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Mental health problems and psychopathology
in infancy and early childhood
An epidemiological study
Anne Mette Skovgaard
This review has been accepted as a thesis together with seven previously
published papers by University of Copenhagen 6 th of November 2009
and defended on 29 th of January 2010.
Official opponents: Tuula Tamminen, Niels Bilenberg and
Merete Nordentoft.
Correspondence: Department Child and Adolescent Psychiatric Centre,
Glostrup Hospital, Ndr. Ringvej 69, 2600 Glostrup, Denmark.
E-mail: anne.mette.skovgaard@regionh.dk
Dan Med Bul 2010;57:B4193
The significance of the first years of living in the determination of
mental health later in life has been discussed since the pioneering
work of Anna Freud (1936, 1973), Rene Spitz (1951) and John Bowlby
(1951). In these works from the early start of child psychiatry, the
understanding of children’s mental illness was primarily based on
hermeneutic interpretations of the consequences of deprivation of
maternal care (Rutter 1979).
Along with the development of child and adolescent psychiatry, the
concept of mental illness in children has reflected shifting focus on
either primary biological aetiology or psycho-dynamic and socio-
cultural risk mechanisms (Neve & Turner 2002). Since the influential
Isle of Wight Study in the 1970’s however, the different and until
then diverging concepts of aetiology have been united in a bio-
psycho-social understanding of psychiatric diseases in children
(Rutter 1989, Costello et al 2005). Besides, the concept of develop-
mental psychopathology has been applied to the understanding of
how nature-nuture interacts over time and how mental health
symptoms evolve at different developmental stages (Rutter 2000,
Costello et al 2006).
Epidemiological research has demonstrated the significance of
childhood psychopathology by the finding of an overall prevalence
of psychiatric disorders in school aged children and adolescents of 16-
18 %, and a high risk of continuity of mental health problems from
school age to adolescence and adulthood (Verhulst et al 1992,
Roberts et al 1998, Costello et al 2005, Maugham & Kim-Cohen 2005).
In the clinical field of child psychiatry, still younger children are
referred to treatment and increasing evidence from the latest dec-
ades point to the significance of early symptoms of disorders previ-
ously not diagnosed until school age (Egger & Angold 2006).
However, epidemiological studies of preschool aged children are
few, and even more limited when it comes to children below the age
of four years (Carter et al 2004, Egger & Angold 2006).
The literature on clinical aspects of mental illness in the first
years of life is sparse, and most handbooks on child and adolescent
psychiatry only mention psychopathological symptoms in children
0-3 years of age in relation to disorders of attachment and behav-
ioural problems, and with comments on early symptoms of autistic
disorders and attention-deficit-hyperactivity disorders ADHD.
From the current stage of knowledge, it is obvious to search for
research data on the early presentation of symptoms, risk factors
and course of mental illness in order to get answers to how and pos-
sibly why mental illness develop.
EPIDEMIOLOGICAL STUDIES OF MENTAL HEALTH PROBLEMS
AND PSYCHOPATHOLOGY IN CHILDREN AGED 0ͳ3 YEARS
͵ A REVIEW OF THE LITERATURE
The literature from the period 1967-2007, was searched in the
database Medline (PubMed) with the search terms: infant, infancy,
toddler, preschool, child, mental health, psychiatry, psychopathol-
ogy, behaviour problems, disorders, illness, disease, disturbances,
diagnoses, epidemiology, prevalence, risk factors, predictors,
precursors, longitudinal, birth cohorts.
Only studies investigating aspects of psychopathology in chil-
dren below the age of 4 years were included. Additional search from
the reference lists of identified literature was performed.
Overall, epidemiological studies of mental health problems and
psychopathology, which have included children 0-3 years of age, fall
in the following three categories:
1. Studies of clinical populations
2. Cross-sectional studies of non-clinically referred populations
3. Longitudinal studies of selected and unselected cohorts
STUDIES OF CLINICAL POPULATIONS OF CHILDREN 0ͳ3 YEARS
Overall, thirteen studies of mental health problems and psychopatho-
logy in clinical populations have been published from 1987 through
2007 from USA, Canada, Austria, Portugal, France and Denmark
(Table 1).
