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Center for Developmental Epidemiology, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, Durham, NC

First published in Psychiatry Weekly, Volume 10, Issue 2, December 28, 2015

Introduction

Early psychiatric problems in childhood, although common, can be particularly vexing for affected children and their families. A limited treatment evidence base (compared to that of the adult literature) and limited access to treatment from specially trained clinicians both compound upon the challenges faced by affected children and their caregivers. New findings from Dr. William Copeland and colleagues now suggest that these challenges are not relegated to childhood and adolescence, however, and may in fact affect individuals’ lives well into adulthood.

Methodological Highlights

The sample in the present study was derived from The Great Smoky Mountains Study, a prospective, longitudinal study of children’s mental health, which began in 1993. The study follows a representative sample of 1,420 individuals who were followed since childhood and are now in their mid-thirties. To date, this sample has been followed through 10–11 different waves of data over the course of 20 years for a total of 9,941 total assessments.

“This was a sample of kids who had not been identified as having any psychiatric problems at baseline,” says Dr. Copeland, “and the goal was to see how many were affected by psychiatric illness and how many got the help they needed. Because of the prospective nature of this study, and the broad structured interviews that were done, we’re also able to examine the long-term outcomes of these problems, and to pull apart the independent effect of mental health functioning on these long-term outcomes.”

Mental Health and Adult Functioning

Each subject underwent as many as six psychiatric assessments throughout childhood. Altogether, 26% of the sample met criteria for a full-threshold psychiatric diagnosis. Sub-threshold symptoms were also accounted for, and were observed in 31% of the sample. The remaining 43% of the sample had no psychiatric symptoms.

“With that, our goal was to look at differences in functioning in adulthood among those three groups,” says Dr. Copeland. “We were interested in relatively significant outcomes that could be easily recognized as signifying a troubled transition to adulthood: for example, not graduating from high school, being incarcerated or convicted of a felony, addiction, or inability to find or sustain employment.”

Adverse outcomes in adult functioning were not uncommon, and were experienced by nearly 25% of the sample. Dropping out of high school (12.4%), a recorded felony charge (7.7%), suicidality (7.1%), and inability to hold down a job (6.6%) were the most common outcomes.

Copeland and colleagues then stratified the risk of adverse outcomes by the severity (or absence) of psychiatric problems in childhood. Nearly 20% of subjects with no psychiatric symptoms in childhood experienced at least one of these adverse outcomes in adulthood, compared to 60% among subjects with a full psychiatric disorder in childhood—a 6-fold increase in odds. Among subjects with subthreshold symptoms, 42% experienced one of these adverse outcomes in adulthood.

Even after accounting for every childhood adversity they could, including maltreatment or impoverishment, Dr. Copeland says that the subthreshold and full diagnosis groups were still at increased risk for these outcomes. “This was one of our key findings, and it suggests that there’s something about these common psychiatric problems that places kids at risk for a disrupted trajectory toward a successful adulthood,” he says.

Certain psychiatric diagnoses were associated with a greater likelihood of adverse outcomes. “Conduct disorder was the best predictor of criminality and incarceration in adulthood, as we would expect,” says Dr. Copeland. “But the strongest predictor of having one of these severe outcomes in adulthood was the number of psychiatric problems that the person had in childhood. Having ≥2 diagnoses was a much better predictor of these adult outcomes than the presence of any specific disorder.”

Treatment: Access and Effects

Among the children with subthreshold or full psychiatric symptoms, only 40% received any type of mental health services, and a much smaller proportion of this subgroup received “gold-standard” services and treatment, according to Dr. Copeland. Most of the children in this study who received services were seen at school by a social worker or guidance counselor.

Could adequate access to mental health services and treatment in childhood forestall adverse outcomes in adulthood functioning? Dr. Copeland says there were too few children who received adequate treatment in this sample to power analyses addressing that question.

“I think the best that we can hope for is that perhaps services will decrease the risk, but I don’t think we’re going to find that the kids receiving services are at decreased risk,” he says. “It’s possible that the kids receiving services were high risk to begin with, which could be the reason they landed in services in the first place.

“These problems are causing tremendous distress to children and families in the moment,” continues Dr. Copeland, “and we don’t necessarily need to show that they cause problems down the road for us to realize that it’s critical to treat them and help these families now. I do think we need to adopt a public health approach toward these problems and try to identify more measures to address early predictors of these problems, rather than waiting for subthreshold or full symptoms to emerge.”

This interview was conducted on August 4, 2015 by Lonnie Stoltzfoos

Disclosure: Dr. Copeland reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

Reference:

Copeland WE, Wolke D, Shanahan L, Costello EJ. Adult functional outcomes of common childhood psychiatric problems: a prospective, longitudinal study. JAMA Psychiatry. 2015;72:892-9

 

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