Attention Deficit and Disruptive Behavior Disorders

Children prenatally exposed to anesthesia for maternal surgery during pregnancy were significantly more likely than unexposed children to receive a diagnosis of a disruptive or internalizing behavioral disorder including attention deficit hyperactivity disorder, behavioral disorders, developmental speech or language disorders and autism, according to a new study. Children prenatally exposed to anesthesia for maternal surgery during pregnancy were significantly more likely than unexposed children to receive a diagnosis of a disruptive or internalizing behavioral disorder including attention deficit hyperactivity disorder, behavioral disorders, developmental speech or language disorders and autism, according to a new study at Columbia University Mailman School of Public Health and Columbia University Irving Medical Center (CUIMC). Until now associations between prenatal exposure to general anesthesia for maternal surgery during pregnancy and subsequent risk of behavioral disorders in children was unclear. The findings are published online in the British Journal of Anesthesia. Prenatal exposure to general anesthesia was associated with a 31 percent increased risk for a subsequent disruptive or internalizing behavioral disorder (DIBD) diagnosis in children, with higher risk when the exposure occurred in the second or third trimester of pregnancy. The probabilities of DIBD diagnosis between exposed and unexposed children were similar in the first three years of life, but diverged thereafter. "For several years there have been concerns about the long-term neurodevelopmental effects of anesthetic exposure in children, with the FDA in 2016 releasing a Drug Safety Communication warning against repeated or lengthy use of anesthesia in young children and pregnant women," said Caleb Ing, MD, MS, associate professor of Anesthesiology and Epidemiology at Columbia Public Health and CUIMC and first author. "Studies evaluating exposures in children however have been limited because children needing surgery and anesthesia may have more underlying health problems which may predispose them to neurodevelopmental disorders. Prenatal exposures are particularly relevant because general anesthetic drugs cross the placenta, and since the need for anesthesia is related to maternal medical problems, the risk of bias due to underlying health problems in children is reduced, according to the authors. "However, caution is advised, as many procedures in pregnant women may be necessary, and avoidance of necessary procedures can have detrimental effects on mothers and their children," advises Ing. The study population was drawn from Medicaid Analytic eXPrenatal eXtract for general anesthetic exposure and was identified using maternal claims with International Classification of Disease for either an appendectomy or cholecystectomy which are the two most common non-obstetric procedures performed during pregnancy. Exposures were classified as occurring in the first, second, or third trimester of pregnancy. The researchers also controlled for a variety of factors including age, race, ethnicity, state of residence, income based on zipcode, and Medicaid enrollment for disability vs. poverty. Each prenatally exposed child was matched with five unexposed children. The population consisted of 16,778,231 deliveries linked to an infant born between 1999 and 2013 with known sex. Of those, 34,271 children were exposed to general anesthesia due to maternal appendectomy or cholecystectomy during pregnancy. "This study provides compelling evidence that prenatal exposure to surgery and general anesthesia may have adverse effects on children's neurobehavioral development ," said Guohua Li, MD, DrPH, professor of Epidemiology and Anesthesiology at Columbia Mailman School and Vagelos College of Physicians and Surgeons, and senior author. "Our findings could help inform preoperative risk assessment in pregnant women, especially when the surgical procedure is elective or when viable treatment is available. Results of this study also give added impetus to research on safer anesthetic drugs and techniques." Co-authors are Jeffrey H. Silber,,Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Deven Lackraj, Stanford Chihuri, and Ling Guo , Columbia University Vagelos College of Physicians and Surgeons; Mark Olfson and Melanie Wall, Columbia Mailman School of Public Health and Vagelos College of Physicians and Surgeons; Caleb Miles, Columbia Mailman School of Public Health; Joseph G. Reiter and Siddharth Jain, Children's Hospital of Philadelphia; and Cynthia Gyamfi-Bannerman, University of California San Diego. The study was supported by the Agency for Healthcare Research and Quality (AHRQ), grant R01HS026493.

