The prevalence of one or more psychiatric disorders in childhood and adolescence increases with age. In a recent review, (25) the mean prevalence rates were 10.2 per cent for preschool children, 13.2 per cent for preadolescents, and 16.5 per cent for adolescents. In the preadolescent age group, psychiatric disorder is more common in boys than girls because of the higher rate of behaviour problems in males; in adolescence, girls have a higher rate of disturbance than boys, primarily because of the higher rate of internalizing disorders, especially depression, in females compared with males. (28)
The prevalence of psychiatric disorder can vary by race and ethnicity.(2 39> Patterns of variation differ for different racial and ethnic groups, and even within a particular ethnic/racial group. For example, the rates of emotional and behavioural disorders among Native American children vary dramatically among tribes and regions/31 Two causal risk factors—difficulty performing in school and growing up in conditions of family adversity—place children of certain racial and ethnic groups at increased risk for emotional and behavioural problems. (32) However, the causal risk factors for psychiatric disturbance may vary for different groups. For example, in the Great Smoky Mountains Study of Youth, while family mental illness was associated with child psychiatric disorder for both Native American and white children, poverty and family deviance was associated with psychiatric disturbance only among the Native American children. (29>
Children with chronic health problems, especially if they are associated with disability, are at a greater than threefold risk for psychiatric disorders and social adjustment problems.(33) The causal variables involved in producing this association include low self-esteem, poor peer relationships, and poor school performance/33) Finally, there is widespread agreement that diseases affecting cerebral function directly result in the highest prevalence rates of emotional and behavioural problems, and within this group, epilepsy results in the highest rates. (343r>
Children with brain disorder have much increased rates of psychiatric disorder. (36) The causal processes involved, including their relative strength and patterns of interaction, are not completely understood. Potential candidates for mediating variables include psychosocial disadvantage, and intellectual and cognitive disability leading to poor school performance, (3Z) and the use of anticonvulsant drugs.(38)
Individual children, from early on in their lives, can differ from each other on behavioural patterns such as inhibition, biological irregularity, emotional intensity, and activity level, and there are stable differences between boys and girls. (39) Temperament has been reported to be an aetiological factor in child psychiatric disorder, (4°) especially if the children live in dysfunctional families. (41,) However, several methodological issues need to be sorted out including the overlapping item content across measures of temperament and symptoms of disorder.(42) A critical review of child temperament and its clinical applications is available. (43)
IQ, learning disorders, and educational retardation
Children who do poorly at school whether because of a specific learning disorder or low IQ are at increased risk for a wide spectrum of psychiatric disorders and delinquency/4 45> The possible mechanisms by which poor school performance leads to increased rates of externalizing disorders have been critically reviewed. (44) Four hypotheses have been identified: externalizing behaviour leads to underachievement; the reverse holds; each leads to the other; underlying variables (e.g. cognitive deficits, abnormal temperament) account for the relationship. At present none of these hypotheses can be eliminated.
Parents with a variety of psychiatric disorders have children with increased rates of psychopathology in general. (46) In addition, there is some evidence from clinic samples that specific parental psychiatric disorders are associated with specific offspring diagnoses. For example, in a controlled family study, the offspring of alcoholic parents were found to have elevated rates of, in particular, conduct disorder, attention deficit disorder, and oppositional disorder. (47)
The mechanisms involved in the transmission of psychopathology from parents with psychiatric disorder to their offspring have been studied most extensively in the case of depressed parents/48,49 Contextual risk (e.g. impaired parenting, marital conflict, family dysfunction) appears to mediate the relationship between parental depression and child behaviour problems. These mediating factors that operate in families with depressed parents are similar to those found in families with non-depressed parents.
A number of family factors including single-parent status, poor parenting, marital discord, family dysfunction, and large family size, have all been associated with increased rates of psychiatric disorders in children.(3 50) There are two major issues in this area. First, as noted above, while there is a good deal of data about correlates of child psychiatric disorder, there is much less information, on which ones are true causal risk factors. Marital discord and poor parenting, for example, are causal risk factors/5!) Second, there is only weak evidence to support the notion that individual disorders have specific patterns of correlates or causal risk factors. (52)
There is a strong relationship between low social class and psychiatric disorder when parental social class is measured by the degree of economic disadvantage, but not when measured by level of occupational prestige.(32) Furthermore, in the case of externalizing disorders, the relationship between low social class and disorder is stronger for teacher-identified disorder than parent-identified disorder. (1.6) In addition, with regard to economic disadvantage, persistent poverty should be distinguished from current poverty. The former significantly predicts internalizing symptoms while only current poverty predicts externalizing symptoms. (53) Finally, the mechanisms that place poor children at increased risk for psychiatric disorder have to do primarily with increased rates of parental and family characteristics associated with child psychiatric disorder rather than the economic disadvantage itself. (54,5,5)
In child psychiatry, protective factors are variables that reduce the incidence or severity of children's emotional or behavioural problems among children at increased risk for these difficulties.(56) There are examples of protective factors in the child, the family, and the wider community.(57) The mechanisms by which they have their effect involve four main processes: reduction of risk impact; reduction of negative chain reaction, establishment and maintenance of self-esteem and self-efficacy; and opening up opportunities/5,59>
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