Exposure to Cannabis in Womb Associated With Behavioral Issues in Tweens, Study Finds

Children who were exposed to cannabis in the womb appear to be at a heightened risk of behavioral problems into at least early adolescence, suggests a report published Monday in JAMA Pediatrics. The findings—which are based on data collected as part of the Adolescent Brain and Cognitive Development Study (ABCD Study)—add to a growing body of evidence about the risks of cannabis use during pregnancy.

According to a media release from the National Institute on Drug Abuse, cannabis use among pregnant women increased from 3% in 2002 to 7% in 2017. In 2018, 4.7% of pregnant women reported cannabis use; 5.4% reported cannabis use in 2019.

A 2020 study by Ryan Bogdan, Ph.D., of Washington University in St Louis and colleagues found that children whose mothers used cannabis after learning they were pregnant were slightly more likely to have sleep, attention, and social problems at ages 9 and 10, among other issues. To determine if these associations remained as the children grew older, David A.A. Baranger, Ph.D., Bogdan, and colleagues followed up with these youth one and two years later. (As was done in the 2020 study, children and caregivers provided feedback on the Child Behavior Checklist and the Prodromal Questionnaire–Brief Child Version.)

The analysis included 10,631 individuals and 30,091 longitudinal assessments (baseline: n = 10,624; mean age, 9.9 years; one-year follow-up: n = 10,094; mean age, 10.9 years; two-year follow-up: n = 9,373; mean age, 12.0 years). The analysis revealed no significant changes in the rate of psychiatric conditions as the children aged.

“[Prenatal cannabis exposure] is associated with persisting vulnerability to broad-spectrum psychopathology as children progress through early adolescence,” Baranger and colleagues wrote. “Increased psychopathology may lead to greater risk for psychiatric disorders and problematic substance use as children enter peak periods of vulnerability in later adolescence.”

For related information, see the Psychiatric News article “Exposure to Alcohol, Cannabis in Womb Can Have Long-Term Consequences.”

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Study Identifies Barriers, Facilitators to African American Parents Seeking MH Care for Children

Many factors influence parents’ abilities to seek help for their children experiencing mental health problems. A report in Psychiatric Services found that African American parents were more likely to postpone seeking professional help for a child experiencing emotional or behavioral problems if they feared the child might be involuntary hospitalized and/or if their health insurance would not cover treatment.

“Barriers to mental health care are greater for African American parents, who are more likely than White parents to experience structural obstacles that hinder timely diagnosis,” wrote Jennifer Richmond, Ph.D., M.S.P.H., of Vanderbilt University Medical Center and colleagues. “African American children are also exposed to systemic racism and other harmful structures in the health care system … As a result, African American children with emotional and behavioral challenges are more often misdiagnosed and less likely to receive early intervention than are White children.”

Richmond and colleagues used data from the Teaching Advocacy Skills for Kids study, which included 289 African American parents living in North Carolina who were raising children with several mental health or developmental challenges. Parents completed a computer-assisted telephone interview upon recruitment to the study. During the interviews, the authors determined whether the parents rapidly sought care (defined as seeking care within 30 days of identifying their child’s need) or deferred care (defined as waiting one year or longer to seek care) for their children after recognizing the children had mental health or developmental challenges.

Parent activation (meaning the parent had the knowledge, skills, and confidence to access and engage in the appropriate services) was assessed using the 13-item parent-focused Patient Activation Measure. The authors also assessed if there were other adults with mental health challenges living in the home; if parents mistrusted doctors; and if they were deterred from getting help for their children for other reasons, including a fear of involuntary hospitalization, lack of health insurance coverage, or not initially finding the children’s behaviors to be bothersome.

About 22% of parents rapidly sought care, while 49% deferred care. Parents were more likely to rapidly seek care if they had higher parent activation scores or if they lived with other adults with mental health challenges. They were less likely to rapidly seek care if their children’s challenges did not initially bother them or if their health insurance would not cover the service. Similarly, they were more likely to defer care if they feared involuntary hospitalization for their children.

Contrary to the authors’ hypothesis, parents were more likely to rapidly seek care for their children if they reported mistrusting doctors. “It is possible that parents who mistrust doctors make different choices for their children than for themselves,” the authors theorized. “For example, parents who mistrust doctors, perhaps because of previous negative health care experiences, may be more motivated to advocate for their child to receive rapid, high-quality care so that their family can avoid further negative experiences.”

For related information, see the Psychiatric Services article “Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care.”

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Punitive Discipline May Work in Short Term but Could Cause Long-Term Emotional Damage

Young children whose parents employed punitive discipline styles, such as smacking or shouting at them, tended to have fewer conduct problems and less hyperactivity, but it came at a high cost: they tended to develop more emotional problems and less prosocial behaviors at age 11, according to a study published in the January issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

The findings offer yet another example of why parents should avoid physical punishment and verbal abuse of children, as was recently emphasized in an updated policy statement against corporal punishment by the American Academy of Pediatrics.

