Review of the NIMH Israeli Kibbutz-City Study and the Jerusalem Infant Development Study

The National Institute of Mental Health (NIMH) Israeli Kibbutz-City Study has followed the development of offspring of schizophrenic parents from middle childhood through early adulthood. During childhood, a subgroup of offspring of schizophrenic patients showed clear neurobehavioral deficits often accompanied by poor social competence. Early followup data suggest that this subgroup of high-risk children is at greatest risk for adult schizophrenia spectrum illness. The Jerusalem Infant Development Study has followed a similar population of children at risk for schizophrenia from before birth through middle childhood. A subgroup of dysfunctioning in the high-risk children showed sensorimotor dysfunctioning in the first year of life, which was followed by perceptual, motor, and attentional dysfunctioning in childhood--identical to that found in the NIMH cohort. Results from both studies support the hypothesis that schizophrenic illness involves constitutional factors whose expression can be observed as early as infancy. Results also illustrate the importance of using data-analytic approaches that (1) look for subgroups within high-risk groups rather than only group differences between high- and low-risk groups, and (2) examine profiles of behavior rather than only single variables.     

Hope, social support, and behavioral problems in at-risk children

This study investigated the effects of hope, social support, and stress on behavioral problems in a high-risk group of 65 children of incarcerated mothers. Children with low levels of hope had more externalizing and internalizing problems. Children who perceived less social support had more externalizing problems, and children who had experienced more life stressors reported more internalizing problems. Regression analyses indicated that hope contributed unique variance to both internalizing and externalizing behavioral problems after social support and stress were controlled. These findings suggest that being confident in one's ability to overcome challenges and having a positive outlook function as protective factors, whereas being less hopeful may place a child at risk for developing adjustment problems. Whether it is possible to foster agency and teach pathways to children with lower levels of hope is discussed.     

Early indicators of developmental risk: Rochester Longitudinal Study

Early indicators of schizophrenic outcomes were sought in a group of children of chronically ill schizophrenic women. A sample of pregnant women with varying degrees of mental illness were examined during the perinatal period and recruited into a 4-year longitudinal evaluation, which included cognitive, psychomotor, social, and emotional assessments at birth, 4, 12, 30, and 48 months of age. The mothers varied on mental health dimensions of diagnosis, severity of symptomatology, and chronicity of illness. Other factors included in the analyses were socioeconomic status (SES), race, sex of child, and family size. Hypotheses were tested to determine the relative impact of three sets of variables on the child's behavior: (1) specific maternal psychiatric diagnosis, (2) severity and chronicity of disturbance independent of diagnosis, and (3) general social status. We found that a specific maternal diagnosis of schizophrenia had the least impact. Neurotic-depressive mothers produced worse development in their children than schizophrenic or personality-disordered mothers. Both social status and severity/chronicity of illness showed a greater impact on development. Children of more severely or chronically ill mothers and lower-SES black children performed most poorly. These results do not support etiological models based on simple biological or environmental transmission of schizophrenia. The role of social and family environmental factors in predicting child cognitive and social-emotional competence was further evaluated using a multiple risk index. Children with high multiple environmental risk scores had much worse outcomes than children with low multiple risk scores.     

Parental stress among parents of toddlers with moderate hearing loss

BackgroundThe purpose of this study was to examine parental stress in parents of toddlers with moderate hearing loss compared to hearing controls. Furthermore, the associations between parental stress and child- and parent-related factors such as language, social-emotional functioning and social support were examined.DesignThe study sample consisted of 30 toddlers with moderate hearing loss and 30 hearing children (mean age 27.4 months). The two groups were compared using the Nijmegen Parenting Stress Index (NPSI) and parent-reports to rate the amount of social support and the children’s social-emotional functioning. Receptive and expressive language tests were administered to the children to examine their language ability.ResultsParents of toddlers with moderate hearing loss reported comparable levels of parental stress to parents of hearing children. Individual differences in parental stress were related to child- and parent-related factors. Poorer social-emotional functioning and language ability of the child were related to higher stress levels in parents. Parents who experienced less social support reported higher stress levels.ConclusionsParents of toddlers with moderate hearing loss experience no more parental stress than parents of hearing children on average. Given parental stress was found to be related to poorer child functioning, early interventionists should be aware of signs of elevated stress levels in parents.     

