Maternal Depression and Child Psychopathology: A Two-Way Street

By Anita M. Schimizzi, Ph.D.

Weve had a lot of research come out on the effects of maternal depression on children.  We know that these kids have higher rates of social, emotional, and mental health issues.  Well, the Journal of Abnormal Psychology recently published a study that looks at the arrow going the other way.  That is, it looks at the effect that child psychopathology has on moms in terms of depression and child-related stress.  What they found was that the street runs both ways between maternal and child mental health.

Raposa and colleagues (2011) looked at data from a large pool of mother-child pairs that had been followed for a pregnancy study.  Information was collected on the pairs during pregnancy to child age five and at child age 15 and 20.  This data was collected from well-known standardized interviews, meaning that they were both reliable and valid in collecting information on certain mental health-related topics.  The researchers looked at maternal depression, child psychopathology, child-related stress, and demographic information. 

The authors were specifically interested in looking at the impact of youth (age 15 and 20) psychopathology on mothers so they controlled for youth gender, SES, and maternal depression prior to age 15.  The results indicated that, indeed, maternal depression could be predicted by having a youth with a history of mental health diagnoses both at the time the youth was 15 and 20 years of age.   

In looking at child-related stress, the number of past child mental health diagnoses significantly predicted a higher number of acute stressors for mothers as well as more chronic stress in the mother-child relationship at age 15.  These increased levels of maternal stress and mother-child relationship stress at age 15 then predicted higher levels of maternal depression when the youth were 20 years old. 

Looking more closely at the data, the authors found that it was the chronic stress in the mother-child relationship and the child-related acute stressors that were the linchpins between child psychopathology and maternal depression.  The stress is what fueled the fires between mother and child mental health.  Going one step further, the researchers found that youth with a history of more than one diagnosis as well as youth that had externalizing disorders (e.g., conduct disorder) had the highest number of child-related stressors and the highest levels of mother-child stress.  Again, all of the findings held up when other potentially stressful variables, such as economic worries and past maternal depression, were controlled for.

So what does this study teach us?  While maternal depression has been found to have negative effects on children, children’s history of mental health problems also has negative effects on maternal depression.  Most importantly, the stress that the child’s poor mental health history brings to the mother’s plate and the mother-child relationship seems to be the key to understand and address.

Tackling the stress can be both overwhelming and complex, making support a must and professional intervention highly recommended.  I know that for some parents that hear the words “parent education”, an image of some know-it-all that tells you how you’re screwing up comes to mind.  On the contrary, parent education sessions can be a lifeline and a source of empowerment for parents.  They can be a place where parents realize that they are not alone in their struggles and gain much-needed support, where they can learn more information on their children’s diagnoses and difficulties, where they can troubleshoot ways to manage trying situations, structure daily living to bring down the stress, and create more positive interactions with their children.  In addition, family and individual therapy can be other tools that can help improve the mother-child relationship as well as the well-being of the entire family. 

Having a child with psychopathology can be a huge challenge.  Managing that challenge in the midst of high levels of parent-child stress and your own depression is a whopper that nobody should have to tackle alone.  Best wishes to all of the moms out there that are facing these challenges.  -Anita

Source: Raposa, E., Hammen, C., & Brennan, P. (2011). Effects of Child Psychopathology on Maternal Depression: The Mediating Role of Child-Related Acute and Chronic Stressors Journal of Abnormal Child Psychology DOI: 10.1007/s10802-011-9536-0

Depressed Dads and Their One Year-Olds

By Anita M. Schimizzi, Ph.D.

There has been a lot of research done on maternal depression and we know that it can have a big impact on children.  We don’t know as much about paternal depression because, quite frankly, there just hasn’t been the same focus on this issue.  I was excited to come across an article by Davis and colleagues, who recognize the importance of fathers’ well-being in their recently published research on paternal depression and behavior toward one year-olds.

Why is it important to explore depression in fathers?  The research that has been done shows that paternal warmth and sensitivity can go down in depressed dads while conflict, hostility, and rejection toward their kids can go up.  Additionally, children’s psychosocial functioning goes down when dads are depressed.  Other research found that direct father-child interactions have a strong relationship with the health and development of their children.