Pryia Rajyaguru, M.R.C.Psych, of Bristol Medical School and colleagues analyzed data from nearly 5,000 mothers who were participating in the UK Millennium Cohort Study, a national longitudinal study monitoring the lives of children born in 2000 and 2001 in the United Kingdom. The mothers completed a questionnaire on their parenting styles when their children were 3 years old, which quantified their use of “active” punishment (such as smacking, shouting, and telling off) and “withdrawal of reward” styles of discipline (such as ignoring, removal of privileges, and sending children to their bedroom). Additionally, the mothers completed a brief questionnaire called the Strengths and Difficulties Questionnaire (SDQ), which asked them to evaluate emotional and behavioral problems in the 3-year-olds; the mothers repeated this assessment when the children were aged 11.

Older mothers used relatively less discipline overall, whereas those who were educated and of higher socioeconomic status used relatively more withdrawal of rewards and less active punishment approaches, the study found. Children subjected to both active punishment and withdrawal-of-reward approaches had fewer conduct problems from age 3 to 11, the researchers wrote. However, those subjected to active punishment developed increased emotional problems not seen with the withdrawal-of-rewards discipline style.

Both approaches, however, increased child-reported emotional symptoms, as measured by a six-item questionnaire completed by the children at age 11. This suggests that both active punishment and withdrawal of rewards might negatively influence the child’s mood.

“This study demonstrates that for those mother-child dyads in which discipline is frequent, the type of approach used appears important with distinct later childhood mental health outcome,” Rajyaguru and colleagues wrote. “[I]f mothers adopted more withdrawal and less active approaches, then later emotional and behavioral problems might be decreased.”

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Persistent, Severe Postpartum Depression Increases Risk of Adverse Outcomes in Children

Children whose mothers reported severe symptoms of postpartum depression lasting at least eight months after childbirth may be more likely to experience behavioral problems and depression compared with children whose mothers’ postpartum depression was not persistent or severe, suggests a study published today in JAMA Psychiatry.

“Health care professionals should identify these women for further referral because early and effective treatment could reduce the continued exposure of the child,” wrote Elena Netsi, D.Phil., of the University of Oxford and colleagues.

To determine whether differing levels of persistence and severity of postpartum depression are associated with subsequent maternal depression and child outcomes, Netsi and colleagues analyzed data contained in the Avon Longitudinal Study of Parents and Children (ALSPAC). ALSPAC is an ongoing population-based study examining the overall health of children born in southwest England between April 1991 and December 1992.

Maternal depression was measured using the self-rated Edinburgh Postnatal Depression Scale (EPDS) at two and eight months. The authors separated the group into three levels of depression severity, based on EPDS score: moderate (13 to 14 points), marked (15 to 16), and severe (17 or more points). Postnatal depression was considered persistent when an individual scored above the EPDS threshold at both the two- and eight-month postnatal assessment.

The authors compared the following outcomes in the children born to women with varying degrees of postpartum depression: child behavioral problems at 3.5 years (based on maternal report), math scores at age 16 (extracted from records of public exams), and offspring depression at 18 (based on self-report). These three offspring outcomes were shown to be associated with postnatal depression in this sample. Children of women with persistent and severe depression had a fourfold increased risk of having behavioral problems at 3.5 years, a twofold increased risk of having lower math scores at 16 years, and a sevenfold increased risk of depression at 18 years.

They also compared the trajectories of later EPDS scores in women with varying degrees of postpartum depression. They found that regardless of the severity level, women with persistent postpartum depression showed elevated depressive symptoms up to 11 years after childbirth compared with women who did not meet the threshold for moderate postpartum depression.

“These results are important because they suggest a change from the current U.S. Preventive Task Force recommendations of universal screening for depression in all pregnant women to universal screening for depression beyond pregnancy,” Myrna M. Weissman, Ph.D., of Columbia University College of Physicians and Surgeons wrote in an accompanying editorial.

Weissman continued, “Having established a highly vulnerable group of mothers still does not answer the question of what to do about interventions or who, when, or how to treat”—a subject she noted is of some debate within the field. “Whether to treat maternal depression first, when to intervene with the mother and her infant and young children, and what treatment to use are open, researchable questions of considerable public health importance, which are worth expenditures of public funds.”

For related information, see the Psychiatric News article “Early Postpartum Depression Screenings Not Enough to Identify High-Risk Women.”

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Study Suggests Few Gamers Meet Proposed Criteria for Internet Gaming Disorder

DSM-5 lists Internet gaming disorder as a potential psychiatric disorder, but notes the prevalence of the disorder is unclear and little is known of its impact on physical, social, and mental health. 

