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A dimensional approach to the mental health of siblings of children with mental health problems: a 20-year systematic review
Abstract
A previous review on the prevalence of psychopathology in siblings of children with mental health problems (MHPs) suggested that these siblings are at increased risk of a broad range of psychopathologies. No disorder-specific risk could be identified. It may be that a different approach to understanding mental health is needed. The following paper aimed to explore if using a dimensional approach could provide greater clarity and insight into the mental health of these siblings by conducting a similar systematic review using dimensional data on the psychosocial functioning of siblings of children with MHPs. An electronic search of publications from 1990 to 2011 identified 29 articles. The findings show that while mean sibling scores on internalising problems, externalising problems, social problems were in the normal range compared to standardised norms, siblings of children with MHPs scored poorer than control children and a greater proportion of siblings scored in the borderline/clinical range compared to children in the general population. Particular areas of functional impairments identified were delinquent behaviour, somatic complaints, anxious/depressed behaviour, and social problems. Effect sizes were moderate to large. Findings on symptom scores with categorical underpinnings were inconsistent. Implications for the debate between dimensional and categorical approaches are discussed and guidelines for future research are outlined. Implications for clinical treatment for siblings are highlighted.
... The use of non-standardised or heterogeneous instruments may have contributed to contradictory results, such as reduced quality of life found in Gettings et al. (2015). Most studies only reported mean scores rather than using measures which could report the proportion of siblings in borderline or clinically elevated range pre-and post-intervention, which would have provided more insight into baseline characteristics of siblings benefitting most from interventions (Giallo & Gavidia-Payne, 2008;Ma et al., 2017). All included studies only assessed one sibling in the family, commonly the sibling closest in age to the target child, which may introduce sampling bias (Ma et al., 2017). ...
... Most studies only reported mean scores rather than using measures which could report the proportion of siblings in borderline or clinically elevated range pre-and post-intervention, which would have provided more insight into baseline characteristics of siblings benefitting most from interventions (Giallo & Gavidia-Payne, 2008;Ma et al., 2017). All included studies only assessed one sibling in the family, commonly the sibling closest in age to the target child, which may introduce sampling bias (Ma et al., 2017). ...
Siblings of persons with neurodevelopmental conditions (NDCs) have increased risk of poorer psychosocial functioning. This systematic review evaluated quantitative and qualitative evidence on sibling mental health and wellbeing outcomes following psychosocial interventions and the risk and protective factors associated with post-intervention outcomes. From 2025 identified studies published from 1991 to 2022 across ten databases, 24 studies were included. The largest immediate post-intervention improvements were in self-esteem, social wellbeing and knowledge of NDCs. The most sustained improvements in intervention groups at follow-up periods were in emotional and behavioural adjustment and NDC knowledge. There were positive, but small, differences in favour of the intervention groups on knowledge of NDCs, self-esteem, coping and the sibling relationship as compared to waitlist control groups. Psychosocial interventions for siblings are heterogeneous, and more data, including consideration of unique family circumstances, are needed to improve reporting and replicability, to measure effectiveness and tailor necessary supports.
... Understanding the needs of siblings of children with mental disorders and the scope of potential existing resources directed at these siblings is needed to reduce the risk to siblings and benefit their family's health. Three previous studies have reviewed the literature on the emotional/behavioral health of siblings of children with a mental disorder [6][7][8]. These studies reported greater rates of sibling psychopathology, poorer parent-healthy sibling relationships, as well as elevated levels of delinquent behaviour, anxiety/depression, and social problems. ...
... We plan to include grey literature, but will exclude systematic-type reviews, meta-analyses and case studies, conference proceedings/abstracts, books, and book chapters, as well as research in progress. Finally, we will exclude studies published before 2011, given that this evidence has been reviewed previously [6][7][8] and to provide a more contemporary scope of potential existing resources designed to address the needs of siblings. ...
Introduction:
Mental disorders affect 1 in 5 children having consequences for both the child and their family. Indeed, the siblings of these children are not insulated from these consequences and may experience elevated levels of psychological distress, placing them at increased risk for developing mental disorders. This protocol describes the methodology for a scoping review that will examine how mental disorders in children impact the mental health of their sibling(s). Further, we aim to examine the role of sex, gender, birth order, age of each child, and familial factors (e.g., parent mental illness, family structure), in sibling mental health. The proposed review will also identify resources that aim to support the needs of siblings of children with mental disorders. Taken together, this proposed review aims to take a fundamental step towards determining intervention targets to reduce the transmission of risk between siblings.
Aim:
The proposed scoping review aims to address the following questions: i) how do mental disorders (in children <18 years of age) impact the mental health of their sibling(s) (also <18 years of age)? ii) Can we identify resources designed to address the needs of siblings of children with mental disorders?
Methods:
We will conduct the proposed scoping review in keeping with the six-stage Arksey and O'Malley Framework and the scoping review methodology provided by the Joanna Briggs Institute. In section i) we outline our research questions. In section ii) we describe our process for identifying studies that examine the mental health of siblings of a child with a mental disorder and studies that provide evidence on resources directed specifically at these siblings. We will search peer-review and grey literature published between 2011 and 2022 from OVID MEDLINE, OVID EMBASE, CINAHL Complete, Proquest Nursing and Allied Health, PsycINFO (via APA platform), Proquest Sociology Collection and Web of Science Core Collection and Proquest Theses and Dissertations. Section iii) describes our process for selecting relevant studies. In sections iv and v, we describe our methods for charting and summarizing relevant data. Finally, in section vi) we describe our integrative knowledge translation plan that aims to include knowledge users in interpretating and translating evidence gathered from the proposed review.
... It is important to report more detailed demographic and participant characteristic information in future studies, given that a range of previous reviews and individual studies have found significant associations between individual-level demographics and sibling wellbeing outcomes (Marquis et al., 2020;Shivers et al., 2013). Most studies in this review only assessed one sibling in the family, commonly the sibling closest in age to the target child, which may introduce sampling bias (Ma et al., 2017). ...