The current study used a nationally representative sample of fathers of one year-olds, 1,746 dads in total.  The men answered questions in four different areas: interactive play (e.g., peek-a-boo), speech and language interactions, reading to the child, and spanking.  Whether or not the fathers had talked with their child’s pediatrician during the past year was also assessed.

Seven percent of the fathers in the study reported being depressed during the past year.  Seventy-seven percent of these dads also had spoken with the pediatrician over the past year.  The chart below shows the results in the four different areas.  As can be seen, there were no differences between fathers that were not depressed and those that were in their reports of playing interactive games and singing songs/nursery rhymes with their children.  Depressed dads were less likely to read to their one year-olds and much more likely to spank them.

In fact, when further analyses were done, depression in fathers predicted reading to their one-year olds at a rate that was less than half of what non-depressed fathers reported and spanking at a rate almost four times that of non-depressed dads.  These findings occurred regardless of variables such as fathers’ age, race, education level, and household income.

Why is this study important?  For starters, paternal reading early on had been associated with positive language development.  The research on spanking overflows with negative consequences for children, such as increased aggression later on.  (Take a look at Dr. Lopez-Duran’s post on spanking for more information.) 

And then there is the obvious.  Depressed dads need and deserve support just as much as depressed moms do.  Parenting is hard enough when we’re feeling well.  Being depressed can make it feel like an unmanageable challenge.  The researchers argue for regular screening of paternal depression during pediatric visits, as most of the fathers in the study report talking with their child’s pediatrician.  Referrals for services can then be made as a result.

I would go further to encourage fathers that are dealing with depression to consider some/all of the following: develop and stay connected to a support network, take time for yourself to do things that bring you joy (even if it’s just a little bit), consider joining a support group for dads, learn alternatives to corporal punishment (see my earlier blog post), take a parenting skills class to get ideas that can be carried out at home, take on a project that can be done in small steps, and make eating well and getting enough sleep a priority.  And remember, you are one of the most important people in your child’s life.  He/she wants you to feel better, too.

Source: Davis RN, Davis MM, Freed GL, Clark SJ (2011). Fathers depression related to positive and negative parenting behaviors with 1-year-old children. Pediatrics, 127 (4), 612-8 PMID: 21402627

Parents, Teens, and Sex: The Talk

By Anita M. Schimizzi, Ph.D.

Are parents’ attempts to keep their teens sexually safe having unintended consequences? 

I came across an article in the December, 2010 issue of the Journal of Family Psychology that looked at adolescent sexual behavior and consequences, and then related these to a variety of parenting factors.  What may surprise some is that the talks that many parents have with their teens to promote sexual safety and/or abstinence were associated with higher levels of sexual initiation, unprotected sex, and sexually transmitted infections (STIs).  What was the most important factor to guard against sexual risks?  The adolescent’s positive perception of the general parent-adolescent relationship appeared to be key.

Deptula, Henry, and Shoeny used data collected from a large and nationally representative sample of adolescents for the National Longitudinal Study of Adolescent Health (Add Health) to look at the relationship between several parent variables (sexual communication with the adolescent, parent-child relationship, general parental involvement, parents’ educational aspirations for their adolescent, allowed independence, sexual communication attitudes, discussion of sexual costs, and parent disapproval of the adolescent having sex) and four sexual risk factors (adolescent sexual activity, intercourse without a condom, unintended pregnancy, and STIs).  They also looked at these variables in relation to ethnicity, gender, and age.  Add Health data collection occurred three times: 1994-5, 1996, and 2001-2.

The investigators found that higher levels of adolescent independence and lower levels of parent-adolescent relationship quality significantly predicted lower levels of condom use and this held especially true for younger adolescents.  Additionally, the teens that had lower levels of condom use could be predicted by having parents that disapproved of teen sexual activity.  So the more time the teen had unsupervised, the lesser the quality of his/her relationship with parents, and the more the parents outwardly disapproved of sex, the more likely their teen was to have unprotected sex.