A considerable diversity was seen across the studies: a)
the age of the children ranged from infancy to 72 months, and re-
sults regarding the age group 0-3 years could not be isolated in all
DANISH MEDICAL BULLETIN
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studies, b) background populations varied with respect to routes
of referral, the proportion of high risk families, e.g with mentally
ill parents and intake from deprived areas. Furthermore, c) a broad
range of diagnostic methods had been applied: retrospective file re-
view, consensus clinical diagnoses and diagnostic classification based
on standardized measures.
Seven studies have investigated DSM diagnoses (Lee 1987,
Hooks 1988, Dunitz 1996, Minde & Tidmarsh 1997, Luby & Morgan
1997, Thomas & Clark 1998, Frankel et al 2004) and nine studies
have classified mental health problems according to Diagnostic
Classification Zero-to Three, DC: 0-3 (Dunitz 1996, Minde & Tidmarsh
1997, Thomas & Clark 1998, Elberling et al 2002, Cordeiro 2003,
Guédeney 2003, Keren et al 2003, Maldonaldo-Durán et al 2003,
Frankel et al 2004). In four of these studies, the DSM and DC: 0-3 di-
agnoses were investigated simultaneously (Dunitz 1996, Minde &
Tidmarsh 1997, Thomas & Clark 1998, Frankel et al 2004). ICD diag-
noses have only been investigated in one study: a nation wide regis-
ter study of 0-3 year old children referred to child psychiatric depart-
ments in Denmark (Skovgaard et al 2001).
The methodological diversity of the clinical studies reviewed,
does not allow any systematic comparison of diagnostic distribution
in referred children. However, it is noteworthy that in several stud-
ies, a high proportion of the children were not diagnosed with a
mental health diagnosis at all, and the most commonly used diagno-
sis across several studies was a condition of non-specific manifesta-
tions: adjustment disorder (Table 1).
STUDIES OF NONͳREFERRED CHILDREN/COMMUNITY
OR GENERAL POPULATION BASED STUDIES
Table 2 shows an overview of prevalence studies of mental health
problems and psychopathology in community or general population
samples.
In 9 of the 12 studies (published 1975-2006), the definition of
cases was based on parent-reported child behaviour in question-
naires or checklists e.g the Behaviour Screening Questionnaire BSQ
developed by Richman and Graham (Richmann et al 1971, 1975) and
from the late 1980’s the Achenbach Child Behaviour Check List CBCL
(Achenbach 1987, 2000). The rates of prevalence of deviant behav-
iour or behavioural and emotional syndromes range from 7.3 %
(Richmann et al 1975) to 12-16 % (Briggs-Gowan et al 2001). In two
studies, child mental health diagnoses were studied in a two stage
design of children aged 2-3 years (Lavigne et al 1996) or 2-5 years
(Egger and Angold 2006) with the use of behavioural screening at
stage one and diagnostic assessment at stage two.
Three studies have investigated DSM diagnoses (Earls 1980,
Lavigne et al 1996, Egger and Angold 2006) and one study ICD diag-
noses (Weyerer 1988). However, among these, the study by Lavigne
et all is the only which report explicitly on diagnoses in children
down to the age of 2-3 years (Lavigne et al 1996). In this study a
sample of 2.262 children aged 2-3 years were recruited from primary
care paediatric clinics in Chicago, US, and studied in a two stage
design, with CBCL screening at first stage and at stage two: in-depth
assessment by, among others, developmental tests and play obser-
Table 1. Studies of mental health problems in clinical populations including children aged 0-3 years (published 1987-2007) – distribution on diagnostic groups.
Primary Syndrome Diagnosis (%) Study N Age
(months)
Diagnostic
classification Develop-
mental
disorder (%)
ADHD (%) Behaviour
disorder (%)
Emotional
disorder (a)
(%)
Feeding and
eating
disorder (%)
Sleep
disorder (%)
Attachment
disorder (%)
Regulatory
disorder (%)
Adjustment
disorder (b)
(%)
No psych.