Objective
This pre-registered systematic review synthesised and evaluated the existing literature on self-reported mental health and wellbeing of siblings of individuals with neurodevelopmental conditions (NDCs).
Methods
From 2437 identified studies published 2000–2022, 81 studies were included: 14 population- or cohort-based, 39 quantitative, 7 mixed method, and 21 qualitative outcome studies.
Results
Seven sibling mental health (any psychiatric disorder, anxiety, depression, bipolar disorder, schizophrenia, internalising and externalising difficulties) and five wellbeing indicators were identified (quality of life, emotional adjustment, social wellbeing, somatic/physical wellbeing, and resilience/growth). Overall, siblings had increased risk of any psychiatric disorder, but they also reported experiences of growth and resilience, primarily in qualitative studies. 41 risk factors and 24 resilience factors associated with these outcomes were identified; the most frequently cited risk factor was symptom severity of the NDC sibling, while the most common resilience factor was adaptive/active coping at the individual sibling level. Studies showed high methodological heterogeneity and 90 different self-report measures were used.
Conclusions
Sibling mental health indictors are heterogeneous and cumulative risk factors may result in poorer wellbeing. There is a need for consistent reporting of family and sibling characteristics, a strengths-based approach to assessment, and identification of protective and resilience-promoting factors.
... The proposal to replace the categorical approach to psychopathology with the dimensional approach in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was one of the most important and controversial changes [1]. Despite some challenges, the dimensional approach does not have many of the issues of the categorical approach [2] and has been widely welcomed for clinical diagnosis and application [3,4]. Following the dimensional approach, one of the most important suggestions in the DSM-5 is the addition of an Alternative Model for Personality Disorders (AMPD) in the third section [1]. ...
Background
The Personality Inventory for DSM-5 (PID-5) and Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) are tools designed for personality dispositions for mental health symptoms. The present study was conducted to compare these models in terms of their relative sensitivity to the symptoms of personality disorders (PDs) and non-personality disorders (NPDs).
Methods
Subjects in this cross-sectional study were 1232 (805 female; 63.5%) community samples in western Iran. Data were collected using the PID-5, the TEMPS-A, the Symptom Checklist-90 (SCL-90-R), and the Personality Diagnostic Questionnaire (PDQ-4). Correlations and Regression models were used to examine associations between traits and symptoms.
Results
Maladaptive traits assessed by the PID-5 were more strongly associated with PD symptoms, whereas affective temperaments measured by the TEMPS-A were more strongly associated with NPD symptoms.
Conclusion
The present findings highlighted the practical utility of both the PID-5 and TEMPS-A indicating risk for psychopathology, but also suggest a distinction between PDs and NPDs in terms of underlying personality dispositions.
... These programs have been shown to be effective in preventing the onset of anxiety/depressive disorders and reducing subthreshold symptoms (Havinga et al., 2021). While multiple observational studies stress the need for targeting siblings of affected individuals for preventive interventions (for a review see Ma et al., 2020), we are not aware of any randomized controlled trial that has studied the effect of an intervention or prevention targeting the identified vulnerabilities in our studies in this particular population. The fact that, in our study, we did not find that unaffected siblings differed from healthy controls on mental health symptoms, (most) cognitive vulnerabilities, and personality, suggests that these may be a direct result of the disorders, rather than prodromal indicators. ...
Background
: Investigating siblings of probands with affective disorders enables the identification of psychopathology-related risk features. Leveraging data from an older adult sample, as compared to most previous sibling studies, enabled us to study more definitive clinical profiling across the lifespan. We examined prevalence of depressive/anxiety disorders in siblings, proband-sibling resemblance in psychopathology-related features, and whether unaffected siblings showed higher levels of these features than healthy controls.
Methods
: The sample (N =929; Mage=50.6) consisted of 256 probands with lifetime depressive and/or anxiety disorders, their 380 siblings, and 293 healthy controls without affected relatives. Fifteen psychopathology-related features were investigated across four domains: mental health symptoms, social vulnerabilities, cognitive vulnerabilities, and personality.
Results
: Lifetime disorders were present in 50.3% of siblings. Prevalence was 2-3 times higher than Dutch population frequencies. We found small to medium probandsibling resemblance across psychopathology-related features (ρ=0.10-0.32). Unaffected siblings reported poorer interpersonal functioning and more negative life events, childhood trauma, and rumination than healthy controls. Limitations: Due to the cross-sectional study design, the directionality of effects cannot be determined. No inferences can be made about potential differences in familial resemblance in psychopathology-related features between high- and low-risk families.
Conclusions
: Siblings of probands with affective disorders are at higher risk for depressive/anxiety disorders. Even when unaffected, still show higher psychosocial vulnerability than healthy controls. Nevertheless, the only modest proband-sibling resemblance across psychopathology-related features suggests that individual mechanisms differentiate clinical trajectories across the lifespan. Identification of these mechanisms is crucial to improve resilience in subjects with familial risk.
... A finding of a 20 year systematic review states that the siblings of children with mental health problems scored in borderline/ clinical range compared to children of general population. Particular areas of functional impairments identified were delinquent behavior, somatic complaints, anxious/ depressed behavior, and social problems (Ma et al. 2017). Studies of Abu-Ajaj (2012) have shown that brothers and sisters of disabled children are at compatibility problems and have low selfesteem than nondisabled children. ...
The present paper examines the difference in the quality of sibling relationship between mentally challenged children and their normal siblings across birth order and gender. Responses of a total of 343 respondents involving one (any) mentally normal elder sibling (n1
=122) and one (any) mentally normal younger sibling (n2=71)
and (any) parent of the mentally challenged children (n3=150) were analyzed for assessing quality of sibling relationship across birth order. Whereas, responses of a total of 210 respondents involving one (any) mentally normal male sibling (n1=70) and one (any) mentally normal female sibling (n2=70) and (any) parent of the mentally challenged children (n3=70) were analyzed for assessing quality of sibling relationship across gender. Sibling Relationship Scale was
administered to assess the quality of sibling relationship between mentally challenged children and their mentally normal siblings. In the present study, analysis across birth order reflected no significant difference on any component of sibling relationship between mentally challenged children and their mentally normal elder or younger sibling. On the contrary, analysis across gender depicted significantly higher overall warmth/ closeness, nurturance and dominance between mentally challenged and mentally normal same-sex siblings than mentally challenged and mentally normal opposite sex siblings. However, no significant gender difference was seen on the components of conflict and rivalry of sibling relationship between mentally challenged children and their mentally normal siblings.