Almost 80% of the adolescents that reported being abstinent during the beginning of the study reported the same a year later.  What predicted sexual activity for the remaining 20%?  Some of the strongest predictors were low parent-child relationship quality, higher levels of parent disapproval of sex, and parents’ talks about sexual costs such as STIs.  That’s right.  The parents that disapproved of sex and emphasized sexual risk had a higher likelihood of having a sexually active teen.

Further, the parents that emphasized sexual costs with their younger adolescents at the beginning of the study had adolescents with a higher rate of STIs at end of it.  Those adolescents with higher parent-adolescent relationship quality had a lower STI rate.

The one significant factor that predicted unintended pregnancy at the end of the study was already having sexual intercourse at the time the study began.  In other words, those teens that reported having sex the longest had a higher rate of unintended pregnancy than their peers.

So what does this study reveal to us?  It appears that the most effective way parents can keep their adolescents sexually safe is by cultivating a positive relationship with them.  In terms of conversations that specifically target sex, the investigators report that their lack of data about the nature of these conversations limits their ability to fully understand them.  They do state, however, that other investigators (Dutra et al., 1999; Mueller & Powers, 1990) found that warm and open communication in general and about sex in particular was associated with lower rates of adolescent sexual activity and/or risk.  In other words, parents may serve their adolescents best by skipping the lectures and moving toward a reciprocal, receptive, and supportive communication style that encourages open discourse about sex and other important topics.

Deptula, D., Henry, D., Schoeny, M. (2010). How can parents make a difference? Longitudinal associations with adolescent sexual behavior. Journal of Family Psychology, 24 (6), 731-739 DOI: 10.1037/a0021760

Supporting Families Affected by Deployment: New Possibilities for Military Families

By Anita M. Schimizzi, Ph.D.

Over the past many years of the wars in Iraq and Afghanistan, I have been left wondering what is being done to support, really support, our military families that remain behind as well as our soldiers that have gone through and continue to go through military deployment.  I came across this study and was both delighted and hopeful to learn about a new program that targets military families in a comprehensive and thoughtful way to ease the stress of deployment.  Read on to find out about it.

Military deployment, including that due to the current operations in Afghanistan and Iraq (OEF/OIF), can bring about a lot of stress for both parents and children and this stress may look different based on the stage of deployment: pre-deployment, deployment, or reintegration.  Gerwitz and colleagues (2011) outline ways in which a new program may give families much needed support as they deal with deployment stress.

The Parent Management Training-Oregon model (PMTO) includes research-based parenting strategies that the authors state can be adapted for military families to help reduce stress in the face of deployment.  Across time, the PMTO model has been shown to positively impact families in a variety of ways, such as improved child behaviors, co-parenting, and marital satisfaction as well as decreased maternal depression, parent and child substance use, and financial stress. The authors have received extensive NIH funding to extend the services available in the After Deployment Adaptive Parenting Tools Program (ADAPT) to include a military-specific PMTO model.

The model includes several key strategies and the authors include them in three broad goals for military families: 1) increase family resiliency; 2) address family stress through each phase of the deployment cycle; and 3) help parents learn emotion regulation techniques to become more effective in parenting.

The authors suggest using the family’s strengths to help them build skills for effectively coping with the stresses of deployment.  A goal-oriented approach would be emphasized to keep the family forward-focused and moving in a positive direction.

To address deployment-related family stress, strategies would be taught that help parents to keep up with routines, rules, and rituals so that their child’s daily lives can feel as safe and predictable as possible.  Parents would learn how to help their children cope with both routine and bigger stressors through problem-solving, setting family goals, and having family meetings. Parents would also learn about their children’s particular stage of development and how the world is viewed and dealt with based on this stage, which could aid parents in helping their children deal with stress.  The importance of keeping transitions to a low during times of deployment would be emphasized since children typically become more stressed as the number of changes in their daily lives goes up.  Finally, parents would be taught how to maintain a united parenting front and to keep common parenting goals so that the couple can better manage shifts in parenting during the deployment cycle.

