Risk Factors in Childhood Psychopathology: A Brief Overview

1. Risk Factors in Childhood Psychopathology:A Brief Overview James H. Johnson, PhD, ABPP Department of Clinical and Health Psychology University of Florida

2. Risk Factors in Childhood Psychopathology • In considering various problems of childhood, a good place to start is to consider factors that can place the child at increased risk for later difficulties. • These factors can either increase the risk of developing specific types of childhood psychopathology or more general psychological problems. • Why Important? • What are examples of important risk factors? • These risk factors include; • Biological Factors • Psychosocial Factors

3. Biological Risk Factors • Biological risks include a range of factors operative before, during or after birth. • In assessing children it is important to obtain information about any of these factors that may have contributed to the child’s presenting difficulties. • This information is often obtained during the parent interview, while getting information about the child’s development.

4. A Brief List of Some Biological Risk Factors • Age of the Mother • Poor Prenatal Nutrition • Maternal Use of Alcohol • Maternal Use of Tobacco • Use of Other Drugs • Prenatal and Postnatal Illnesses • Pregnancy and Birth Complications • Genetic Factors

5. Age of Mother • Pregnancies in either very young or older females are at increased risk for complication. • One risk factor with increased age is Down’s syndrome. • Leads to mental retardation, usually mild • This is a chromosomal abnormality related to the #21 chromosome (trisomy 21) • Maternal age; Below 30 = 1 in 1,500; 40 – 44 = 1 in 130; Over 45 = 1 in 65 births).

6. Muscle hypotonia; low muscle tone*Flat facial profile, a somewhat depressed nasal bridge and a small nose*Dysplastic ear; an abnormal shape of the ear*Simian crease, a single deep crease across the center of the palm*Hyperflexibility, an excessive ability to extend the joints*Epicanthal folds, small skin folds on the inner corner of the eyes*Excessive space between large and second toe*Enlargement of tongue in relationship to size of mouth Down’s Syndrome

7. Down’s Syndrome • Increased rates of: • Congenital heart problems, • Childhood leukemia • Digestive tract obstructions • Respiratory problems, • Susceptibility to infection, • Adults with Down syndrome are also at increased risk forAlzheimer’s disease. • While approximately 6% of the general population will develop the disease, the figure is about 25% for people with Down syndrome.

8. Age of Mother • Overall the incidence of pregnancy and birth complications increases from 10.43% in women 20 – 29 to 19.29 % in women 35 – 39. • Increased frequency of hypertension, diabetes, and bleeding in the third trimester. • Results in increased need for testing such as amniocentesis, which can result in complications, although the rate is low.

9. Poor Maternal Nutrition • Poor nutrition prior to and during the pregnancy can result in developmental delays as well as specific types of physical conditions. • As but one example, it has been estimated that the standard 400 mg dosage of Folic acid that comes in most daily vitamins is capable of reducing the rates of spina bifida by a full 50 %. • Importantly, it is necessary for the mother to have been taking Folic Acid prior to pregnancy.

10. Maternal Use of Alcohol • Heavy alcohol use by the mother during pregnancy can result in Fetal Alcohol Syndrome (FAS). • Over 40% of women who drink heavily have children with FAS. • FAS is characterized by a pattern of malformations and disabilities resulting from heavy and/or binge drinking during pregnancy.

11. Maternal Use of Alcohol • It results in developmental delays, physical stigmata, perceptual-motor, attention, and activity level problems. • Lower levels of alcohol intake during pregnancy can also lead to “Fetal Alcohol Effects” reflected in significant development delays. • No “safe” level of alcohol intake in pregnancy has been determined.

12. Recent Case Example: Alcohol + • Mother of seven-year old child • Didn’t know she was pregnant until 5 mos. • Drank 5 – 6 beers every weekend • On birth control pills until 5 months • Had illness treated with codine • Child with severe developmental delays, serious early academic problems and both ADHD and Oppositional Defiant features.

