EARLY CHILDHOOD SCREENING PREDICTS LATER BEHAVIORAL PROBLEMS

Significant emotional or behavioral problems are often not detected until affected children begin school.  Moreover, even in moderately severe cases, children with emotional and behavioral problems may not receive appropriate screening and intervention until they have been in school for several years.  Researchers from the University of Connecticut and the University of Massachusetts have just published the results of an interesting study, in the journal Pediatrics, in which they screened children for behavioral and psychological problems at a very early age, and then followed them as they subsequently entered elementary school.

A total of 1,004 socio-economically and ethnically diverse children were evaluated in this study.  The children’s parents completed a standardized Brief Infant-Toddler Social and Emotional Assessment survey when their children were between 12 and 36 months of age (the average age of the children participating in this research study was 24 months).  These children were again evaluated once they entered elementary school, at an average age of 6 years.  Both parents and the children’s teachers participated in this latter evaluation of social and behavioral problems in this large group of children. 

Among those infants and toddlers with evidence of social, developmental and emotional problems detected upon their initial evaluation, 49% were reported, when these children subsequently began elementary school, to have significant behavioral and social difficulties in class, based upon their teachers’ evaluations.  The initial Brief Infant-Toddler Social and Emotional Assessment and Evaluation survey also predicted which babies and toddlers would later develop significant criteria for psychiatric disorders.  Among those infants and toddlers who had evidence of developmental or behavioral difficulties on their initial survey, more than two-thirds (68%) were found to meet the criteria listed for specific psychiatric disorders after reaching elementary school.

As a disclaimer, I will mention that the disciplines of Psychiatry and Psychology are rather unique among the clinical sciences in that it is very difficult (if not impossible) to obtain completely objective research data in clinical research studies such as this one.  Human behavior is extremely complex, variable, and unpredictable.  Thus, unlike research studies that randomize different groups of patients to receive different medical therapies, or studies that involve laboratory experiments, clinical psychiatric and psychological research studies cannot completely control all of the experimental factors that might skew either the resulting data, or, for that matter, its interpretation.  Therefore, I generally do not include such studies in my column.  In this case, however, I chose to include this particular study, because I believe that it may be helpful for some parents (and teachers) to know about its findings.

While I absolutely do not advocate performing routine psychiatric testing on children who do not have any evidence of significant behavioral or psychiatric problems, the results of this study suggest that it may be possible to pick up evidence of significant behavioral or/and psychological problems in the majority of “at risk” children long before they begin their school years.  While not every child with “abnormal” scores on the Infant-Toddler evaluation survey ultimately experienced psychiatric illnesses by the time they reached elementary school, in this study, more than two-thirds of such children were, in fact, subsequently diagnosed with a psychiatric disorder after starting elementary school. 

Perhaps, if identified during late infancy or while still a toddler, children who are at high risk of developing significant emotional or psychiatric illnesses might be able to undergo more intensive early screening and, if appropriate, begin therapy before they start attending school.  If effective therapy is available prior to beginning elementary school for any significant emotional or psychiatric illnesses that are identified early, then these children might have a much more positive and successful experience at school in their later years.

 

PSYCHIATRIC DISORDERS AMONG PARENTS OF AUTISTIC CHILDREN

The incidence of autism in the United States has been, inexplicably and dramatically, rising in recent years.  According to the Autism Society of America, autism is currently diagnosed in 1 of every 150 children born, and approximately 1.5 million people in the US are thought to have an autistic disorder.  Currently, the care of autistic patients is thought to cost around $90 billion per year, and some experts predict that this cost will rise to $200 billion dollars, or more, within the next 10 years.  There is also evidence, from the London School of Economics, that the early diagnosis and treatment of autism can reduce the lifetime cost of caring for such patients by as much as two-thirds (in most cases, the difficulties in communication and social interactions that are the hallmarks of autism can usually be detected within the first 3 years of life).

There is a great deal of debate about the potential causes of autistic disorders.  Recent studies have shown that at least some cases of autism do appear to be linked to specific gene mutations, suggesting that some cases of autism are very likely a result of inheritance.  There has also been a tremendous controversy regarding autism and its link, if any, with childhood vaccinations (and the mumps, measles and rubella, or MMR, vaccine, in particular).  However, multiple rigorous clinical research studies have, so far, failed to find any link between the development of autism and vaccinations.  In most cases, autism is diagnosed during the same age range as when children are beginning to receive their immunizations, and many public health experts have suggested that this factor is the most likely explanation for the apparent onset of the symptoms of autism following vaccinations. 