Children of psychotic mothers. Performance of 3-year-old children on tests of attention.

Children of mentally ill mothers (N = 21), believed to be at risk for the subsequent development of psychopathology (high-risk group) were compared with children of well mothers (N = 21)(low-risk group) on the Embedded Figures Test (EFT) and the Peabody Picture Vocabulary Test (PPVT). Results indicated that children in the high-risk group perform less well than low-risk children on the EFT (particularly on the more difficult stimuli), but do not differ from low-risk children on the PPVT. These results are interpreted as showing greater impairment of attention among children of mentally ill mothers than among children of well mothers.     

Brief Report: Effect of a Focused Imitation Intervention on Social Functioning in Children with Autism

Imitation is an early skill thought to play a role in social development, leading some to suggest that teaching imitation to children with autism should lead to improvements in social functioning. This study used a randomized controlled trial to evaluate the effect of a focused imitation intervention on initiation of joint attention and social-emotional functioning in 27 young children with autism. Results indicated the treatment group made significantly more gains in joint attention initiations at post-treatment and follow-up and social-emotional functioning at follow-up than the control group. Although gains in social functioning were associated with treatment, a mediation analysis did not support imitation as the mechanism of action. These findings suggest the intervention improves social functioning in children with ASD.     

Developmental delay in P300 production in children at high risk for developing alcohol-related disorders.

BACKGROUND: Reduction of P300 amplitude in children and adolescents at high risk for developing alcoholism has frequently been reported. It has been hypothesized that this reduction represents a developmental delay in reaching age-appropriate levels in P300 amplitude. Using latent growth analysis of longitudinal data obtained at yearly intervals, this study seeks to define normal growth, and determine if the pattern seen in high-risk children differs from that obtained in normal low-risk controls. METHODS: A total of 156 children from either high or low-risk families have been assessed multiple times (two-thirds more than 4 times) using both a clinical assessment (K-SADS) and ERP evaluation performed on the same day. A total of 635 separate assessments were available for modeling. RESULTS: Quadratic growth curves revealed a slower rate of change in P300 amplitude in high-risk than low-risk males. High-risk girls showed reduced visual P300 amplitude only when the presence of a K-SADS diagnosis was considered. No differences were seen for P300 latency. CONCLUSIONS: This study confirms the hypothesis that when reduction of P300 amplitude is seen in males at high risk for developing alcoholism, it is due to a developmental delay.     

Genetic boundaries of the schizophrenia spectrum: evidence from the Finnish Adoptive Family Study of Schizophrenia

OBJECTIVE: Identification of the genetically related disorders in the putative schizophrenia spectrum is an unresolved problem. Data from the Finnish Adoptive Family Study of Schizophrenia, which was designed to disentangle genetic and environmental factors influencing risk for schizophrenia, were used to examine clinical phenotypes of schizophrenia spectrum disorders in adopted-away offspring of mothers with schizophrenia spectrum disorders. METHOD: Subjects were 190 adoptees at broadly defined genetic high risk who had biological mothers with schizophrenia spectrum disorders, including a subgroup of 137 adoptees at narrowly defined high risk whose mothers had DSM-III-R schizophrenia. These high-risk groups, followed to a median age of 44 years, were compared diagnostically with 192 low-risk adoptees whose biological mothers had either a non-schizophrenia-spectrum diagnosis or no lifetime psychiatric diagnosis. RESULTS: In adoptees whose mothers had schizophrenia, the mean lifetime, age-corrected morbid risk for narrowly defined schizophrenia was 5.34% (SE=1.97%), compared to 1.74% (SE=1.00%) for low-risk adoptees, a marginally nonsignificant difference. In adoptees whose mothers had schizophrenia spectrum disorders, the mean age-corrected morbid risk for a schizophrenia spectrum disorder was 22.46% (SE=3.56%), compared with 4.36% (SE=1.51%) for low-risk adoptees, a significant difference. Within the comprehensive array of schizophrenia spectrum disorders, schizotypal personality disorder was found significantly more often in high-risk than in low-risk adoptees. The frequency of the group of nonschizophrenic nonaffective psychoses collectively differentiated high-risk and low-risk adoptees, but the frequencies of the separate disorders within this category did not. The two groups were not differentiated by the prevalence of paranoid personality disorder and of affective disorders with psychotic features. CONCLUSIONS: In adopted-away offspring of mothers with schizophrenia spectrum disorders, the genetic liability for schizophrenia-related illness (with the rearing contributions of the biological mothers disentangled) is broadly dispersed. Genetically oriented studies of schizophrenia-related disorders and studies of genotype-environment interaction should consider not only narrowly defined, typical schizophrenia but also schizotypal and schizoid personality disorders and nonschizophrenic nonaffective psychoses.     