13. Fetal Alcohol Syndrome

14. Tobacco Use During Pregnancy • Tobacco use by the mother during pregnancy can result in • premature birth and associated low birth weight, • miscarriages, • decreased placental blood flow and • subtle developmental delays. • There are also data to suggest that heavy smoking may relate to later risk for conduct disorder in the child. • Several, but not all, studies have found a significant association between smoking during pregnancy and ADHD.

15. Use of Other Drugs • Use of other drugs such as narcotics and cocaine can likewise result in adverse outcomes. • Children born to mothers who use narcotics can be born addicted. • Children of drug abusing mothers often show developmental delays, serious problems with emotional regulation, and problems with attention and activity level, among other difficulties. • This may contribute to significant problems in the quality of early mother-child interaction patterns. • Drug effects are often confounded by living in an environment where drug abuse is common.

16. Cocaine and Pregnancy • Findings from NIDA suggests that 1 – 2 % of newborns are exposed to cocaine. • A range of potential effects on the fetus have been documented: • Spontaneous Abortion • Prematurity and Low Birth Weight • Microcephaly • Fetal Growth Retardation • Placental Abruption- A dangerous birth complication in which the placenta separates from the uterus prematurely. • Some studies have suggested that the rate of SIDS may be as high as 15% or 30 times that seen in the general population. • The main concern has been the effects of cocaine on the developing brain. • Across the board, researchers have found that, as a group, children exposed to cocaine in the womb have lower IQ scores and more learning, emotional, and behavior problems.

17. Pre or Postnatal Illnesses/Injuries • Viral illnesses like Rubella during the first trimester can result in a range of problems including deafness, heart problems, cleft palate, and mental retardation. • Congenital Rubella has also been shown to significantly increase the rates of infantile autism. • Head injuries and childhood illnesses with high fevers have also been show to increase the risk for learning problems, developmental delays and ADHD. • It has also been suggested that early strep infections can be associated with OCD like features or tic disorders in children.. P.A.N.D.A.S. – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

18. Pregnancy and Birth Complications • Diverse pregnancy and birth complications (e.g., anoxia, prematurity, toxemia (preeclampsia), low birth weight, meconium staining) have been found to be associated with a wide range of childhood problems. • Associations include general developmental delays, speech and language problems, school difficulties, and ADHD, among others.

19. Genetic Factors • Genetic factors have been shown to be significant contributors to a range of child and adult psychological disorders. • Disorders with significant genetic loadings include Autism, ADHD, Schizophrenia, and Bipolar disorder, among others. • Genetics may interact with environmental and other biological factors. – Diathesis-Stress effects • The significant role of genetic contributions to childhood disorders makes it necessary to thoroughly assess family history of mental illness when conducting interviews with parents of children seen in the clinic. • We will consider findings related to genetics in greater detail as we discuss various child disorders.

20. Child Temperament: Overview • An additional biological risk factor is childhood temperament. • Temperament can be thought in terms of inborn individual differences in behavioral style that are reflected in the child’s interaction with his/her environment. • The child’s temperament makeup can make him or her either easy or difficult to parent.

21. Early Work in the Area of Temperament • Note Thomas and Chess (1968) and the New York Longitudinal Study • Attempted to delineate individual differences in the behavioral style of infants and young children. • Studied 141 children from infancy through adolescence. • Found nine dimensions of temperament that differentiated among children as young as 2 - 3 months of age. • These were assumed to reflect biologically based individual differences in behavioral style.

22. Dimensions of Temperament • Rhythmicity • Approach-Withdrawal • Adaptability • Intensity of Response • Quality of Mood • Activity Level • Distractibility • Persistence • Threshold of Responsiveness

23. Categories of Temperament • Easy versus Difficult Temperament • Five distinguishing dimensions • Rhythmicity • Approach-Withdrawal • Adaptability • Mood • Intensity of Response • Slow-to-Warm-Up • Low activity, tendency to withdraw, and slow to adapt; may show negative mood but with low intensity. Note: Other researchers have also suggested other dimensions (e.g. Behavioral Inhibition).