... A finding of a 20 year systematic review states that the siblings of children with mental health problems scored in borderline/ clinical range compared to children of general population. Particular areas of functional impairments identified were delinquent behavior, somatic complaints, anxious/ depressed behavior, and social problems (Ma et al. 2017). Studies of Abu-Ajaj (2012) have shown that brothers and sisters of disabled children are at compatibility problems and have low selfesteem than nondisabled children. ...
A teratogen is a drug or other substance capable of damaging the DNA and interfering with the development of an embryo and it may lead to birth defects or developmental malformations. The present study is carried out to evaluate the Indian Medicines Nilavembu Kudineer and Madulai Manapagu. In Siddha system, Nilavembu Kudineer is given to treat Dengue fever whereas Madulai Manapagu is to improve the hemoglobin content and the management of hormonal imbalance in women. The results exemplified the overall percentage mortality, hatchability, and deformities were observed as low in Madulai Manapagu than Nilavembu Kudineer. The teratogenic index of Nilavembu Kudineer is higher than 1 (1.33), whereas LC50 EC50 values were observed as 80 μg/ ml and 60 μg/ml respectively. Hence, Nilavembu Kudineer is considered as teratogenic when compared to Madulai Manapagu.
... The existing empirical literature supports this. For example, siblings of children with MHPs have significantly more social problems than control siblings ( Ma, Roberts, Winefield, & Furber, 2015c). Thus, identified siblings may have difficulties navigating social situations due to less developed or limited social skills, including skills such as conflict resolution. ...
While it is well recognized that family relationships have a significant impact on child mental health and vice versa, little research has examined the impact of living with a child with mental health problems (MHPs) on family relationships for their siblings. This report aims to synthesize the existing literature and comment on the current state of evidence. An electronic search of publications from 1990 to 2011 was conducted and 22 studies were included. The findings show that families of children with MHPs have less positive (e.g. less supportive) and more negative (e.g. more conflictual, aggressive) sibling relationships and more negative parent-sibling relationships compared to control families. Exceptions were sibling relationships in families of children with conduct disorder (more positive) and anxiety disorders (not significantly different from controls). Limitations of the existing literature include the types of measures used and the use of single informants. Methodological guidelines for future studies are outlined.
This study investigates the self-reported impact of children’s psychiatric disorders on their siblings and assesses what forms of support such children most value. We used a qualitative research design with open interviews to stimulate children between 8 and 15 years old to talk about their experiences living with a brother or sister with a psychiatric disorder. Their stories were analysed within a hermeneutic phenomenological framework in order to identify narrative themes and interpret the meaning of shared experiences. From our analysis, nine shared narrative themes emerge. Overall, siblings report feeling conflicted about adapting their lives to their brother’s or sister’s disorder and signal a need for personalized attention from parents. They also indicate that being involved in the care for their brother or sister helps them to better understand their behaviour. Finally, siblings reveal that, in their experience, formal, protocolized forms of support foreground family problems and stress. Thus, we recommend to involve children in the care process; to acknowledge their personal needs and conflicts; and to be mindful of the style of support: help offered in an informal or playful way, instead of formal and protocolized, could be a more effective way of meeting siblings’ needs.
While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed.
While it is well recognized that family relationships have a significant impact on child mental health and vice versa, little research has examined the impact of living with a child with mental health problems (MHPs) on family relationships for their siblings. This report aims to synthesize the existing literature and comment on the current state of evidence. An electronic search of publications from 1990 to 2011 was conducted and 22 studies were included. The findings show that families of children with MHPs have less positive (e.g. less supportive) and more negative (e.g. more conflictual, aggressive) sibling relationships and more negative parent-sibling relationships compared to control families. Exceptions were sibling relationships in families of children with conduct disorder (more positive) and anxiety disorders (not significantly different from controls). Limitations of the existing literature include the types of measures used and the use of single informants. Methodological guidelines for future studies are outlined.
Qualitative metasynthesis is an interpretive integration of primary qualitative research. It is a relatively new research methodology with questions remaining about utility, validity, and qualitative philosophical integrity. The aim of this article is to present an example of qualitative metasynthesis and to explore the utility, interpretive value, and clinical applications of metasynthesis in advancing our knowledge of the wellbeing and needs of siblings of children with mental health problems. An electronic search of publications from 1990–2011 was conducted. Ten articles were included and analyzed using thematic synthesis and constant targeted comparison. Qualitative metasynthesis allowed novel interpretations beyond those found in primary research in terms of theoretical frameworks and clinical implications. In addition, qualitative metasynthesis produced findings greater in depth and consistency and with more direct clinical implications than primary research and quantitative reviews. Qualitative metasynthesis provides a pathway by which more conclusive, reliable, and generalizable findings are produced and interpretive power and clinical utility are increased. It represents a significant advancement in qualitative methodology with the potential to provide unique contributions to research, theory, and evidence-based practice. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed.
To examine factors that differentiate children raised in the same family who are psychiatrically referred from those who are not, 100 referred 4- to 12-year-old children were compared to siblings on a battery of standardized language tests and behavioral checklists. Results indicate a relation among psychiatric referral, externalizing psychopathology, and receptive language disorders. A higher percentage of siblings had language disorders than would be expected based on community prevalence figures; and in 24% of cases, these disorders had not been suspected prior to assessment. Results are discussed in relation to factors that place children within a family at risk for psychopathology.