Daytime cortisol and stress reactivity in the offspring of parents with bipolar disorder

The hypothalamic-pituitary-adrenal (HPA) axis is compromised in major depression and bipolar disorder (BD). It is not known however whether HPA abnormalities predate the onset of these disorders. Preliminary data indicated that the adolescent offspring of parents with BD (high-risk), as compared to adolescents of parents with no mental disorder (low-risk), had higher levels of daytime salivary cortisol. The present study re-examined the cortisol increase after awakening and basal cortisol levels in a larger sample, and tested the hypothesis that high-risk offspring are more reactive to psychosocial stress than low-risk offspring. Saliva samples were collected from 58 adolescents, 29 high-risk (14 male/15 female, 16.8 years) and 29 (14 male/15 female, 16.6 years) low-risk, in their natural environment during at least two days. Twenty-five high-risk (13 male/12 female) and 25 low-risk (13 male/12 female) youth completed a child adaptation (15 years) or the standard version of the “Trier Social Stress Test”. Consistent with our previous finding, high-risk offspring had higher daytime levels of cortisol in their natural environment than low-risk offspring, and the difference was unrelated to clinical symptoms or other known confounds. Irrespective of risk status, female participants had higher daytime levels of cortisol than male participants. In contrast, there were no group differences in the cortisol response to the laboratory psychosocial stressor. The offspring of parents with BD show evidence of increased daytime basal HPA functioning with normal reactivity to psychosocial stress.     

Risk, protective factors, and supportive interventions in chronic airway obstruction

Fifty-nine patients with chronic airway obstruction completed the Schedule of Recent Experiences and Social Assets Scale (SAS) to measure life stress and social supports. Patients with highest stress and lowest SAS scores (the high-risk group) were randomly assigned to a pulmonary rehabilitation group, self-help support group, or waiting-list control group. Patients with lower stress and/or higher SAS scores (the low-risk group) served as controls. Six months later, a records review showed that high-risk control patients were hospitalized more often than low-risk control patients and for more days than high-risk patients in rehabilitation and self-help support groups. Discriminant analysis determined that SAS and life stress scores predicted subsequent hospitalization, but age, sex, previous hospitalizations, and severity of illness did not. Measurements of stress and social supports can help identify high-risk patients. In turn, professionals might assist these patients by increasing their supports.     

Crime and the schizophrenia spectrum: a diathesis-stress model

Previous studies support a relationship between schizophrenia and antisocial behavior. In the present study, offspring of schizophrenics showed a greater degree of antisocial behavior than did offspring of parents without psycho-pathology. The present study clarifies the interplay between risk for schizophrenia and developmental factors in determining antisocial behavior. Those variables which distinguished high-risk criminal behavior from high-risk non-criminal behavior were irritability and shortened attention span in infancy, paternal absence during ages 15 to 17, lower WAIS Verbal IQ, impoverished neighborhood, family discord and negative attitude towards father. In a multiple regression analysis, paternal absence in adolescence, shortness of attention span, and low Verbal IQ each contributed a unique portion of the variance in antisocial behavior. A block of interaction terms (Stressor X Risk) did not contribute a significant portion of the variance in antisocial behavior, suggesting that those factors which predict antisocial behavior in the high-risk group are the same factors which predict antisocial behavior in the low-risk group. In addition, a significant portion of the variance in phenotypic outcome (criminal vs. schizophrenic) was accounted for by passivity in infancy (predictive of schizophrenia) and low Verbal IQ (more common in high-risk criminals). Shortened attention spans in infancy were found to precede both criminal behavior and schizophrenia in this sample. This feature may therefore indicate a genetic vulnerability to schizophrenia.     