24. Dimensions of Temperament • Distributions of temperament makeup in children. • More Easy than Difficult Children • In the 141 children in the NYLS • 10% Difficult Temperament • 30% Easy Temperament • 15% Slow-to-Warm-Up Temperament

25. Child Temperament As A Risk Factor • Relationship to problems of adjustment • General Adjustment • 70% of difficult children in the NYL study developed behavior problems in adolescence. • Only 18% of easy children did. • Follow-up into adulthood documented a significant relationship between temperament at age 3-5 and adult psychiatric disorder. • Other studies have also suggested a link between difficult temperament and adjustment problems. • ADHD • Anxiety

26. Other Temperament Related Issues • The Concept of Goodness-of-Fit • Goodness of Fit in Normal Children • Studies of Abuse • Foster Care Research • Impact of Temperament on Parents • Intervening in Families with Difficult Children.

27. Psychosocial Risk Factors • In addition to biological risk factors, there are a range of psychosocial circumstances that can have an impact on the child. • These factors can increase the child’s risk for developing specific forms of psychopathology or other more general problems that may require treatment.

28. Selected Examples of Psychosocial Risk Factors • Effects of Cumulative Life Stress • Effects of Divorce • Marital Violence • Physical Abuse • Sexual Abuse

29. Effects of Cumulative Life Stress • Experiencing numerous life changes within a restricted period of time has been found to be associated with a range of child health and adjustment problems. • Anxiety • Depression • Increased Rates of Drug Use • Recurrent Abdominal Pain • Problems in Diabetic Control • General Problems with Health and Adjustment

30. Effects of Cumulative Life Stress • There is also evidence that high levels of stress in expectant mothers can impact offspring. • Animal Studies – Stressed rats have longer pregnancies and more spontaneous abortions. • Expectant mother’s show links between life stress and pregnancy and birth complications. • There is also some evidence to suggest links between stress during pregnancy and the development of difficult temperament and delays in motor and mental development.

31. Some Issues in Life Stress Research • Assessing Life Stress • Major Life Events and Daily Hassles • Desirable versus Undesirable Life Events • The Issue of Appraisal • Moderators of Life Stress: Who is At Risk?

32. Effects of Divorce • Divorce is not a single event –rather it ushers in a range of major life stressors and life transitions that can impact on the child. • Changes in Residence • Changes in School • Loss of Friends • Possible Separation From One Parent • Possible Economic Hardships • Possible Parental Conflict • Possible Remarriage and new Step-family • All of these can serve as significant stressors that can impact on the child in multiple ways.

33. Effects of Divorce • Divorce can have a major impact on the child in terms of both its short and long term effects. • These effects have been well documented by ongoing research conducted by by Mavis Hetherington (Virginia) and Judith Wallerstein (California) as well as by many other researchers.

34. Divorce: Short Term Effects • Short term effects usually take the form of Emotional Problems and Behavioral Difficulties. • Such effects are not surprising as divorce often separates the child from one of the parents, with whom he/she may have a positive relationship. • This may elicit anger and possibly guilt. • Also, many of the contingencies and rules that have previously served to control the child’s behavior may have been disrupted. • Emotional responses and changed rules and contingencies can have a major impact on behavior.

35. Divorce: Longer Term Effects • Wallerstein’s work highlights the much longer term effects of divorce on many children. • She notes that, as children grow older, they often continue to view their parents divorce as the single most formative experience in their lives, with major divorce-related issues arising as they approach adulthood. • “Almost all confront issues of love, commitment, and marriage with anxiety and sometimes, very great concerns about betrayal, abandonment, and not being loved.

36. Divorce as a Prototypic Event • It would seem that divorce, which involves a major falling apart of the prototypic relationship of the child’s early life can have very negative and pervasive effects that continue over time and serve to color the child and adult view of relationships and the world. Question What may be learned about relationships from experiencing parental divorce?

