD or ID. Conclusions: ASD and ID are independent risk factors for behavioural and emotional problems. ASD (but not ID) is positively associated with maternal emotional disorder. Approaches to diagnosing hyperactivity and conduct problems in children with ASD may need to be reconsidered.     

Unmet mental health need and access to services for children with special health care needs and their families.

OBJECTIVES: Studies suggest that children with disabilities or serious health conditions are vulnerable to mental health problems due to adjustment and limitation problems. The aim of this study was to examine rates and predictors of unmet mental health need among children with special health care needs (CSHCN) and their family members and to determine if race/ethnicity and language are associated with unmet need for the child and family members who have a mental health need attributed to the child's special needs. METHODS: Data are from the 2001 National Survey of Children with Special Health Care Needs, a nationally representative sample of CSHCN. RESULTS: Rates of unmet need were higher for CSHCN and family members of CSHCN with a chronic emotional, behavioral, or developmental problem (EBDP) compared to CSHCN with a mental health need but not a chronic EBDP. In multivariate analysis controlling for condition impact and demographics, among CSHCN with a chronic EBDP, African-American children had greater odds of unmet need (OR 1.60, 95% CI, 1.12-2.28), and family members of Hispanic children with a Spanish language parent interview had greater odds of unmet need compared to others (OR 4.48, 95% CI, 1.72-11.63). Lacking a personal doctor or nurse was associated with higher odds of unmet need for CSHCN with and without a chronic EBDP. CONCLUSION: Parents reported prevalent mental health needs of CSHCN as well as family members. Given the importance of family members to the care of CSHCN, research on racial/ethnic disparities in access to perceived needs should focus on children and their family members.     

Identification and management of psychosocial problems by preventive child health care

OBJECTIVES: To assess the degree to which physicians and nurses working in preventive child health care (child health professionals [CHPs]) identify and manage psychosocial problems in children, and to determine its association with parent-reported behavioral and emotional problems, sociodemographic factors, and general and mental health history of children. DESIGN: The CHPs examined the child and interviewed parents and child during their routine health assessments. The parents completed the Child Behavior Checklist. SETTING: Nineteen child health care services across the Netherlands, serving nearly all school-aged children routinely. SUBJECTS: Of 4970 children aged 5 through 15 years, eligible for a routine health assessment, 4480 (90.1%) participated. MAIN OUTCOME MEASURES: Identification and management of psychosocial problems by CHPs. RESULTS: In 25% of all children, CHPs identified 1 or more psychosocial problems. One in 5 identified children were referred for further diagnosis and treatment. Identification of psychosocial problems and subsequent referral were 6 times more likely in children with serious parent-reported problem behavior according to the Child Behavior Checklist total problem score (8% of total sample). However, CHPs identified no psychosocial problems in 43% of these children and therefore undertook no action. Other child factors associated with CHPs' identification and referral were past treatment for psychosocial problems, life events, and academic problems. After adjustment for these, sociodemographic characteristics did not predict referral. CONCLUSIONS: The CHPs identify psychosocial problems in school-aged children frequently and undertake actions for most of them. Screening for psychosocial problems may be a promising option to reduce these problems, but accurate identification should be enhanced.     

Mental health care utilization and expenditures by children in foster care

OBJECTIVE: To determine the percentage of children with mental health diagnoses and utilization and expenditures of mental health services among children in foster care compared with other children receiving Medicaid, including those with disabilities. DESIGN: Analysis of Medicaid claim and eligibility records in southwestern Pennsylvania for fiscal year 1995. POPULATION: A total of 39,500 children between ages 5 and 17 years continuously eligible for Medicaid in southwestern Pennsylvania were included in the analysis. MAIN OUTCOME MEASURES: Percentage of children with mental health diagnoses and mental and general health care utilization and expenditures classified by participation in foster care and Medicaid eligibility. RESULTS: Children in foster care were 3 to 10 times more likely to receive a mental health diagnosis, had 6.5 times more mental health claims, were 7.5 times more likely to be hospitalized for a mental health condition, and had mental health expenditures that were 11.5 times greater ($2082 vs $181) than children in the Aid to Families With Dependent Children (AFDC) program. Overall, utilization rates, expenditures, and prevalence of psychiatric conditions for children in foster care were comparable with those of children with disabilities. CONCLUSIONS: Children in foster care are significantly more likely to suffer from mental health conditions and use more mental health and general health services than AFDC children. Service use and expenditures are comparable with those of disabled children, suggesting that reimbursement rates and care management for children in foster care need to be reexamined.     