Diagnosis
(%)
Relationship
disorders
(DC 0-3: Axis II)
(%)
Lee et al (1987) 129 12-72 DSM-III 7.8 7.8 8.5 1.6 - - - - 27.1 - 7.8
Hooks et al (1988) 193 Infancy-60 DSM-III 8.8 0.1 2.0 4.7 - - 0.1 - 10.9 15.0 5.7
Dunitz et al (1996) 82 0-24 DSM-IV/DC: 0-3 - - - 9.8 43.9 9.8 15.9 - 9.8 - -
Minde & Tidmarsh
(1997)
57 15-48 DSM-IV/DC: 0-3 5.3 - - 8.4 - - - 36.8 10.4 21.0 52.6
Luby & Morgan (1997) 116 9-70 DSM-III-R 37.0 30.2 11.2 11.2 - - - - 9.5 26.60 -
Thomas&Clark (1998) 64 12-47 DSM-IV/DC: 0-3 - 20.3 21.8 21.8 - - - - 46.9 - -
Skovgaard et al (2001) 529 0-47 ICD-10 11.0 0.8 8.1 4.2 2.5 0.2 10.8 - 30.4 25.0 -
Elberling & Skovgaard
(2002)
114 0-47 DC: 0-3 24.6 - - 18.4 8.8 - 8.8 12.3 6.1 21.9 50.0
Guédeney et al (2003) 85 0-37 DC: 0-3 12.9 - - 20.0 1.2 7.1 11.8 11.8 4.7 23.5 72.6
Keren et al (2003) 414 0-42 DC: 0-3 - - 1.4 6.5 11.8 10.0 1.9 5.1 8.2 55.2 52.0
Cordeiro et al (2003) 343 0-48 DC: 0-3 18.7 - - 26.2 (d) 2.9 1.8 - 6.4 5.5 23.3 63.9
Maldonado-Durán et al
(2003)
167 0-36 DC: 0-3 9.5 - - 6.5 4.1 2.9 1.1 42.0 11.3 9.5 37.2
Frankel et al (2004) 177 0-58 DSM-IV/DC 03 (c) 3.4 4.0 6.8 4.5 1.7 0.6 9.6 7.9 11.3 5.7 7.3
(a) Inclusive mixed disorder of emotional expressiveness, anxiety disorders and mood disorders.
(b) Inclusive post traumatic stress disorder.
(c) Only DSM diagnosis here.
(d) Inclusive reactive attachment disorder.
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vation. Diagnostic classification was done by psychologists as
“best estimate diagnosis” according to DSM III-R and a global rating
of impairment by C-GAS. The prevalence of having a child psychiatric
diagnosis including all areas except general and pervasive develop-
mental disorders was 13.6 % in 2 year old children and 26.5 % in 3
year olds. If only severe cases were included, the prevalence in the
same age groups was respectively 7.1 and 14.0 % (Lavigne et al
1996, 1998).
Egger & Angold investigated 1.073 children aged 2-5 years with
CBCL screening at stage one, and at stage two, a total of 307 children
were assessed with the structured Preschool Age Psychiatric
Assessment (PAPA) which includes DSM-IV criteria relevant for axis I
diagnoses in young children and not including general and pervasive
developmental disorders (Egger & Angold 2006). The overall preva-
lence rate of severe to moderate psychopathology except for gen-
eral and pervasive developmental disorders was 16.2 %. Separate
data for age groups within the age span were not informed (Egger &
Angold 2004, Egger & Angold 2006).
LONGITUDINAL STUDIESͳ BIRTH COHORTS
Longitudinal research has demonstrated a continuity of several
aspects of mental health problems from childhood to adult age and
hereby contributed to the current understanding of developmental
psychopathology (Rutter, Kim Cohen & Maugham 2006).