Sibling relationships are an important context for development, but are often ignored in research and preventive interventions with youth and families. In childhood and adolescence, siblings spend considerable time together, and siblings' characteristics and sibling dynamics substantially influence developmental trajectories and outcomes. This paper reviews research on sibling relationships in childhood and adolescence, focusing on sibling dynamics as part of the family system and sibling influences on adjustment problems, including internalizing and externalizing behaviors and substance use. We present a theoretical model that describes three key pathways of sibling influence: one that extends through siblings' experiences with peers and school, and two that operate largely through family relationships. We then describe the few existing preventive interventions that target sibling relationships and discuss the potential utility of integrating siblings into child and family programs.
Flaws in the design, conduct, analysis, and reporting of randomised trials can cause the effect of an intervention to be underestimated or overestimated. The Cochrane Collaboration’s tool for assessing risk of bias aims to make the process clearer and more accurate
The aim of this meta-analysis was to provide an up-to-date review of the literature to enhance our understanding of how chronic health conditions (CHCs) affect siblings, both positively and negatively.
PsycINFO and Medline were systematically searched. Inclusion criteria were as follows: (a) peer-reviewed, empirical research report; (b) sample n ≥ 10; and (c) reports statistics on siblings' internalizing problems, externalizing problems, and/or positive self-attributes.
Overall, there was a significant small negative effect of CHCs on siblings (d(+) = -.10). Siblings of children with CHCs had more internalizing problems (d(+) = .17), more externalizing problems (d(+) = .08), and less positive self-attributes (d(+) = -.09) than comparisons. Older siblings and siblings of children with life-threatening and/or highly intrusive CHCs were more at risk for psychological problems.
This study identified several mechanisms through which CHCs affect siblings. Future research should focus on parent-child dynamics and the longitudinal development of positive self-attributes and internalizing problems as well as on identifying what works in services for siblings of children with CHCs.
Background:
The International Multi-centre ADHD Genetics (IMAGE) project with 11 participating centres from 7 European countries and Israel has collected a large behavioural and genetic database for present and future research. Behavioural data were collected from 1068 probands with ADHD and 1446 unselected siblings. The aim was to describe and analyse questionnaire data and IQ measures from all probands and siblings. In particular, to investigate the influence of age, gender, family status (proband vs. sibling), informant, and centres on sample homogeneity in psychopathological measures.
Methods:
Conners' Questionnaires, Strengths and Difficulties Questionnaires, and Wechsler Intelligence Scores were used to describe the phenotype of the sample. Data were analysed by use of robust statistical multi-way procedures.
Results:
Besides main effects of age, gender, informant, and centre, there were considerable interaction effects on questionnaire data. The larger differences between probands and siblings at home than at school may reflect contrast effects in the parents. Furthermore, there were marked gender by status effects on the ADHD symptom ratings with girls scoring one standard deviation higher than boys in the proband sample but lower than boys in the siblings sample. The multi-centre design is another important source of heterogeneity, particularly in the interaction with the family status. To a large extent the centres differed from each other with regard to differences between proband and sibling scores.
Conclusions:
When ADHD probands are diagnosed by use of fixed symptom counts, the severity of the disorder in the proband sample may markedly differ between boys and girls and across age, particularly in samples with a large age range. A multi-centre design carries the risk of considerable phenotypic differences between centres and, consequently, of additional heterogeneity of the sample even if standardized diagnostic procedures are used. These possible sources of variance should be counteracted in genetic analyses either by using age and gender adjusted diagnostic procedures and regional normative data or by adjusting for design artefacts by use of covariate statistics, by eliminating outliers, or by other methods suitable for reducing heterogeneity.
The International Multi-centre ADHD Genetics (IMAGE) project with 11 participating centres from 7 European countries and Israel has collected a large behavioural and genetic database for present and future research. Behavioural data were collected from 1068 probands with the combined type of attention deficit/hyperactivity disorder (ADHD-CT) and 1446 'unselected' siblings. The aim was to analyse the IMAGE sample with respect to demographic features (gender, age, family status, and recruiting centres) and psychopathological characteristics (diagnostic subtype, symptom frequencies, age at symptom detection, and comorbidities). A particular focus was on the effects of the study design and the diagnostic procedure on the homogeneity of the sample in terms of symptom-based behavioural data, and potential consequences for further analyses based on these data.
Diagnosis was based on the Parental Account of Childhood Symptoms (PACS) interview and the DSM-IV items of the Conners' teacher questionnaire. Demographics of the full sample and the homogeneity of a subsample (all probands) were analysed by using robust statistical procedures which were adjusted for unequal sample sizes and skewed distributions. These procedures included multi-way analyses based on trimmed means and winsorised variances as well as bootstrapping.
Age and proband/sibling ratios differed between participating centres. There was no significant difference in the distribution of gender between centres. There was a significant interaction between age and centre for number of inattentive, but not number of hyperactive symptoms. Higher ADHD symptom frequencies were reported by parents than teachers. The diagnostic symptoms differed from each other in their frequencies. The face-to-face interview was more sensitive than the questionnaire. The differentiation between ADHD-CT probands and unaffected siblings was mainly due to differences in hyperactive/impulsive symptoms.
Despite a symptom-based standardized inclusion procedure according to DSM-IV criteria with defined symptom thresholds, centres may differ markedly in probands' ADHD symptom frequencies. Both the diagnostic procedure and the multi-centre design influence the behavioural characteristics of a sample and, thus, may bias statistical analyses, particularly in genetic or neurobehavioral studies.
Suicide attempts (SA) constitute a serious clinical problem. People who attempt suicide are at high risk of further repetition. However, no interventions have been shown to be effective in reducing repetition in this group of patients.
Multicentre randomized controlled trial. We examine the effectiveness of "ALGOS algorithm": an intervention based in a decisional tree of contact type which aims at reducing the incidence of repeated suicide attempt during 6 months. This algorithm of case management comprises the two strategies of intervention that showed a significant reduction in the number of SA repeaters: systematic telephone contact (ineffective in first-attempters) and "Crisis card" (effective only in first-attempters). Participants who are lost from contact and those refusing healthcare, can then benefit from "short letters" or "postcards".
ALGOS algorithm is easily reproducible and inexpensive intervention that will supply the guidelines for assessment and management of a population sometimes in difficulties with healthcare compliance. Furthermore, it will target some of these subgroups of patients by providing specific interventions for optimizing the benefits of case management strategy.