Emotional, social, and behavioral functioning of children with sickle cell disease and comparison peers

This research examined the emotional, social, and behavioral functioning of children with sickle cell disease (SCD) and classroom comparison peers from the perspective of primary and secondary caregivers. It was hypothesized that children with SCD would have more internalizing (emotional) and social problems and fewer externalizing (behavioral) problems than comparison peers. Caregivers of 70 children with SCD and 67 comparison peers completed the Child Behavior Checklist (CBCL) during visits to the children's homes. Relative to comparison peers, children with SCD were perceived by primary caregivers as having more total and internalizing problems and less total competence. Additionally, significantly more children with SCD exceeded clinical cutoffs on the CBCL. While caregivers of children with SCD perceive these children to be at a slightly elevated risk for problems across multiple domains, a significant number of children with SCD have problems in the clinical range. The authors recommend that vigorous screening programs for mental health problems should be included in the routine care of children with SCD, and programs of psychosocial intervention research should be implemented to ameliorate problems for the children at greatest risk.     

Practitioner Review: Children in foster care – vulnerabilities and evidence‐based interventions that promote resilience processes

Background: An increasing number of children are placed in foster care (i.e., a kin or nonkin family home other than the biological parent) due to experiences of physical, sexual, emotional, or psychological abuse, and/or neglect. Children in foster care are at increased risk for a host of negative outcomes encompassing emotional, behavioral, neurobiological, and social realms. Methods: Areas of risk and vulnerability among foster children are described, including emotional and behavioral deficits, impaired neurobiological development, and social relationship deficits. Evidence suggesting the significance of family placement changes and prenatal exposure to substances as contributing mechanisms is presented. Based on a systematic search of the PsycINFO database (to March 2012), eight efficacious evidence‐based interventions for foster families are summarized. Findings: Although the development of evidence‐based interventions that improve outcomes for foster children has lagged behind the delivery of interventions in other service sectors (e.g., mental health and educational sectors), several interventions across childhood and adolescence offer promise. Service system constraints offer both challenges and opportunities for more routine implementation of evidence‐based interventions. Conclusions: Given the increased likelihood of poor outcomes for foster children, increased efforts to understand the pathways to vulnerability and to implement interventions shown to be effective in remediating risks and improving outcomes for this population are indicated. Evaluation of efficacious interventions in countries outside of the United States is also needed.     

Transgenerationale Effekte mütterlicher Angst

Background

To date little is known about the transgenerational effects of maternal anxiety on child emotional and behavioral problems and on the quality of mother-child interactions.

Methods

The sample consisted of 54 mothers and their preschool children. In addition to standardized questionnaires, observational measures were performed.

Results

Associations were shown between maternal anxiety and child emotional and behavioral problems. Higher levels of maternal anxiety were associated with less maternal responsiveness and more controlling behavior and with less cooperative and more threatening behavior from children.

Conclusions

The preliminary results with methodical restrictions show that even small elevations of maternal anxiety levels can have an impact on the quality of mother-child interactions and may result in child emotional and behavioral problems. Future studies are needed focusing on representative samples and including standardized clinical interviews (mothers) and proxy-reported assessment of emotional and behavioral problems (children).     

Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey.

OBJECTIVE: Childhood psychosocial problems have profound effects on development, functioning, and long-term mental health. The pediatrician is often the only health professional who regularly comes in contact with young children, and it is recommended that health care supervision should include care of behavioral and emotional issues. However, it is unknown whether pediatricians believe they should be responsible for this aspect of care. Our objective was to report the proportion of physicians who agree that pediatricians should be responsible for identifying, treating/managing, and referring a range of behavioral issues in their practices, and to examine the personal physician and practice characteristics associated with agreeing that pediatricians should be responsible for treating/managing 7 behavioral issues. METHODS: The 59th Periodic Survey of members of the American Academy of Pediatrics was sent to a random sample of 1600 members. The data that are presented are based on the responses of 659 members in current practice and no longer in training who completed the attitude questions. RESULTS: More than 80% of respondents agreed that pediatricians should be responsible for identification, especially for attention-deficit/hyperactivity disorder (ADHD), eating disorders, child depression, child substance abuse, and behavior problems. In contrast, only 59% agreed that pediatricians were responsible for identifying learning problems. Seventy percent thought that pediatricians should treat/manage ADHD; but for other conditions, most thought that their responsibility should be to refer. Few factors were consistently associated with higher odds of agreement that pediatricians should be responsible for treating/managing these problems, except for not spending their professional time exclusively in general pediatrics. CONCLUSIONS: These data suggest that pediatricians think that they should identify patients for mental health issues, but less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Those not working exclusively in general pediatrics were more likely to agree that pediatricians should be responsible for treating and managing children's mental health problems.     