However, when the literature is restricted to studies of un-se-
lected populations which includes data from the first three years of
living, only two studies which are addressing the longitudinal per-
spective of developmental psychopathology remain: The Dunedin
Study (Silva 1990) and the ALSPAC Study (Golding et al 2001).
The Dunedin Multidisciplinary Health and Development Study,
DMHS collected data from a birth cohort of 1037 children born at
the same hospital in Dunedin, New Zeeland in 1972-1973. The over-
all aim was to study health, development and behaviour of children
and adolescents and to identify correlates of normal and abnormal
development (Silva 1990, Mc Gee et al 1995). The Dunedin study has
demonstrated associations between psycho-motor development
and early child temperament measured at child age three years on
one side and later psychopathology on the other (Caspi et al 1995),
but no mental health variables were recorded from this study before
the age of three year (Caspi et al 1996).
The Avon Longitudinal Study of Parents and Children, ALSPAC,
has collected data on 10.000 children, born in 1991-1992 in the
county of Avon, UK in a comprehensive study of child health and de-
velopment. Within the study, detailed data from questionnaires to
parents, medical records and biological samples were collected from
pregnancy and onward. Information on child health was obtained
from questionnaires to parents send out the first month after birth
and then two times a year. Clinical assessment of a randomly se-
lected sample of 1000 children included assessment of cognitive
function at child age 4 and 18 months, and assessment of language
development at child age 25 months. Parenting was assessed at
child age 12 months (Golding et al 2001). However, no data on child
psychopathology in the first three years of life have been reported
from this study.
Table 2. Community/ general population studies of prevalence of mental health problems and psychopathology including children aged 0-3 years (published 1975-2007).
Study Population N Age Method Informants Case-definition Area of psychopathology Prevalence %
Richmann, Stevenson &
Graham (1975, 1982) General population
(UK)
Two stage
1. 705
2. 212 3 BSQ Parent Behaviour Screening Questionnaire Scale Behavioural problems 7.3
Earls & Richmann (1980) General population
(London/UK) 58 3 BSQ Parent Behaviour Screening Questionnaire Scale Behavioural, social and psychosomatic
problems 15.5
Earls (1980) Rural community
(US) 100 3 BSQ Mother Behaviour Screening Questionnaire Scale
Clinical consensus/DSM III criteria Deviant behaviour
DSM III diagnoses 16.5
Earls (1980) Rural community
(US) 85 3 BSQ Father Behaviour Screening Questionnaire Scale Deviant behaviour 8.3 (score>10)
Weyerer et al (1988) General population
(Germany) 358 * 3-14 Standardized psychiatric
examination Mother
Child ICD 9
Rutter’s multiaxial scheme ICD 9 18.4
Larson, Pless, Miettinen,
(1988) Birth cohort
(Canada) 756 3 CBCL Parent Child Behaviour Checklist Deviant Score
(CBCL) CBCL Syndrome 11.1
Koot & Verhulst (1991) General population
(Netherlands) 421 2-3 CBCL Parent Child Behaviour Checklist Syndrome Score
(CBCL) Behaviour Syndrome 7.8
Stallard (1993) Community health clinic
(UK) 1.170 3 BCL Parent Behaviour Checklist Score
(BCS) Behaviour items 10.0
Lavigne (1996) Community/
paediatric sample (US)
Two stage
1. 2.262
2. 256 2-3 Two stage
1. CBCL
2. CBCL, BSID, play obs. Parent DSM III-R DSM III disorders 13.6/ 7.1 ** (2 years)
26.5/ 14.0 ** (3 years)
Sourander (2001) Community /Finland 374 3 CBCL Parent Child Behaviour Checklist Score (CBCL) Behaviour Syndrome 7.9
Briggs-Gowan et al (2001) Community sample
(US) 1.280 2 ITSEA
CBCL/2-3 Parent Child Behaviour Checklist Score (CBCL) Emotional and behavioural symptoms 12-16
Egger& Angold (2006) Community sample (US) Two stage
1. 1.037
2. 307 2-5 Two stage
1. CBCL
2. PAPA Parent DSM IV DSM IV disorders 16.2
(* data concerning children <5 years of age is not specified, ** all / severe)
BSQ (Behaviour Screening Questionnaire), BCL (Behaviour Checklist), BSID (Bayley’s Scales of Infant development, CBCL (Child Behaviour Checklist), ITSEA (Infant Toddler Social and Emotional assessment), PAPA (Preschool Age Psychiatric Assess-
ment) DSM (Diagnostic and Statistical Manual of Mental disorders) ICD (International Classification of Diseases)
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LONGITUDINAL STUDIES OF POPULATIONS
SAMPLED ACCORDING TO RISK
The Manheim Study of Children at Risk seems to be the only study
published where systematic data on infant-toddler mental health
have been collected in the first years of living (Laucht et al 1993).