A new Swedish study, also just published in the journal Pediatrics, takes a look at the incidence of psychiatric illnesses in the parents of children who have been diagnosed with an autistic disorder.  As is the case in most of Scandinavia, and in much of Europe, essentially the entire population has access to universal healthcare provided by the federal government and its contractors.  It is for this reason that huge numbers of patients can be followed in clinical research studies in such countries, as a wide range of clinical data is routinely entered into central public health databases, even in countries with relatively small populations. 

This particular study was the result of collaboration between researchers from Sweden’s famed Karolinska Institute, the University of North Carolina at Chapel Hill, and the Mount Sinai School of Medicine here in New York.  Using the Swedish Medical Birth Register and the Swedish Multi-Generation Register, and other centralized public health databases, the researchers identified 1,227 children born between 1977 and 2003 who were subsequently treated for an autistic disorder.  For comparison purposes, more than 30,000 other children born during the same interval, but without any history of autism, were also included in this research study.  The researchers were then able to further assess this public health data to determine the incidence of treatment for psychiatric disorders among the parents of both groups of children born between 1977 and 2003 (editorializing for a moment here, and needless to say, conducting a study like this is never likely to be approved here in the United States).

In this study, the incidence of mental health disorders among the parents of autistic children was found to be significantly greater than what was observed among the parents of the much larger “control” group of parents of non-autistic children.  Specifically, schizophrenia was found to be more common in both mothers and fathers of autistic children, while depression and personality disorders were found to be more common among mothers of autistic kids, only.

While the results of this study, as with previous studies, suggests that at least some cases of autism might be inherited (and might be associated with other psychiatric disorders that are also thought to be heritable), one must be very careful in drawing conclusions from this data.  Certainly, caring for a child with autism, or other serious mental or physical illnesses, is a tremendously taxing and stressful undertaking.  I can easily imagine that parents who are faced with, potentially, the lifelong care of a severely disabled child could rather easily succumb to the stresses of such demands by developing emotional or psychiatric illnesses themselves. 

Unfortunately, this study, which was based solely on confidential public health records in Sweden, cannot tell us very much about the details of mental illness among parents of autistic children.  Also, as I have already mentioned, virtually all clinical studies involving psychiatric testing and evaluation are associated with a significant likelihood of subjectivity and bias, due to the inherent complexity of assessing human behavior and personality.  All of these disclaimers aside, this study still suggests that at least some significant percentage of autism cases may be linked to specific genetic factors which, in turn, may also be associated with other psychiatric illnesses within families.  The recent identification of specific gene mutations associated with at least some cases of autism also suggest that many (but not all) cases of autism are likely to be the result, at least in part, of specific and potentially heritable genetic factors.

 

SOCIAL & PSYCHIATRIC PROFILES OF YOUNG ADULTS BORN PREMATURELY

As neonatal intensive care units have become increasingly sophisticated in caring for extremely premature babies, more and more of these tiny infants are surviving into adulthood.  There have been numerous clinical research studies published about this group of patients, with some studies finding a significant increase in the incidence of lifelong physical and mental health difficulties among those who were very premature at birth.  As is often the case with public health research, there have also been quite a few studies published that have suggested that most people who were born prematurely do just fine if they survive into adulthood.

A new Dutch study in the Journal of Pediatrics, which was part of a larger ongoing study of children and adults born prematurely, evaluated 656 healthy adolescents who were born very prematurely, and compared them with their same-age peers with respect to general lifestyle, risk-taking behaviors, the presence of psychiatric disorders, and social interactions. 

Interestingly, both the teenage boys and teenage girls who had been born prematurely were less likely to smoke than their peers who had been born after a full-term pregnancy.  The teenage boys born prematurely were also less likely to drink alcohol than their full-term counterparts, while the adolescent girls who were born prematurely consumed alcohol as often as the girls who were born at full-term.  Lifetime illicit drug use was also significantly less common among the teens (boys and girls) who were born prematurely, when compared to their full-term birth peers.  With the notable exception of using public transportation without paying the fare… the adolescents born prematurely were far less likely to be involved in criminal activity than the kids who born at full-term.  Although the boys born prematurely appeared to experience greater difficulty in establishing relationships than their full-term peers, on the whole, the incidence of psychiatric disorders did not differ significantly between the two groups of adolescent boys and girls.

Healthy adolescents who were born “very pre-term,” or at a “very low birth-weight,” like those who were included in this study, represent a very select subgroup of young adults who have managed to grow and thrive, and to achieve excellent overall health, despite severe prematurity at birth.  In this particular subgroup of young adults born very prematurely, risk-taking behavior appeared to be less common than was observed in the general population.  At the same time, increased difficulties with initiating new relationships appeared to be more common among the teens who were born prematurely, especially among the boys.  While the explanations for these differences in social behavior between the two groups of teens is not unclear, they are nonetheless intriguing and worthy of further study.

 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

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