To increase emotion regulation in parents, they would be given individual and couple support in managing their own stress.  Also, parents would learn how to keep tabs on their emotions as they parent.  For example, they would learn how to keep calm and neutral while working with their children on following directions.  Finally, parents would be taught how to increase positive parenting techniques and decrease critical or coercive ones.

The authors suggest that the PMTO model could be offered in a web-based, group format, making it highly accessible to military families.  They go on to state that it does not replace the need for more intensive services for soldiers and families that undergo severe stress, such as substance abuse, serious injury or death, and PTSD.  Overall, the model appears to be a promising step toward giving military families the support that they need and deserve as they cope with the difficulties of deployment.

Source: Gerwitz, A. H., Erbes, C. R., Polusny, M. A., Forgatch, M. S., & DeGarmo, D. S. (2011). Helping Military Families Through the Deployment Process: Strategies to Support Parenting, Professional Psychology: Research and Practice, 42 (1), 56-62. DOI 10.1037/a0022345

Monday Briefs: Anti-psychotic drugs during pregnancy.

By Nestor Lopez-Duran PhD


FDA updates warning on use of anti-psychotic medications during pregnancy.

Today I came across a news report on Yahoo news regarding a recent FDA update to the pregnancy section of the label on anti-psychotic drugs. Specifically, the FDA indicates that infants born to mothers who take anti-psychotic drugs during the 3rd trimester are at high risk for developing withdrawal or extrapyramidal symptoms (atypical muscle and motor functioning).

The specific announcement is as follows:

[2-22-2011] The U.S. Food and Drug Administration (FDA) is informing healthcare professionals that it has updated the Pregnancy section of drug labels for the entire class of antipsychotic drugs. The new drug labels now contain more and consistent information about the potential risk for abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy.

Antipsychotic drugs are used to treat symptoms of psychiatric disorders such as schizophrenia and bipolar disorder, and have been shown to improve daily functioning in individuals with these disorders. Common brand names for antipsychotic drugs include Haldol, Clozaril, Risperdal, Zyprexa, Seroquel, Abilify, Geodon, and Invega (see List of Antipsychotic Drugs below).

Healthcare professionals should be aware of the effects of antipsychotic medications on newborns when the medications are used during pregnancy. Patients should not stop taking these medications if they become pregnant without talking to their healthcare professional, as abruptly stopping antipsychotic medications can cause significant complications for treatment.

The symptoms of EPS and withdrawal in newborns may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding. In some newborns, the symptoms subside within hours or days and do not require specific treatment; other newborns may require longer hospital stays.

Two important things are worth noting. First, the FDA correctly warns parents AGAINST stopping the medication if they are pregnant without first talking to their physician because stopping the medication abruptly could lead to adverse side effects. In addition, it is important to discuss with your physician the overall consequences of not taking the drug (beyond just side effects) in order to better understand the possible risks and benefits. It is possible that not taking the medication could lead to consequences that may be significantly more harmful to the baby or fetus than the risk for withdrawal symptoms. This possibility is something you need to discuss with your physician.  I highlight this issue because the public tends to react strongly to these type of FDA warnings to unfortunate consequences. For example, after the FDA warned that anti-depressant medications (such as Prozac) could increase the risk for suicide in some teens, the use of anti-depressants in teens dropped dramatically and the teen suicide rate actually increased significantly.

Second, this warning was based on 69 cases of possible withdrawal or extrapyramidal symptoms in newborns. In most of these cases, the mother was taking other drugs in addition to the anti-psychotic medication, which makes it difficult to determine whether the withdrawal symptoms were due to the anti-psychotic or to other drugs (such as anti-anxiety medications).

Here is the official FDA warning:

In sum, please do not stop taking your medication without first consulting with your physician and discussing the possible risks and benefits of taking this medication while pregnant.

DISCLAIMER: I do not receive any direct payment from the pharmaceutical industry and my research has never been funded by drug companies. I do not receive any financial compensation from any statement regarding medication use. As a psychologist, I do not prescribe medication in my practice.

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Pregnancy timing and autism risk: Wait 3 years between births to lower your childs risk?