The study population of 362 children born in the Rhine-Neckar
Region, Germany, in 1986-1988 were sampled at birth according to
high, moderate or low respectively biological risks (e.g pregnancy
and birth complications) and psycho-social risks (family background).
Parents were interviewed by the Manheim Parent Interview MEI, a
standardized interview developed from the Rutter Parent Question-
naire (Rutter 1989) to cover diagnostic criteria of relevance in early
childhood (Esser et al 1989). Parent-child interaction was assessed at
3 months and the children were individually assessed at 3 and 24
months regarding cognitive and general psycho-motor function
using the Bayley’s scale of Infant Development (Laucht et al 1993).
The first outcome assessed at age 3 months demonstrated sig-
nificant and different impact of biological and psycho-social risk fac-
tors on child mental health (Laucht et al 1993). At 24 months, the
bio logical risk factors described at birth seemed to have decreased
in influence, whereas the importance of psycho-social risks had be-
come more prominent (Laucht et al 1997, 2000).
Conclusion: Epidemiological studies of psychopathology in chil-
dren below the age of four years are few and no studies have pub-
lished data on prevalence and risk mechanisms regarding the whole
spectre of mental illness in the first years of life in unselected popu-
lations.
AIMS OF THE THESIS
The principal objective was to start the longitudinal study of develop-
mental psychopathology from birth to adolescence/ adult life.
The research aims were the following:
1. To establish a general population birth cohort suitable for the
investigation of mental health problems and psychopathology
prospectively from birth
2. To study the presentation and prevalence of mental health diag-
noses in children 1½ years of age.
3. To study risk factors and predictors of psychiatric illness from
the first year of life.
4. To investigate the potentials of screening for infant mental
health problems in an existing child health surveillance
programme.
The work presented in this thesis is based on the following
hypo theses:
– Infants and toddlers suffer from mental illness like older
children do.
– Disorders of neurodevelopment: mental retardation, pervasive
developmental disorders, PDD and attention deficit hyperactiv-
ity disorders, ADHD manifest in the first years of life.
– Risk factors and predictors of later child mental illness can be
identified in the first year of life.
– General health professionals are able to screen for mental
health disorders in infancy.
METHODS
DESIGN
PAPER I: THE COPENHAGEN COUNTY CHILD COHORT
͵ DESIGN OF A LONGITUDINAL STUDY OF CHILD MENTAL HEALTH
The design is a prospective birth cohort study of mental health
problems.
This thesis concern the first stages of the study covering the pe-
riod from birth to 18 months supplied by a register follow-up of hos-
pital admissions for mental health problems covering the age period
from birth trough 36 months in the same cohort.
Study populations
The study population comprises all children born of mothers with
address in sixteen (out of eighteen) municipalities in the former
County of Copenhagen in the period from 1st of January to 31st of
December 2000.
The children were identified through midwifes birth registration
to the Civil Personal Registration System (CPR) and constitute the
Copenhagen Child Cohort, CCC 2000 (named The Copenhagen
County Child Cohort, CCCC 2000 until Copenhagen County was
merged in the Capital Region in 2007).