With the advent of rapid whole genome sequencing, children presenting with an intellectual disability or developmental delay are recommended to have their DNA sequenced to identify the underlying genetic cause. Researchers have now published the results of an analysis of data from almost 2,800 young people with rare genomic variants -- changes to their DNA -- that are associated with intellectual disability. A major study of children with intellectual disabilities has highlighted the additional challenges that they often face, including a much-increased likelihood of being diagnosed as autistic, as well as Attention Deficit Hyperactivity Disorder (ADHD) and other mental health difficulties. With the advent of rapid whole genome sequencing, children presenting with an intellectual disability or developmental delay are recommended to have their DNA sequenced to identify the underlying genetic cause. To capitalise on this recent NHS development, researchers at the University of Cambridge, University College London and Cardiff University established IMAGINE ID ( ), a national UK cohort study that aims to discover how genetic changes affect children and young people's behaviour, in order to inform better care of families and children now and in the future. Writing in The Lancet Psychiatry today, the researchers have published the results of an analysis of data from almost 2,800 young people with rare genomic variants -- changes to their DNA -- that are associated with intellectual disability. Professor Lucy Raymond from the University of Cambridge, the study's senior author, said: "Thanks to all the families that have taken part in our research, we've been able to conduct the largest study to date of the impact of rare genetic variants associated with intellectual disability. What we've found from parents is that these children are extremely likely to develop other neurodevelopmental or mental health conditions, which can present additional challenges both to the children and their families." All the participants were aged between four and 19 years. Just under three-quarters (74%) had an intellectual disability caused by a duplication or deletion of sections of DNA -- a so-called copy number variant (CNV). The remaining young people had a disability caused by a single 'spelling error' in their DNA -- a change in the A, C, G or T nucleotides -- referred to as a single nucleotide variant (SNV). Compared to the English national population, children in the study were almost 30 times as likely to have been diagnosed as autistic. In the general population, 1.2% of people are diagnosed with the condition compared to 36% of the study participants. Similarly, 22% of the study population were diagnosed with ADHD, compared to 1.6% of the general population, meaning that they were more than 13 times more likely to have the condition. Around one in eight children (12%) had been diagnosed with oppositional defiant disorder, in which children are uncooperative, defiant, and hostile toward others -- a rate 4.4 times higher than in the general population. One in ten (11%) had an anxiety disorder, a 1.5 times increased risk. Rates of childhood depression were significantly lower, at just 0.4% compared with 2.1% of the general population, but this may increase over the next few years as some mental health disorders do not start until later adolescence or early adult life. Almost all of the children (94%) were reported to have at least one significant physical health problem, including disturbed sleep (65%), motor or movement disorders (64%) or seizures (30%). Dr Jeanne Wolstencroft from Great Ormond Street Institute of Child Health, University College London, said: "Routine genomic testing now allows parents to understand the genetic cause of intellectual disabilities in an increasing number of children but, because so many of these conditions are rare, we still lack information on the impact this has on their children's future mental health. "We already know that intellectual disabilities tend to be associated with an increased likelihood of neurodevelopmental conditions, as well as emotional and behavioural difficulties, but we found that where there is an identifiable genetic cause, the likelihood is amplified considerably. This suggests that these children should be provided with early assessment and help where appropriate." The team has also shown for the first time that children with intellectual disability caused by a genetic variant inherited from a family member, are more likely to come from a more deprived socioeconomic background. This suggests that some parents or family members with the same variant may also have unrecognised difficulties that placed them at a social and educational disadvantage. These children were more likely to be diagnosed with a neuropsychiatric condition and were also more likely to exhibit behavioural difficulties. Professor David Skuse from Great Ormond Street Institute of Child Health, University College London, said: "We hope this work helps improve the targeting of assessments and interventions to support families at the earliest opportunity. We'd like to see better training for health care providers about the wider use and utility of genetic testing. We have identified its potential value in terms of prioritising children with mental health needs for child mental health services, who are currently hugely limited in the UK." The research was funded by the Medical Research Council (part of UK Research & Innovation) and the Medical Research Foundation. Additional support was provided by the NIHR Cambridge Biomedical Resource Centre and the NIHR GOSH BRC.

New research has found an association between the COVID-19 pandemic and a ‘sharp’ increase in mental health issues for children aged 11 to 12 years old. The study, conducted by the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London (KCL), examined the mental health of adolescent children using a sample representative of the general population. Researchers then compared levels of emotional and behavioural problems immediately before and during the COVID-19 pandemic. Participants, including children aged 11 to 12 years old and their mothers, provided mental health data between December 2019 and March 2020 and again three months later. Within the 202 participants included, 89% were assessed both pre- and post-onset of COVID-19, with 44% of those reporting an increase in symptoms of depression and 26% reporting the same about PTSD. According to the study, published in JCPP Advances, girls and children with prior experience of emotional problems had elevated rates of depression both pre- and post-onset of COVID-19. Researchers noted that the group which experienced the most notable increase in behavioural problems were those with no prior experience of mental health issues, suggesting that these problems were associated with the pandemic. “Our findings indicate that referrals for depression and disruptive behaviour problems during the pandemic are likely to be made up of two kinds of young people; those with the onset of new mental health problems for which COVID-19 related issues may be the most relevant, and others where COVID-19 has added to pre-existing vulnerability with a need for attention to both,” said Nicola Wright, department of biostatistics & health informatics at KCL. “What’s not yet clear is whether COVID-19 exposure has simply ‘brought forward’ the first episode of depression in children who would have become depressed later in its absence. Meanwhile the findings underline the need for a better understanding of risk and protective factors for COVID-19 related mental health problems as a basis for new treatments,” she added.