By Nestor Lopez-Duran PhD

The results of last weeks poll are in and the autism article won by a wide margin. So here are some thoughts on the recent pregnancy timing and autism study.

A team from Columbia University was interested in examining the link between Inter Pregnancy Interval (e.g., time between pregnancies; IPI) and autism. IPI is important because short intervals between pregnancies (e.g., having kids too close together) is associated with specific physiological factors that have been linked to developmental problems, such as low birth weight, prematurity, etc.

For the study, the researchers examined all births in California from 1992 to 2002. They were able to identify 662,730 sibling pairs for which they had information about the timing of the pregnancies. That is, they identified the number of months between the births of the first and the second sibling. They then obtained a large number of demographic and clinical information such as race/ethnicity, gestational age of the pregnancies, paternal age, etc. They were also able to gather information about the autism diagnosis of these children from the Department of Developmental Services (DDS) records.

A total of 3,137 second-born siblings with autism were identified. An important characteristic of this study is that the DDS does not provide services to children with only PDD-NOS or Aspergers. Therefore the results are specific to the presence of full autism.

The authors then calculated whether the probability of having autism among second-born siblings changed as a function of the number of months that lapsed since the birth of the first-born sibling.

Below you will see a graph that summarizes the very surprising results. On the horizontal axis you see the IPI in months. That is, the number of months between the birth of the first and second-born siblings. On the horizontal axis you will find the odds ratio (a type of probability) that the second-born child will have autism. The line in the middle across the odds ratio of 1 reflects a 50-50 chance that the second-born child will have autism. When the odds ratio is above this line, it means that the probability of autism increases. When the odds ratio is below the line, it means that the probability of autism decreases.

As you can see, the probability that the second-born child had autism was very high if the time between pregnancies was under 12 months. In contrast, the probability was lower if the time between pregnancies was longer than 24 months.

The numbers below give you an even better picture. Once you control for a number of factors such as childs sex, parental age, etc etc, having pregnancies close together greatly increased the risk for autism in the second-born child. Specifically:

– Children born less than 12 months after their siblings were close to 300% more likely to have autism when compared to second-born children born 48 months after the first sibling.

– Children born between 12 and 23 months after their siblings were 110% more likely to have autism when compared to second-born children born 48 months after the first sibling.

– Children born between 24 and 35 months after their siblings were 42% more likely to have autism when compared to second-born children born 48 months after the first sibling.

The risk finally stabilized at 36 months. Specifically, being born 36 months after their siblings did not increase or decrease the chance of autism as compared to kids born 48 months after their siblings. Likewise, being born many many months after their siblings (for example more than 84 months) did not reduce the chance of having autism as compared to those born 36 months after their siblings.

This suggests that waiting 36 months between pregnancies would reduce the risk of autism but waiting longer provides no added benefit.

Now the really interesting question is why. What is the mechanism that could explain this finding?

The authors suggest that a likely cause may be folate depletion. Short time between pregnancies is associated with nutritional depletion and folate depletion in particular. Folate is a critical nutrient needed during pregnancy for DNA synthesis and levels of maternal folate decline drastically during the 12 months after having a child.

Here is an useful article from the National Institutes of Health about folate

The Reference: Cheslack-Postava, K., Liu, K., & Bearman, P. (2011). Closely Spaced Pregnancies Are Associated With Increased Odds of Autism in California Sibling Births PEDIATRICS, 127 (2), 246-253 DOI: 10.1542/peds.2010-2371

Depression during pregnancy and birth complications.

By Nestor Lopez-Duran PhD

Editors note: Due to the yesterday especial editorial on bullying and suicide, Mondays brief comes to you a date late. Wednesdays post will be published tomorrow as expected. We will review the latest study on vaccines and autism.

The leading causes of childhood disabilities are prenatal and neonatal complications, such as preterm birth, low birth weight, and intrauterine growth restriction. There are multiple factors that can lead to these complications, such as smoking, drinking, and experiencing some medical conditions.  Some studies have suggested that maternal depression can increase the risk for these complications but other studies have found that depression has no impact on these complications. Why the discrepancy? The latest issue of the prestigious journal Archives of General Psychiatry included a comprehensive meta-analysis of the association between depression during pregnancy and birth complications. In the meta-analysis, the authors merged the results previous studies on this topic in order to examine factors that could explain the differences between the studies.

