In our neuropsychology practice we see a large number of children with special health care needs (i.e., medical conditions) as well as children with neurodevelopmental or psychiatric conditions (autism, language impaiments, ADHD). Although the main goal of these evaluations is to identify their patterns of cognitive strengths and weaknesses to guide intervention, we always evaluate the current mental health functioning of these children. We do this because we often see that these children have high levels of anxiety and depression, which many times go unnoticed. Although this is a very common clinical observation, and many studies have shown that specific chronic physical or developmental conditions are associated with internalizing mental health symptoms (depression and anxiety), less is know about the prevalence of mental health symptoms in this population and the factors that increase the risk for experiencing or developing internalizing symptoms.
The current issue of the journal Pediatrics includes a study examined the prevalence and correlates of internalizing symptoms among Children with Special Health Care Needs (CSHCN). CSHCN are children “ who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and related services of a type or amount beyond those required by children generally.” This includes close to 14% of all US children. The authors examined data obtained from the National Survey of Children with Special Health Care Needs conducted in 2005-2006. This telephone survey was completed by 40,465 families with CSHCN. The authors examined 1) whether a parent reported elevated symptoms of depression or anxiety in the target child (i.e., CSHCN) and a number of demographic and health related variables that could be potentially related with a reduction or increase in the odds of experiencing internalizing symptoms. The demographic variables included: the child’s gender, age, race/ethnicity, primary language, poverty status, insurance status, urban vs. rural residence, parents’ education, and parents’ marital status. The health related variables included: the type of health condition or symptom that qualified the child as CSHCN, frequency of activity limitations due to the condition, number of physician visits, number of school days missed, amount paid for care, hours spent coordinating care, and parental employment changes related to the child’s condition.
- 32% of all CSHCN experienced internalizing mental health symptoms, but this rate varied significantly by the age of the child
- Only 16% of 3 to 5 year old children experience internalizing symptoms, but this rate increased to almost 39% for children 12 to 17 years of age. There was no difference in the rates of internalizing symptoms for children 12-14 years old as compared to those 15-17 years old.
- After controlling for specific demographic variables (e.g., SES) non-Hispanic black children were 26% less likely to experience internalizing symptoms than non-Hispanic white children.
- Living in a house without both biological parents increased the odds of experiencing internalizing symptoms between 28% and 56%.
- Being uninsured increased the odds of experiencing internalizing symptoms by 51% as compared to having private insurance.
- Having high levels of activity limitations increased the odds of internalizing symptoms by 139%
- More internalizing symptoms were also associated with having more visits to the physician, missing more school days, financial problems, and having a parent having to quit or to cut back on work due to the child’s health problem.
Below is a table with the proportion of children with specific conditions that experienced internalizing problems.
As you can see, the conditions most strongly associated with internalizing symptoms were autism spectrum disorders (70.7% of children with ASD experienced internalizing symptoms), behavior problems (69%), and developmental delays (61%). The conditions least associated with internalizing symptoms were asthma (22%), diabetes (29%), and allergies (29%).
These results highlight how prevalent depressive and anxiety symptoms are among children with special needs. This is particularly worrisome among adolescents. It appears that by age 12, close to 40% of these children are experiencing noticeable levels of anxiety and depression. The results suggest that parents, physicians and other health care providers should be attentive to the possible presence of anxiety and depression among these children, specially during adolescence.
The reference: Ghandour, R., Kogan, M., Blumberg, S., & Perry, D. (2010). Prevalence and Correlates of Internalizing Mental Health Symptoms Among CSHCN PEDIATRICS, 125 (2) DOI: 10.1542/peds.2009-0622
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