One possible reason for the continued neglect of statistical power analysis in research in the behavioral sciences is the inaccessibility of or difficulty with the standard material. A convenient, although not comprehensive, presentation of required sample sizes is provided. Effect-size indexes and conventional values for these are given for operationally defined small, medium, and large effects. The sample sizes necessary for .80 power to detect effects at these levels are tabled for 8 standard statistical tests: (1) the difference between independent means, (2) the significance of a product-moment correlation, (3) the difference between independent rs, (4) the sign test, (5) the difference between independent proportions, (6) chi-square tests for goodness of fit and contingency tables, (7) 1-way analysis of variance (ANOVA), and (8) the significance of a multiple or multiple partial correlation.
Attention-deficit/hyperactivity disorder (ADHD) is associated with widespread cognitive impairments, but it is not known whether the apparent multiple impairments share etiological roots or separate etiological pathways exist. A better understanding of the etiological pathways is important for the development of targeted interventions and for identification of suitable intermediate phenotypes for molecular genetic investigations.
To determine, by using a multivariate familial factor analysis approach, whether 1 or more familial factors underlie the slow and variable reaction times, impaired response inhibition, and choice impulsivity associated with ADHD.
An ADHD and control sibling-pair design.
Belgium, Germany, Ireland, Israel, Spain, Switzerland, and the United Kingdom.
A total of 1265 participants, aged 6 to 18 years: 464 probands with ADHD and 456 of their siblings (524 with combined-subtype ADHD), and 345 control participants.
Performance on a 4-choice reaction time task, a go/no-go inhibition task, and a choice-delay task.
The final model consisted of 2 familial factors. The larger factor, reflecting 85% of the familial variance of ADHD, captured 98% to 100% of the familial influences on mean reaction time and reaction time variability. The second, smaller factor, reflecting 13% of the familial variance of ADHD, captured 62% to 82% of the familial influences on commission and omission errors on the go/no-go task. Choice impulsivity was excluded in the final model because of poor fit.
The findings suggest the existence of 2 familial pathways to cognitive impairments in ADHD and indicate promising cognitive targets for future molecular genetic investigations. The familial distinction between the 2 cognitive impairments is consistent with recent theoretical models--a developmental model and an arousal-attention model--of 2 separable underlying processes in ADHD. Future research that tests the familial model within a developmental framework may inform developmentally sensitive interventions.
The goal of this study was to investigate the occurrence, severity and clinical correlates of emotional lability (EL) in children with attention deficit/hyperactivity disorder (ADHD), and to examine factors contributing to EL and familiality of EL in youth with ADHD.
Methods: One thousand, one hundred and eighty-six children with ADHD combined type and 1827 siblings (aged 6-18 years) were assessed for symptoms of EL, ADHD, associated psychopathology and comorbid psychiatric disorders with a structured diagnostic interview (PACS) as well as parent and teacher ratings of psychopathology (SDQ; CPRS-R:L; CTRS-R:L). Analyses of variance, regression analyses, chi 2-tests or loglinear models were applied.
Results: Mean age and gender-standardized ratings of EL in children with ADHD were > 1.5 SD above the mean in normative samples. Severe EL (> 75th percentile) was associated with more severe ADHD core symptoms, primarily hyperactive-impulsive symptoms, and more comorbid oppositional defiant, affective and substance use disorders. Age, hyperactive-impulsive, oppositional, and emotional symptoms accounted for 30% of EL variance; hyperactive-impulsive symptoms did not account for EL variance when coexisting oppositional and emotional problems were taken into account, but oppositional symptoms explained 12% of EL variance specifically. Severity of EL in probands increased the severity of EL in siblings, but not the prevalence rates of ADHD or ODD. EL and ADHD does not co-segregate within families.
Conclusion: EL is a frequent clinical problem in children with ADHD. It is associated with increased severity of ADHD core symptoms, particularly hyperactivity-impulsivity, and more symptoms of comorbid psychopathology, primarily symptoms of oppositional defiant disorder (ODD), but also affective symptoms, and substance abuse. EL in ADHD seems to be more closely related to ODD than to ADHD core symptoms, and is only partly explainable by the severity of ADHD core symptoms and associated psychopathology. Although EL symptoms are transmitted within families, EL in children with ADHD does not increase the risk of ADHD and ODD in their siblings.
We evaluated the Children's Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.
Attention deficit hyperactivity disorder (ADHD) is a discrete clinical syndrome characterized by the triad of inattention, hyperactivity, and impulsivity in the context of marked impairments. Molecular genetic studies have been successful in identifying genetic variants associated with ADHD, particularly with DSM-IV inattentive and combined subtypes. Quantitative trait locus (QTL) approaches to linkage and association mapping have yet to be widely used in ADHD research, although twin studies investigating individual differences suggest that genetic liability for ADHD is continuously distributed throughout the population, underscoring the applicability of quantitative dimensional approaches. To investigate the appropriateness of QTL approaches, we tested the familial association between 894 probands with a research diagnosis of DSM-IV ADHD combined type and continuous trait measures among 1,135 of their siblings unselected for phenotype. The sibling recurrence rate for ADHD combined subtype was 12.7%, yielding a sibling recurrence risk ratio (sib) of 9.0. Estimated sibling correlations around 0.2-0.3 are similar to those estimated from the analysis of fraternal twins in population twin samples. We further show that there are no threshold effects on the sibling risk for ADHD among the ADHD probands; and that both affected and unaffected siblings contributed to the association with ADHD trait scores. In conclusion, these data confirm the main requirement for QTL mapping of ADHD by demonstrating that narrowly defined DSM-IV combined type probands show familial association with dimensional ADHD symptom scores amongst their siblings.
• We evaluated the Children's Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.