37. Marital Violence • While there is less research on exposure to marital violence than on child abuse, the work that has been done suggests that observing violence between parents can have a significant impact on the child and his/her behavior. • The effects seem to be on increasing overall adjustment problems, anxiety, depression and other internalizing problems such as fearfulness and insecurity.

38. Marital Violence • These features seem to be more pronounced in children who have been abused themselves. • These children also show increased levels of aggression. • They also often display inappropriate attitudes regarding violence as a means of resolving conflict and a greater willingness to use violence themselves.

39. Child Maltreatment • Unfortunately, child abuse in various forms is a common problem experienced by children. • Difficult to obtain good estimates of prevalence. • The frequency is highlighted by statistics from the Department of Health and Human Services (1999) which suggested more than two million reports, and 967 deaths due to maltreatment in 1997. • The national rate of victimization was 13.9 victims per 1,000 children under the age of 18 in the U.S. population.

40. Professional Obligations • In clinical practice it is often necessary to report suspected child maltreatment to the Department of Child and Family Services. • ALL mental health practitioners and health care professionals and others that work with children (e.g., teachers, school office personnel, social workers, child care workers, law enforcement officers, etc.) have an obligation to report abuse and neglect. • Under penalty of law !!!!!

41. The Nature of Child Abuse and Neglect • Child abuse and neglect involves the: • Physical or mental injury. • Sexual abuse or exploitation. • Negligent treatment or • Maltreatment. • of a child under 18 by a person responsible for the child’s welfare where. • the child’s health or welfare is threatened or harmed.

42. Physical Abuse • Is characterized by intentionally inflicting physical injury on a child. • Physical abuse may involve • Injuries intentionally inflicted by hitting, punching, beating, kicking, throwing, biting, and burning. • The injury may have occurred during a single episode or multiple episodes and can range from minor cuts/abrasions to fatality-related head and internal injuries.

43. Sexual Abuse • Any act where the child is coerced by an adult to engage in sexual contact for the purpose of gratifying the abuser. • Sexual abuse includes but is not limited to: • Fondling the child’s sexual parts, • Exposure of the abuser’s sexual parts to the child. • Forcing the child to fondle the abuser’s sexual parts, • Sexual intercourse, • Exposure to explicit pornographic materials.

44. Physical Neglect • The failure to provide the child with necessities and stimulation that contribute to the health and development of the child such as: • Leaving the child unsupervised at home • Failing to provide adequate food and nourishment, shelter, and clothing, and • Living in unsanitary conditions.

45. Psychological Maltreatment • Involves intentional acts that harm the emotional well-being of a child. • Examples include: • Belittling and degrading a child, • Threats to physically harm or abandon the child, • Exposing the child to domestic violence within the home.

46. Medical Neglect • Medical neglect occurs when medically necessary intervention is not obtained for a child in medical need.

47. Child Abuse: Etiology • Views Emphasizing Parental Causes • Psychopathology • Lack of Empathy • Low Frustration Tolerance, Impulsivity • History of Abuse • Views Emphasizing Child Characteristics • Problem Behavior • Special Characteristics • Views Emphasizing Social Factors • Stress- Poverty-Social Isolation • Most cases likely involve a combination of factors

48. Child Abuse: Effects • There is a considerable body of literature documenting the negative psychological and behavioral effects of child abuse. • Effects can include impaired self esteem, anxiety, depression, emotionally constricted and inhibited behavior, irritability, extreme aggressive behavior, and PTSD. • Other studies suggest even more severe potential outcomes.

49. Child Abuse: Long Term Effects • In a study by Brown et. al (1999) investigating the effects of abuse, sexual abuse, and neglect in childhood (N = 776) on adult depression and suicidal behavior it was found that: • Adolescents and young adults with a history of childhood maltreatment were 3 times more likely to become depressed or suicidal compared to individual without such a history. • Risk of repeated suicide attempts was 8 times greater for youth with a sexual abuse history.

50. Child Abuse Effects • Abuse, like divorce, can also impact on the child’s general view of relationships and of the world. • Those who are supposed to love you are the ones who hurt you and who you can’t trust. • Effects on Later Relationships????