A total of 6090 children were born in the study area which had a
background population of 527.563 inhabitants per 1st of January
2000. The participating municipalities are located around the city of
Copenhagen and comprise urban and to a lesser degree semi-rural
areas, representing a broad spectrum of socio-economical and eth-
nical backgrounds.
From the CCC 2000 baseline population, 3 study populations are
investigated in this thesis:
I: The whole CCC 2000 cohort at child age 0-11 months
All cohort children were described at baseline with data from Danish
national registers and prospective recordings from community
health nurses’ home visits one to four times in the period from birth
to child age 11 months.
Participation at baseline
Of 6.090 children born in the study area, data from the Medical Birth
Register, MFR, were available on 6.072, 99,7% of the children. For
5.624 (91%) standardised data from at least one home visit were
available and data from three or more home visits were available for
5.362 children (88 %). One municipality withdrew from the study by
1st of October 2000, and in this municipality only children born
before that date were entered in the cohort.
The cohort constitutes 9 % of all children born in Denmark in
the year 2000. The cohort children did not differ significantly from
the general population of Danish children born in the same year with
regard to data recorded in the Medical Birth Register, MFR
(See Appendix 1) except for a higher proportion of parents with
other ethnic background than Danish.
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II: CC 1½ - A subpopulation investigated at age 1½ years
A sample of children for a thorough child psychiatric examination at
the age of 18 months, was selected from a CCC 2000 sub-cohort of
children from 6 municipalities (N=2155).
Only children for whom information from at least four health
nurse visits were available was considered eligible for the sampling
(N=1896).
Sampling was done with the following considerations:
– to include all cases of putative mental health problems and
psychopathology as identified by the child health nurses from
the municipalities
– to obtain an unbiased sample of 18 months old children from
the general population, serving both as source for a control
group in a nested case-control study of the health nurses
screening, and for studying developmental psychopathology in
the general population
– to examine no more than 400 children in depth, given resource
constraints of the study
– to enable future comparisons between the sub-cohort and the
rest of CCC 2000 in order to identify effects from intervention
towards children identified with mental health problems at
child age 1½ years.
Accordingly, from the six sub-cohort municipalities with a total of
1896 eligible children (having four home visits 0-10 months) an
iterative random sampling was performed in order to obtain the
desired number of approximately 200 cases and 200 controls.
Hereby a total of 411 children were selected to participate in
the child psychiatric assessment at age 18 months: 205 were cases
according to health nurses conclusions of concern and 206 children
of no concern served as controls.
Furthermore, from the same population, naïve to case-control
status, a random sample of 306 children was formed (see Fig 1).
Exclusion: Children with severe physical disabilities and children
from families, where the parents did not speak Danish were after-
wards excluded from this part of the study.
Participation rate: 65 % (n=134) among health nurse cases, 79 %
(n= 162) among controls, and 69 % (n=211) in the random sample
study.
In accordance with one of the exclusion criteria, analyses of at-
trition in data from Danish National Registers (see Appendix 1),
showed that non-participant children were significantly more often
from families with other ethnic background than Danish, but other-
wise no significant differences were found.
Comparison between the children in the six municipalities in
CC 1½ study and in the remaining municipalities in CCC 2000, sho wed
no differences with regard to putative child psychiatric risk factors
(ethnicity, parent’s ages, single parents, birth weight, Apgar score and
peri-natal illness measured as days spend in hospital after birth).
Reliability study in CC 1½
A reliability study was performed using raw data from the child
assessments of 18 children in the CC 1½ study. The children were
selected (blind to the investigators) from the children investigated at
1½ years in order to represent children with different mental health
problems and children with no mental health problems.
III: The CCC 2000 register follow-up study of mental health diagnoses
recorded at hospitals within the first three years of life
Of the 6090 children in CCC 2000, 6065 could be followed-up in the
National Register of Patients and the Psychiatric Central Register in a
study of mental health diagnosis recorded at hospitals between birth
and 36 months. Included as cases in this study were all children who
had received at least one ICD-10 diagnosis of a mental health
disorder (F-diagnoses and R 62.0: Psycho-motor retardation). A total
of 87 children were included, all of whom had been recorded in the
National Register of Patients. Out of these, 34 had additionally been
recorded in the Psychiatric Central Register (Fig 1).