Psychopathology risk transmission in children of parents with substance use disorders

OBJECTIVE: Children of fathers with substance use disorders are at increased risk for psychopathology, including conduct disorder, attention deficit hyperactivity disorder (ADHD), major depressive disorder, and anxiety disorders. This study examined the distinct influences of parent substance use disorder and other psychopathology in the transmission of the risk for psychopathology to their children. METHOD: The subjects were 1,167 children (ages 6-14 years; 62% were male, 38% were female) from 613 families recruited according to a high-risk paradigm. Of these families, 294 had fathers with a substance use disorder (high-risk group), and 319 had fathers without a substance use disorder or other mental disorder (low-risk group). In all families, father, mother, and children were directly assessed. Mixed-effects ordinal regression analyses controlled for the nested data structure. RESULTS: For conduct disorder, ADHD, major depression, and anxiety disorders, the results indicated that the predominant predictor of specific mental disorders in offspring was a history of the corresponding disorders in both parents. CONCLUSIONS: These results support specific parent-child transmission for childhood psychopathology.     

Language in young children with neurofibromatosis-1: Relations to functional communication,attention, and social functioning

In this study, the language abilities of 30 children with Neurofibromatosis Type 1 (NF1) aged 4–6 years were examined using a standardized measure of language. Relations of language to multiple parental report measures of functional communication, social skills, and attention problems were investigated. Difficulties in core language skills were observed, and more than 1/3 of the children struggled on at least one language index. Language abilities were significantly related to parental report of functional communication, social interaction and communication, and social skills, such that language difficulties may be a risk factor for communication and social interaction challenges and communication-related adaptive behavior in children with NF1. Though receptive language abilities were an area of particular difficulty for many children with NF1, they were not significantly related to parental ratings of social functioning and functional communication. Few significant relations were found between language and parent-reported attention problems, although some trends were noted. Hence attention difficulties in children with NF1 may contribute to, but do not appear to fully account for, language difficulties. In sum, there is an increased risk of language difficulties for young children with NF1, and lab-measured language difficulties appear to relate to everyday communication and social interaction functioning.     

The influence of social class, strain and social support on symptoms of anxiety and depression in mothers of toddlers

Background: The aim of the study was to identify risk and protective factors for anxiety and depression among mothers of toddlers. Methods: A population-based sample of 921 Norwegian mothers with 18-month-old children completed a questionnaire designed to examine the impact of socioeconomic and demographic factors, somatic health problems, negative life events, chronic strain and social support on symptoms of anxiety and depression (HSCL-25). Results: There was a moderate aversive effect of negative life events and chronic strain and a moderate protective effect of social support on the symptom level, but no interaction effects were found between the risk and protective factors. Behaviour problems among the children clearly seemed to affect the mothers' symptom level. The symptom level varied with background factors like the mothers' education, employment status and age even after controlling for the effect of strain and social support. The largest effect of the background factors seemed to be indirect, however, mediated through their effect on the risk and protective factors. Conclusions: Although problems with the children's behaviour and child care arrangements were observed to have a strong impact on the mothers' symptom level, the frequencies of such problems appeared to be less dependent on socioeconomic conditions than did other types of strain. Accepted: 21 July 1998     

The mental health of children affected by armed conflict: protective processes and pathways to resilience

This paper examines the concept of resilience in the context of children affected by armed conflict. Resilience has been frequently viewed as a unique quality of certain 'invulnerable' children. In contrast, this paper argues that a number of protective processes contribute to resilient mental health outcomes in children when considered through the lens of the child's social ecology. While available research has made important contributions to understanding risk factors for negative mental health consequences of war-related violence and loss, the focus on trauma alone has resulted in inadequate attention to factors associated with resilient mental health outcomes. This paper presents key studies in the literature that address the interplay between risk and protective processes in the mental health of war-affected children from an ecological, developmental perspective. It suggests that further research on war-affected children should pay particular attention to coping and meaning making at the individual level; the role of attachment relationships, caregiver health, resources and connection in the family, and social support available in peer and extended social networks. Cultural and community influences such as attitudes towards mental health and healing as well as the meaning given to the experience of war itself are also important aspects of the larger social ecology.     