Maternal IQ, child IQ, behavior, and achievement in urban 5-7 year olds

In one study of children in 27 families with maternal retardation, those children with higher intelligence quotient (IQ) were more likely to have multiple behavior problems than those with lower IQ. If true, this result would affect clinical practice, but it has not been replicated. Because the setting of the initial observation is similar to the setting of childhood lead poisoning, we attempted a replication using data from the Treatment of Lead-Exposed Children (TLC) study, in which 780 children aged 12-33 mo with blood lead levels 20-44 microg/dL were randomized to either succimer treatment or placebo and then followed up to 5 y. Of 656 mothers of TLC children with IQ measured, 113 demonstrated mental retardation (IQ <70). Whether maternal IQ was <70 or >or=70, children with IQ >or=85 were rated more favorably on cognitive tests and behavioral questionnaires than children with IQ <85; these measures included Conners' Parent Rating Scale-Revised at age 5, the Developmental Neuropsychological Assessment at ages 5 and 7, and the Behavioral Assessment System for Children at age 7. Among children of mothers with IQ <70, those with IQ >or=85 did not show more severe clinical behavioral problems, nor were they more likely to show multiple behavior problems. Children with higher IQ have fewer behavior problems, irrespective of the mother's IQ. In the special setting of mothers with IQ <70, children with higher IQ are not at greater risk of behavior problems.     

Adolescents in rural communities seeking help: who reports problems and who sees professionals?

BACKGROUND: This study examined whether adolescents who were at various stages of the help-seeking process differed on demographic characteristics, use of informal helpers, and markers of emotional and behavioral adjustment. METHOD: Youths (N = 644; Grades 7-12) living in three rural communities completed a survey at school. Three comparisons were made: teenagers who reported having serious problems versus few or no problems in the past year; teenagers who felt that they did or did not need professional help with these problems; and teenagers who had or had not sought professional help. RESULTS: Rural youths with serious problems were more likely to be girls and to be living with someone other than a parent, were less likely to talk to family members about problems, and reported more negative emotional and behavioral adjustment. Teenagers who perceived a need for professional help also reported poorer emotional and behavioral adjustment. Adolescents who sought professional help were more likely to be in senior high, were less likely to talk to others about problems, and were lower on anxiety. CONCLUSIONS: Rural adolescents' demographic characteristics, use of informal helpers, and markers of emotional and behavioral adjustment each contribute to our understanding of their help-seeking behavior. Future studies must examine how these and other variables combine to discern who reports problems, who perceives a need for help, and who sees professionals.     

Recognizing and managing long-term sequelae of childhood maltreatment

Childhood maltreatment is a serious public health problem and represents a significant challenge to pediatricians. Maltreated children present with a variety of emotional and behavioral problems. Pediatricians should screen for risk factors associated with maltreatment and psychiatric sequelae associated with maltreatment. Because of the complexity of psychiatric sequelae in childhood maltreatment, children who have been maltreated will likely require multidisciplinary treatment in mental health care settings. Therefore, pediatricians need to be knowledgeable about mental health services in their communities and actively assist the family in obtaining services. Although we are gaining a more sophisticated understanding of the impact that maltreatment has on the mental health of children and adolescents, much remains to be done. It is critical for pediatricians to work within their professional organizations and their individual communities to address the systemic issues that create barriers to care for patients who have suffered maltreatment. It is also critical for pediatricians to encourage their professional organizations to establish good working relationships with other organizations in areas where they share interest, need, and commitment. Such collaborative relationships at local, state, and national levels can facilitate governmental policy changes that are needed to protect and care for children and adolescents. Only through such efforts can we bring about lasting changes that will support the health and well-being of children and adolescents.