Background:
There is evidence of relationships among serotonin, aggressive behavior, and a childhood history of socially adverse-rearing conditions. This study examines the prolactin response to fenfluramine hydrochloride challenge in young boys who show clinically significant aggressive behavior or who are raised in a social environment that is conducive to the development of chronic aggression.Methods:
A series of 34 younger brothers of convicted delinquents underwent standardized psychiatric and observation-based assessments of their social-rearing environments that were conducted during home visits. Approximately 2 years later, these boys underwent a reassessment of psychiatric status and an assessment of central serotonergic activity using the fenfluramine challenge procedure.Results:
Increasing degrees of aggressive behavior at either assessment were positively correlated with the prolactin response to fenfluramine challenge. Furthermore, adverse-rearing circumstances that were conducive to the development of aggressive behavior also exhibited positive correlations with the prolactin response. This association between adverse rearing and the prolactin response was statistically independent of that between aggression and the prolactin response.Conclusion:
In young boys, aggressive behavior and social circumstances that are conducive to the development of aggressive behavior are positively correlated with a marker of central serotonergic activity.
This meta-analysis synthesized research since 1990 pertaining to the social competence of children with learning disabilities in inclusive classrooms. Comparisons with average- to high-achieving classmates resulted in medium to large effect sizes for teachers' perceptions of social competence, peer preference ratings, positive peer nominations, global self-worth, and self-perceptions of scholastic performance. A second set of comparisons with children designated as low in academic achievement yielded moderate effect sizes for teachers' perceptions of social competence and for peer social preference ratings. Small effect sizes were obtained for global self-worth and self-perceptions of scholastic performance. It was concluded that (a) children with learning disabilities and children designated as low in academic achievement are at a greater risk for social difficulties than are average- to high-achieving children, and (b) children with learning disabilities and their low-achieving classmates do not appear to have accurate self-perceptions of social acceptance.
Younger siblings of adolescents with histories of antisocial behavior are at high risk for developing conduct problems. Information about risk exposure in youths at familial risk for conduct problems is critical to the design of informed preventive interventions. The prevalence of well-validated risk factors for conduct problems was examined in a sample of 92 preschool-aged siblings of adjudicated youths. As expected, preschoolers at familial risk for conduct problems were exposed to a range of sociocultural, biological, and parenting risks. Risk exposure was associated with concurrent conduct problems and social competence in the preschool period. Only a minority of preschoolers was reported by parents to have clinically significant conduct problems, and this subgroup had more risks than children with conduct problems in the normal range. Findings are discussed in the context of preventive interventions for high-risk children and families.
This study describes results from an ongoing family study of adolescent boys and their families designed to investigate potential risk factors for substance abuse. The adolescent treatment probands have severe drug and alcohol related problems and were recruited through a residential rehabilitation program. To date, the sample includes 251 individuals: 39 male probands and their families and 34 control families matched for age and geographic location (zip code). Probands and participating family members are given a structured interview which assesses alcohol and drug problems, and various psychiatric symptoms. The purpose of the present study was to examine the coaggregation of depressive symptoms, antisocial behavior, and alcohol misuse. Multivariate pedigree analyses were performed using a model that allowed for the estimation of vertical familial transmission, residual sibling resemblance, and assortative mating. Spouse correlations were estimated at .57, .21, and .31 for antisocial behavior, depressive symptoms, and alcohol abuse, respectively. Residual sibling environment (i.e., sibling resemblance unaccounted for by parent-offspring transmission) was not found for alcohol problem symptoms, but did contribute to resemblance for antisocial behavior and depressive symptoms. The proportion of variance accounted for by vertical familial transmission was estimated at approximately 30 to 40%. More important, correlations among the transmissible family factors for these psychiatric syndromes ranged from .58 to .73, suggesting substantial overlap among the underlying familial antecedents for these disorders. Am. J. Med Genet. 74:183–191, 1997 © 1997. Wiley-Liss, Inc.
The present study examined the effect of Obsessive Compulsive Disorder (OCD) on child and adolescent sibling relationships. In previous research on adult OCD, siblings of OCD sufferers showed a high level of occommodotion to obsessive-compulsive symptoms and subsequent depression. No research has been conducted on the effect of OCD on child and adolescent sibling relationships. This small but important pilot study investigated sibling accommodation to obsessive-compulsive symptoms, sibling relationship quality, and depression and anxiety in siblings of children who have OCD. The study had two components. First, siblings of children with OCD were examined before and after a 14-week treatment program for OCD. Second, these siblings were compared at prebefore treatment with a comparison group of siblings whose brother or sister did not meet diagnostic criteria for either OCD or any other childhood disorders (i.e., comparison group). Three outcomes were noted. Siblings of OCD children accommodated to obsessive-compulsive symptoms and were distressed by the presence of OCD in their brother or sister. Furthermore, the quality of sibling relationships in OCD families improved with successful treatment of OCD. Finally, anxiety and depression were higher in siblings of an OCD child or adolescent, compared to siblings in the comparison group. Given the significant impact that OCD has on the sibling relationship, implications for family-based treatment, incorporating a sibling support component, are addressed.
Observed 57 children (37 anxiety-disordered and 20 non-clinic-referred children; aged 7-16 yrs) and their siblings interacting with their parents while completing a complex puzzle task. Consistent with previous findings, mothers were more involved and more intrusive during the task with their anxiety-disordered child than mothers of non-clinic-referred children. Mothers in the clinic-referred group were also significantly more involved and more intrusive during interactions with the anxious child's sibling than mothers of non-clinic-referred children. Although fathers were more involved during the task than mothers overall, no significant differences in overinvolvement were found between fathers of anxiety-disordered children and fathers of non-clinic-referred children. Both mothers and fathers were equally involved with the anxious child and the sibling of the anxious child. Although this study provides support for the association between maternal overinvolvement and the anxiety disorders, it suggests that overinvolvement does not occur exclusively in the context of relationships with the anxiety-disordered child. (PsycINFO Database Record (c) 2010 APA, all rights reserved).