Parent-child bonding and family functioning in depressed children and children at high risk and low risk for future depression

OBJECTIVE: To evaluate parent-child bonding and familial functioning in depressed children, children at high risk for depression, and low-risk controls. METHOD: Diagnoses of children and their relatives were obtained via structured interviews with all available informants. Depressed children (n = 54) received a diagnosis of current major depressive disorder (MDD). The high-risk children (n = 21) had no lifetime diagnoses of mood disorders, but at least one first-degree relative with a lifetime history of depression. The low-risk controls (n = 23) had no lifetime psychiatric disorders and no first-degree relative with a lifetime history of mood disorders. Parent-child bonding was evaluated with the child's report on the Parental Bonding Instrument (PBI). Familial functioning was evaluated with each parent answering the Family Assessment Device (FAD). RESULTS: Significant differences were found between the MDD and low-risk children on most parameters of the PBI and FAD. The children with MDD reported significantly elevated maternal overprotection, and their fathers scored significantly lower on the FAD scales of Behavioral Control and General Functioning, compared with the high-risk children. Mothers of high-risk children had significantly lower scores on the Roles and Affective Involvement dimensions of the FAD compared with mothers of low-risk children. Current maternal depression had a deleterious effect on the child's perception of maternal protection and paternal care, mother's report on all FAD scales, and father's report on most FAD scales, whether interacting with the child's depression or existing even if the child was not depressed. CONCLUSION: Maternal depression and its interaction with the child's depression appear to have negative consequences for parent-child bonding and family functioning.     

The mental health of children affected by armed conflict: Protective processes and pathways to resilience

This paper examines the concept of resilience in the context of children affected by armed conflict. Resilience has been frequently viewed as a unique quality of certain ‘invulnerable’ children. In contrast, this paper argues that a number of protective processes contribute to resilient mental health outcomes in children when considered through the lens of the child's social ecology. While available research has made important contributions to understanding risk factors for negative mental health consequences of war-related violence and loss, the focus on trauma alone has resulted in inadequate attention to factors associated with resilient mental health outcomes. This paper presents key studies in the literature that address the interplay between risk and protective processes in the mental health of war-affected children from an ecological, developmental perspective. It suggests that further research on war-affected children should pay particular attention to coping and meaning making at the individual level; the role of attachment relationships, caregiver health, resources and connection in the family, and social support available in peer and extended social networks. Cultural and community influences such as attitudes towards mental health and healing as well as the meaning given to the experience of war itself are also important aspects of the larger social ecology.     

Maternal stress and social support prospectively predict infant inflammation

Maternal stress has been suggested to be a risk factor for offspring health, while social support has been shown to be a protective factor for offspring functioning. Currently, research has yet to investigate how both of these factors may relate to infant inflammatory processes and associated biological aging in the first years of life. In 48 mother-infant dyads, we investigated whether maternal parenting stress and social support when infants were 12 and 18 months of age were cross-sectionally associated with infant salivary C-reactive protein (sCRP) during these times. In addition, we investigated whether parenting stress and social support were prospectively associated with later sCRP and changes in sCRP from 12 to 18 months of age, as well as whether those changes in sCRP were associated with subsequent infant salivary telomere length (sTL), a marker of biological aging. Analyses revealed that while there were no cross-sectional associations between maternal factors and infant sCRP, maternal parenting stress and social support when infants were 12 months of age predicted infant sCRP at 18 months of age. Further, maternal social support predicted changes in infant sCRP from 12 to 18 months of age. We observed a null association between infant sCRP and sTL. Implications for the ways that maternal mental health and social support may impact biological mechanisms related to disease processes in infants are discussed.     

Early onset psychiatric disorder in high risk children and increased familial morbidity

The relationship between child psychopathology and familial morbidity in second degree relatives was examined for children considered at risk on the basis of parental affective illness. Second degree relatives in high-risk families with no child psychopathology were no different from low-risk families in their rates of depression and anxiety. Second degree relatives in high-risk families positive for child psychopathology had significantly higher rates of depression and anxiety than relatives of low-risk children and relatives of high-risk children with no disorder. The implications of these findings are discussed with respect to risk status, prepubertal onset of psychopathology, and familial morbidity for specific psychiatric disorders.