Among the many factors that the authors examined, I want to focus on a specific issue: whether the previous studies measured depression as a categorical construct (e.g., comparing mothers who met diagnostic criteria for a depressive disorder against those who didnt meet criteria) or as a continuous construct (comparing those with more symptoms of depression to those with less symptoms of depression). Overall, the authors found the following:

Effects of Depression on Pre-Term Birth:

Depression during pregnancy, when measured as a categorical construct, increased the risk for pre-term birth by 39%. In contrast, depression symptoms increased the risk by only 3%.

Effects of Depression Low Birth Weight:

Depression during pregnancy, when measured as a categorical construct, increased the risk for low birth weight by 49%. In contrast, depression symptoms did not impact the risk for low birth weight.

Effects of Depression on Intrauterine Growth Restriction:

Depression during pregnancy, when measured as a categorical construct, increased the risk for intrauterine growth restriction by 45%. In contrast, depression symptoms did not impact the risk for intrauterine growth restriction.

These results suggest that having some symptoms of depression may not increase the risk of birth complications. However, having clinical depression significantly increases the risk for complications. This is not entirely surprising since there are significant differences between experiencing symptoms of depression, many of which are common and normative, and having a diagnosed depressive disorder. In this case, it seems that having a depressive disorder is a risk factor for prenatal and neonatal complications. This highlights the need to screen for depression during pregnancy so that those affected can receive treatment.

The authors concluded:

Clearly, pregnancy is an important time to universally screen women for depression, especially those who are socioeconomically disadvantaged, and to improve their timely access to evidence-based prenatal and mental health services. Improved accuracy of diagnosis and treatment of antenatal depression combined with education about harmful but potentially modifiable lifestyle practices could lead to decreased rates of PTB and LBW.

The reference:

Grote, N., Bridge, J., Gavin, A., Melville, J., Iyengar, S., & Katon, W. (2010). A Meta-analysis of Depression During Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction Archives of General Psychiatry, 67 (10), 1012-1024 DOI: 10.1001/archgenpsychiatry.2010.111

Is daycare good for my child? Daycare effects on school performance.

By Nestor Lopez-Duran PhD

One drawback of our culture of individualism is that it perpetuates the myth that we all have equal opportunities for success and that the only thing that is needed to achieve our goals is personal effort. The research on environmental contributions to academic and professional success strongly argues against this myth. Actually, our privileges and disadvantages start at birth. For example, factors associated with parental socio-economic status during early childhood, such as parental education, has a major impact on childrens academic performance. The critical question is why is this the case and what can we do about it.

One well supported theory purports that that these kids are exposed to limited learning experiences before they start school, which leads to poor school readiness. This means that these kids are already behind their peers when they enter kindergarten and thus have  difficulty catching up throughout their education. If this is the case, providing rich learning opportunities to these kids before they start kindergarten, such as those provided at daycare centers, could have a major impact on the kids school readiness and academic achievement.

In an article just published in the Journal of Child Psychology and Psychiatry a team from the University of Montreal studied the daycare experiences and academic performance of 1,863 children born in 1997 and 1998. They were interested in examining whether the expected differences in school readiness and achievement between kids with advantaged and disadvantaged backgrounds persisted if the kids attended quality daycare.

The results:

– As expected, kids of parents with limited education scored lower in tests of academic readiness before starting first grade and performed worse in academic achievement tests in 1st grade than kids whos parents had more education.

– However, attending daycare before kindergarten greatly improved the performance of kids from disadvantaged backgrounds. In contrast, for  kids whose parents had high levels of education, attending daycare didnt change their academic performance.