The conceptual issues are briefly noted with respect to the distinctions between classification and diagnosis; the question of whether mental disorders can be considered to be 'diseases'; and whether descriptive psychiatry is outmoded. The criteria for diagnosis are reviewed, with the conclusion that, at present, there are far too many diagnoses, and a ridiculously high rate of supposed comorbidity. It is concluded that a separate grouping of disorders with an onset specific to childhood should be deleted, the various specific disorders being placed in appropriate places, and the addition for all diagnoses of the ways in which manifestations vary by age. A new group should be formed of disorders that are known to occur but for which further testing for validity is needed. The overall number of diagnoses should be drastically reduced. Categorical and dimensional approaches to diagnosis should be combined. The requirement of impairment should be removed from all diagnoses. Research and clinical classifications should be kept separate. Finally, there is a need to develop a primary care classification for causes of referral to both medical and non-medical primary care.
AbstractRecently, a number of authors have concluded that there are few suitable instruments for the systematic assessment of children's adaptive functioning. The Social Adjustment Inventory for Children and Adolescents (SAICA) is a new semistructured interview that was designed for administration to school‐aged children as a self‐report, or to parents about their children, for use in clinical and epidemiological studies. The SAICA provides an evaluation of children's functioning in school, in spare time activities, and with peers, siblings, and parents. Data from a study of 124 children, ages 6 to 18, of parents with and without a history of major depression support the construct, convergent, and discriminant validity of the instrument. The children's own histories of DSM‐III, Axis I diagnoses, rather than major depression in their parents, were found to reliably distinguish their patterns of social functioning. Children with dysthymia had the poorest functioning in all areas by both children's and mothers' reports. These results suggest that the SAICA is a promising instrument for the assessment of social adjustment among children and adolescents.
Examined the impact of disturbed adolescents (aged 12–18 yrs) who had been hospitalized from 1 to 3 times on the psychological adjustment and sibling relationships of younger siblings (aged 9–25 yrs). Compared to 15 younger siblings of nondisturbed adolescents, the younger siblings of previously hospitalized adolescents reported more psychological distress, poorer social relationships, a more negative view of their older brothers and sisters, and less identification with their older siblings. Only 4 younger siblings reported receiving more parental attention than their disturbed siblings. Results suggest that this perceived lack of parental support may have long-term negative effects for the siblings of disturbed adolescents.
The diagnostic accuracy of the Child Behavior Checklist (CBCL) scales for attention-deficit hyperactivity disorder (ADHD) were examined using receiver-operating characteristic (ROC) analysis. Three logistic regression models were estimated in an initial sample of 121 children with and without ADHD. These models were then tested in a cross-validation sample (N = 122) and among the 111 brothers and 108 sisters of the initial and cross-validation samples. In all four groups, the CBCL Attention Problems scale had the highest discriminating power for ADHD. Adding other scales did not increase the area under the curve of the ROC significantly. These findings suggest that the CBCL Attention Problems scale could serve as a rapid and useful screening instrument not only to help identify cases likely to meet criteria for ADHD in clinical settings but also to identify cases of ADHD among the siblings of children with ADHD.
Thirteen (42%) of 31 siblings of 29 probands with depression (n = 21) or anxiety disorders (n = 8) attending a clinic met DSM-IIIR criteria for psychiatric disorder, a rate nearly three times greater than reported from community studies. The diagnoses were heterogeneous. Compared with probands, sibling cases had half the level of comorbidity and significantly lower levels of psychosocial impairment. Comparisons of temperamental characteristics showed that higher levels of emotionality, but no other aspect of temperament, was associated with an increased likelihood of a sibling being a case. Higher emotionally in all cases (sibs and probands) was associated with greater comorbidity in general and the diagnoses of dysthymia and separation anxiety in particular.
As part of a larger, prospective study, the authors examined concurrent and prospective relations among parenting and child antisocial behavior in inner-city boys at high risk for delinquent behavior.
One hundred twenty-six younger brothers (aged 6 to 10 years) of convicted delinquents in New York City and their parents were assessed; 15 months later 112 boys were reassessed. Demographics, parenting, and child diagnosis were examined as they relate to child externalizing behavior problems. Hierarchical multiple regression analyses predicted changes in Externalizing scores from year I parenting.
At years I and II, 22% and 27% of boys, respectively, scored above the clinical cutoff for Externalizing. Controlling for earlier Externalizing, each of three domains of parenting still made significant independent contributions to later Externalizing scores, explaining 17% of the variance. Altogether this model explained 51% of the variance in year II Externalizing scores.
Data support a cumulative risk model, whereby each of several adverse parenting factors further compounds the likelihood of child conduct problems.
The goal of the present investigation was to create a phenotype definition in relatives of probands that reflects a more genetic form of attention deficit hyperactivity disorder (ADHD). Logistic regression was applied to the first-degree relatives of ADHD and normal control probands to create a quantitative phenotype that combined information across psychiatric, cognitive, and demographic domains. Models were run separately in mothers, fathers, sisters, and brothers. Although there was some overlap between the variables retained in each model, no two models had exactly the same variables. Our results suggest that the use of fitted logits may be valuable as a potential index of caseness. Since different characteristics were included in different groups of relatives, our results suggest that gender and generation may moderate the expression of ADHD.
Attention-deficit hyperactivity disorder (ADHD) is a familial disorder that places the siblings of ADHD children at high risk for ADHD, conduct, mood, and anxiety disorders. Although the pattern of psychiatric risk has been well documented by prior family studies, neither the short- nor long-term outcome of these high-risk siblings has been prospectively examined.
To document the 4-year psychiatric, psychosocial, and neuropsychological outcome of the siblings of children with ADHD.
DSM-III-R structured diagnostic interviews and blind raters were used to conduct a 4-year follow-up of siblings from ADHD and control families. The siblings were also evaluated for cognitive, achievement, social, school, and family functioning.
At follow-up, significant elevations of behavioral, mood, and anxiety disorders were found among the siblings of ADHD children. The high-risk siblings had high rates of school failure and showed evidence of neuropsychological and psychosocial dysfunction. These impairments aggregated among the siblings who had ADHD.
The siblings of ADHD children are at high risk for clinically meaningful levels of psychopathology and functional impairment. In addition to supporting hypotheses about the familial transmission of ADHD, the results suggest that the high-risk siblings might be appropriate targets for primary preventive interventions.