A study published Friday in AJP in Advance suggests that while Internet-based games among adults are popular, only a small proportion of gamers appear to meet the proposed criteria for Internet gaming disorder listed in DSM-5. While those who met the proposed criteria for Internet gaming disorder played video games more regularly than those who did not meet the criteria for the disorder, there were no differences between the groups in physical, social, and mental health outcomes, Andrew K. Przybylski, Ph.D., of the University of Oxford and colleagues reported.

These conclusions were drawn from an analysis of survey data responses from four cohorts totaling nearly 19,000 adults in the United States, United Kingdom, Canada, and Germany; two of the cohorts were exclusively young adults (aged 18 to 24) while the other two included adults of all ages. The surveys were designed to answer several questions, including what is the acute prevalence rate of the Internet gaming disorder and how does this prevalence compare with that for gambling disorder? 

The researchers found that between 0.3% to 1.0% of the population might qualify for an acute diagnosis of Internet gaming disorder, though about two-thirds of active gamers do not report any diagnostic symptoms. The estimated prevalence of acute gambling disorder in the same cohort was between 1.0% to 2.6%. “This provides tentative evidence that despite being a new and popular activity, Internet-based games might be less dysregulating than gambling,” the authors wrote.

The authors continued, “If one extrapolates from our data, upwards of 160 million American adults play Internet-based games, and as many as one million of these individuals might meet the proposed DSM-5 criteria for addiction to online games. This represents a large cohort of people struggling with what could be clinically dysregulated behavior. However, because we did not find evidence supporting a clear link to clinical outcomes, more evidence for clinical and behavioral effects is needed before concluding that this is a legitimate candidate for inclusion in future revisions of the DSM.”

For related information, see “Can Medications Help People With Gambling Disorder?” by Grace Hennessy, M.D., the director of the Substance Abuse Recovery Program at the Department of Veterans Affairs at New York Harbor Heath Care System.

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Study Finds Overall Uptick in Youth Prescribed Antipsychotics

From 2006 to 2010, antipsychotic use increased among U.S. adolescents and young adults but not in children 12 and under, according to a study published online Wednesday in JAMA Psychiatry.

Mark Olfson, M.D., M.P.H., a professor of clinical psychiatry at Columbia University, and colleagues retrieved data on antipsychotic prescriptions filled by or for young people (aged 1 to 24 years) in 2006, 2008, and 2010 from the IMS LifeLink LRx Longitudinal Prescription database, which includes about 60 percent of all retail pharmacies in the United States. The researchers then calculated the percentage of young people for whom one or more antipsychotic prescriptions were filled during the study year by sex and age group, and generalized the IMS prevalence to the entire U.S. population of young people, including those who did not fill a prescription.

The percentages of young people whose antipsychotic prescriptions were filled in 2006 and 2010, respectively, were 0.14% and 0.11% for younger children (1 to 6 years), 0.85% and 0.80% for older children (7 to 12 years), 1.10% and 1.19% for adolescents (13 to 18 years), and 0.69% and 0.84% for young adults (19 to 24 years). Further analysis of the 2010 data revealed that across all age groups, males were more likely than females to have filled their antipsychotic prescriptions; among young people treated with antipsychotics in 2010, receiving a prescription from a psychiatrist was less common among younger children (57.9%) than among other age groups (range, 70.4%-77.9%).

“In view of evidence of widespread antipsychotic prescribing outside of U.S. Food and Drug Administration–labeled indications and concerns regarding the adverse metabolic effects of second-generation antipsychotics, this decline [in the rate of antipsychotic use among children 12 and under] is a welcome development,” the authors wrote. “Nevertheless, age and sex antipsychotic use patterns suggest that much of the antipsychotic treatment of children and younger adolescents targets age-limited behavioral problems.”

When evaluating treatment options for the youngest children with disruptive behaviors, practice guidelines recommend that “consideration of antipsychotic medications should be limited to those who have severe, sustained, and intractable impairment in multiple settings or who pose safety risks,” the authors noted. They added that if such therapy is initiated, young patients should be continually reassessed to minimize treatment duration. However, as the authors pointed out, children treated with antipsychotics most commonly receive prescriptions from physicians who are not psychiatrists.

“Given the paucity of high-quality empirical evidence supporting the efficacy and safety of antipsychotic treatment in this age group, these treatment patterns raise potential safety concerns and underscore the importance of improving access for young children with severe mental health problems to high-quality, specialized child and adolescent mental health services,” they concluded.

For more on antipsychotic use among children and adolescents and practice guidelines, see the Psychiatric News article “Recent Rise in Youth on Antipsychotics Raises Concerns Among Experts.”

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