– In addition, attending daycare, whether formal or informal, eliminated the gap between the kids in some key measures. For example:

The lollipop test is a well known measure of academic readiness. As you can see, there was no difference in scores between kids of mothers with high or low levels of education as long as the kids attended daycare. In contrast, not attending daycare had a great negative impact on the academic readiness of the kids whose mothers had low levels of education.  These effects were observed after controlling for a long list of possible explanatory variables, such as gender, birth weight, maternal age, income, breastfeeding, etc.

In conclusion, this study suggests that attending daycare has a significant positive impact on academic readiness and achievement for kids of parents with limited education.

I know, I have to work on the brief portion of Mondays briefs .

This post is sponsored by Kendall College. Get your early childhood education degree.

Geoffroy, M., Côté, S., Giguère, C., Dionne, G., Zelazo, P., Tremblay, R., Boivin, M., & Séguin, J. (2010). Closing the gap in academic readiness and achievement: the role of early childcare Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2010.02316.x

ADHD and Conduct Disorder: Delinquency in teens with ADHD and other conditions

By Nestor Lopez-Duran PhD

Given the high rates of ADHD diagnoses in the USA, and recent discussions about the likely misdiagnoses of tens of thousands of children, it is easy for some to dismiss ADHD as jus a term used by zealous clinicians to label kids who just want to be kids. But such an attitude ignores the real struggles that kids with true ADHD experience as compared to their non-affected peers.

For example, this week I read a study just published in the prestigious Journal of Abnormal Child Psychology that examined the association between ADHD and delinquency. Specifically, the study explored whether kids diagnosed with ADHD in early childhood were more likely than their peers to engage in criminal behavior in adolescence. Likewise, given the high co-occurrence of ADHD and other behavioral disorders, such as conduct disorder and oppositional defiant disorder, the study also explored whether the combination of ADHD and these disorders put these kids at an even higher risk for committing violent and/or criminal acts in adolescence.

The study included over 400 boys who were followed from early childhood into adolescence. In early childhood, 209 of the participants did not have any diagnosis (control group), 47 were diagnosed with ADHD only, 135 were diagnosed with ADHD and oppositional defiant disorder (ODD), and 106 were diagnosed with ADHD and conduct disorder (CD). Once the kids reached adolescence 8 years later, the researchers examined the kids participation in delinquent acts (e.g., theft, assault, arson, etc).

The results:

In the graphic above you can see the percentage of children in each of the 4 groups (1. controls; 2. ADHD only; 3. ADHD/ODD; 4. ADHD/CD) that first engaged in severe delinquent acts (e.g., assault with a weapon, arson, rape, etc) at specific ages. As you can see, the group with comorbid ADHD and conduct disorder were the most at risk, with 20% committing a severe act by age 13 and over 40% by age 18. We could dismiss this as simply reflecting the role of conduct disorder. That is, we could argue that it is not the ADHD but the conduct disorder that is leading to more severe criminal acts. But take a look at the two lines in the middle. Virtually identical, these lines represent the kids with ADHD and oppositional defiant disorder as well as the kids with ADHD only. Both groups were significantly more at risk than their control peers. Specifically, the study found that both of these groups were more likely to offend earlier, commit a greater variety of crimes, and initiate severe delinquency than comparison participants, and by comparison the authors mean those without a diagnosis of ADHD.

The research then suggests that kids with ADHD, even those who do not show serious conduct problems in early childhood (the ADHD only group), are at a high risk for engaging in severe delinquent behavior in adolescence. This finding is even more upsetting when you consider that the participants in this study received outstanding care during early childhood. Specifically, these kids had taken part in a large treatment study that involved intensive intervention, including parent management training and medication when necessary. The particular intervention used in that study is known as one of the most effective intervention for kids with ADHD. So the disturbing aspect of the findings is that these kids were at such high risk for severe delinquent behavior DESPITE receiving proper intervention. This highlights two issues: 1) the need to develop more effective interventions focused on preventing future delinquency among kids with ADHD, and 2) the need for parents, educators, and clinicians to closely monitor these kids in an effort to prevent severe delinquency.