There is evidence of relationships among serotonin, aggressive behavior, and a childhood history of socially adverse-rearing conditions. This study examines the prolactin response to fenfluramine hydrochloride challenge in young boys who show clinically significant aggressive behavior or who are raised in a social environment that is conducive to the development of chronic aggression.
A series of 34 younger brothers of convicted delinquents underwent standardized psychiatric and observation-based assessments of their social-rearing environments that were conducted during home visits. Approximately 2 years later, these boys underwent a reassessment of psychiatric status and an assessment of central serotonergic activity using the fenfluramine challenge procedure.
Increasing degrees of aggressive behavior at either assessment were positively correlated with the prolactin response to fenfluramine challenge. Furthermore, adverse-rearing circumstances that were conducive to the development of aggressive behavior also exhibited positive correlations with the prolactin response. This association between adverse rearing and the prolactin response was statistically independent of that between aggression and the prolactin response.
In young boys, aggressive behavior and social circumstances that are conducive to the development of aggressive behavior are positively correlated with a marker of central serotonergic activity.
ADHD is a familial disorder with high rates of comorbidity with conduct disorder in childhood and antisocial personality and substance use disorders in adulthood. A growing literature suggests that ADHD with antisocial comorbidity may be nosologically distinct from other forms of ADHD. Previously, we proposed a family-based stratification that defined Antisocial families as those with either conduct disorder or antisocial personality disorder in the probands or relatives. To provide predictive validity for that stratification, we assessed psychopathology in these families 4 years after their initial assessment. Results show that the probands and siblings from Antisocial families had higher rates of psychopathology during the 4-year follow-up period compared with siblings from Non-antisocial and control families. They also had more deviant ratings on the Child Behavior Checklist (especially for anxious/depressed, delinquent, and aggressive behavior). We found fewer group differences in the academic, psychosocial, and intellectual correlates of ADHD. These results confirm and extend previous work indicating that Antisocial ADHD may be a nosologically and clinically meaningful subform of ADHD.
Attention-deficit hyperactivity disorder (ADHD) affects approximately 3%-5% of children in the United States. In the current psychiatric nomenclature, ADHD comprises three subtypes: inattentive, hyperactive-impulsive, and combined. In this study, we used four analytic strategies to examine the association and linkage of the dopamine transporter gene (DAT1) and ADHD. Our sample included 122 children referred to psychiatric clinics for behavioral and learning problems that included but were not limited to ADHD, as well as their parents and siblings. Within-family analyses of linkage disequilibrium, using the transmission disequilibrium test (TDT), confirmed the 480-bp allele as the high-risk allele. In between-family association analyses, levels of hyperactive-impulsive symptoms but not inattentive symptoms were related to the number of DAT1 high-risk alleles. Siblings discordant for the number of DAT1 high-risk alleles differed markedly in their levels of both hyperactive-impulsive and inattentive symptoms, such that the sibling with the higher number of high-risk alleles had much higher symptom levels. Within-family analyses of linkage disequilibrium, using the TDT, suggested association and linkage of ADHD with DAT1 and that this relation was especially strong with the combined but not the inattentive subtype. The relation of DAT1 to ADHD increased monotonically, from low to medium to high levels of symptom severity. Our results replicate and extend previous findings of the association between the DAT1 gene and childhood ADHD. This represents one of the first replicated relations of a candidate gene and a psychiatric disorder in children.
To review the literature over the past decade on the genetics of childhood neuropsychiatric disorders.
A computerized search was performed for articles published in the past decade, and selected papers were highlighted.
The past decade of research has illuminated the complex genetics of early-onset mental disorders. Advances in statistical methodologies and laboratory-based gene-hunting techniques are laying the foundation for a deeper understanding of both the biological and environmental factors that contribute to mental illness. Researchers are on the verge of identifying and characterizing genetic vulnerabilities involved in common childhood psychiatric syndromes.
Although the study of the genetics of childhood psychiatric disorders has advanced significantly over the past decade, considerable work remains. The identification of genes conferring vulnerability to psychiatric illnesses will have the potential to transform the field by providing insight into both biological and environmental determinants that contribute to serious developmental and psychiatric disorders in children and adolescents. These advances promise new understanding and new avenues for prevention and treatment. They will also present physicians and families with significant clinical and ethical challenges.
Observed 57 children (37 anxiety-disordered and 20 non-clinic-referred children) and their siblings interacting with their parents while completing a complex puzzle task. Consistent with previous findings, mothers were more involved and more intrusive during the task with their anxiety-disordered child than mothers of non-clinic-referred children. Mothers in the clinic-referred group were also significantly more involved and more intrusive during interactions with the anxious child's sibling than mothers of non-clinic-referred children. Although fathers were more involved during the task than mothers overall, no significant differences in overinvolvement were found between fathers of anxiety-disordered children and fathers of non-clinic-referred children. Both mothers and fathers were equally involved with the anxious child and the sibling of the anxious child. Although this study provides support for the association between maternal overinvolvement and the anxiety disorders, it suggests that overinvolvement does not occur exclusively in the context of relationships with the anxiety-disordered child.
This work examines distinct aspects of effortful control and attention predicted aggression in a group of children at elevated risk for the development of conduct problems. Results suggested that behavioral inhibition, rather than attentional control, best predicted maternal reports of child aggressive behaviors.
We examined the criterion validity of parent and self-report versions of the Junior Temperament and Character Inventory (JTCI) in children with high levels of externalizing problems. The sample included 412 children (206 participants and 206 siblings) participating in a family study of attention and aggressive behavior problems. Criterion validity analyses included (a) correlations between temperament scales and emotional and behavioral scales and (b) correlations between temperament and intelligence and achievement scales. Temperament scales displayed strong convergent and discriminant validity. Across informants and samples, JTCI scales assessing novelty seeking and harm avoidance discriminated between internalizing and externalizing problems. Reward dependence, persistence, cooperativeness, and self-directedness displayed similar patterns of negative relations to emotional and behavioral scales and positive relations to intelligence, achievement, and competence.