The authors stated:

For children with ADHD, an elevated risk for nonnormative delinquency is just one of a slew of probable negative life outcomes, including school drop-out, interpersonal difficulties, substance use, and unemployment (Barkley et al. 2007; Mannuzza et al. 1993; Molina et al. 2007b; Weiss and Hechtman 1993). These outcomes highlight the intense need for treatment in individuals diagnosed with ADHD. All PALS probands participated in an 8-week intensive Summer Treatment Program and their parents received a standard course of behavioral parent training (Pelham and Hoza 1996). They also received an average of 6 years of pharmacological intervention. However, the findings of this study and others from this same sample (Molina et al. 2007b; Kent et al. 2010) suggest that these interventions were not sufficient to prevent the negative outcomes that are common for children with ADHD.

The reference:
Sibley, M., Pelham, W., Molina, B., Gnagy, E., Waschbusch, D., Biswas, A., MacLean, M., Babinski, D., & Karch, K. (2010). The Delinquency Outcomes of Boys with ADHD with and Without Comorbidity Journal of Abnormal Child Psychology DOI: 10.1007/s10802-010-9443-9

Kids Bikes: Are cycling and football the most dangerous sports for children?

By Nestor Lopez-Duran PhD

The journal of the American Academy of Pediatrics just published a fascinating examination of emergency room visits for concussions from 2001 to 2005 in 100 US hospitals among kids aged 8 to 19. The authors were particularly interested in examining the role of sports in concussion-related ER visits.

– Of 502,784 concussions among 8-19 years old, 50% were sports related injuries.

– Among pre-high school kids (8-13 y old), 58% of all concussions were sports related.

– Among high school kids (14-19y old), 46% of concussions were sports related.

Which sports sends the most kids to the hospital for concussions?

Here is a graph showing the % of all sports related concussions accounted by each sport/activity for8-13 year old kids:

As you can see above, for kids age 8-13, cycling accounted for the highest percentage of sports related concussions (18%), football was a close second, accounting for about 10% of all sports related brain injuries.

Now here is the same graph for older teens (14 to 19 years old):

In older teens, football is, by far, responsible for more concussions than any other activity or sport: football accounted for close to 40% of all sports related concussions. Basketball and Soccer each accounted for over 10% of sports related concussions. In contrast, cycling accounted for just over 5% of concussions among these older kids.

Whats a parent to do?

Before you put your kids bike on craigslist, there is something you need to know about these data. Cycling could be considered the most dangerous sport for young kids as so far as it is responsible for the highest percentage of sports related brain injuries. However, cycling is also extremely popular, with millions of kids riding bikes every year. This popularity could explain why cycling accounts for so many ER visits. So the data presented today doesnt help us understand the probability of injury when participating in each sport, which I would consider a better definition of dangerous. Let me give you an example with FABRICATED DATA. Imagine that cycling results in 1 brain injury for every 100,000 child bike user hours (for every 100,000 hours that a child is riding a bike, one child will have a brain injury). In contrast, snowboarding may result in 1 brain injury for every 1,000 snowboarding hours. In this scenario, the risk of experiencing a brain injury is significantly higher when snowboarding than when cycling. Specifically, you could argue that snowboarding is 100 times more dangerous than cycling. Yet, because cycling is significantly more popular (in terms of use) than snowboarding, cycling would send more people to the hospital. (Again these last statements are based on a hypothetical case with fabricated data. I dont really know if snowboarding is more dangerous than cycling.)

So the graphics presented above tell us which sports and activities are sending the most people to the hospital, but not necessarily which sport/activity is the most dangerous in terms of the probability of injury to the participants.

What would I do? I would likely minimize (but not forbid) cycling in my kids until they are 13, and I would enforce a no exceptions helmets on at all times policy when they ride their bikes. If my kid decides he wants to play football, I would enforce a 1-2 concussion limit, because the danger of a catastrophic event (e.g., second impact syndrome) increases dramatically after you experience a concussion. Here is a wonderful website about youth sports concussion by the CDC.

The reference:
Bakhos, L., Lockhart, G., Myers, R., & Linakis, J. (2010). Emergency Department Visits for Concussion in Young Child Athletes PEDIATRICS, 126 (3) DOI: 10.1542/peds.2009-3101