Attrition from CCC 2000 in the period 1.1 2000-31.12 2003
(in the first 3 years of life)
Based on data from the National registers, The National Birth
Registry (MFR), the National Register of Patients (LPR) described in
Appendix 1, the attrition from the cohort in the period from 1.1
2000-31.12 2003 was 17 children, of whom 16 died within the first
few months of life and further one died between the age of 12 and
36 months.
Baseline data
Data from National Registers (Appendix 1)
In Denmark, all citizens have a unique 10-digit ID- number, which
follows them throughout life. This personal number informs birth
Table 3 Background Characteristics of CCC 2000
Data derived from Medical Birth Register (Appendix 1)
(N= 5624)
Variable (categorical) N (%) Distribution n (%)
Sex 5624 (100%)
Boys 2891 (51,4)
Girls 2733 (48,6)
Etnicity
(Parents born i DK) 5608 (99,7%) None 879 (15,7)
One 675 (12,0)
Two 4054 (72,3)
Affluence 5624 (100%) High 1202 (21,4)
Medium 1919 (34,1)
Low 2503 (44,5)
Parents living together (at the child’s birth date) 5608 (99,7%) Yes 5192 (92,6)
No 416 (7,4)
Parity
(Mothers total no of live-born children) 5251 (93,4%) 1 1976 (37,6)
2 2247 (42,8)
3 735 (14,0)
4 293 (5,6)
Birth complications
(child)
5624 (100%) No 5130 (91,2)
Yes 494 (8,8)
Serious congenital disorder 5624 (100%) Nej 5521 (98,2)
Ja 103 (1,8)
Smoking during pregnancy 5502 (98,6%) Never 4216 (76,6)
Yes, but stopped 118 (2,2)
Yes 1168 (21,2)
Variable (continuos) N (%) Mean (SD) (Range)
Mothers age (years) 5608 (99,7%) 30,3 (26,7-33,7) 16,5 – 46,3
Fathers age (years) 5527 (98,3%) 32,6 (28,9-36,3) 17,9 – 61,8
Birth weight (gram) 5519 (98,1%) 3500 (3150-3900) 612 – 5900
Gestational age (weeks) 5567 (99,0%) 40,0 (38,9-40,9) 25,1 – 44,1
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date and sex and it is stored together with information about places
of residence, nationality and the ID-number of the parents. All
national Danish registers use the ID-number, which makes linkage
between different registers and across time very accurate. (For
details see Appendix 1). In the first stages of The CCC 2000 study
presented in this thesis, data from the following registers have been
included: The Civil Personal Registration System (CPR), The Medical
Birth Registry (MFR), the National Register of Patients (LPR) and The
Psychiatric Central Register (PCR).
Data collected by community health nurses
Community health nurses visiting all infant families have been an
integrated part of the general child health surveillance in Denmark
for more than fifty years. The health nurses are educated in paediat-
ric child care and prevention and their key function is to promote
child health by general health assessment and parent counselling
(Sundhedsstyrelsen (eng. National Board of Health), 1995).
Health nurses are informed by midwifes about all deliveries in
the municipality and all families with a newborn child are offered
free home visits during the child’s first year of life. In the majority of
municipalities in Denmark, families are offered a mean of three
home visits, and only few families decline.
The health nurses follow overall national guidelines
(Sundhedsstyrelsen, 1995), however, no standardization of the
health nurse recordings has formerly been applied.
Standardization of community health nurse recordings
– the CCC 2000 health nurse record
Prior to the study, the CCC 2000 health nurse record was developed
to serve as tool for 1) a standardized collection of data obtained by
the traditional routines at home visits at specific ages during the first
years of life and 2) the inclusion of core areas of infant mental health
as variables in the record.
By tradition, the health nurses in the municipalities entered in
the study, made on average four home visits to infant families within
the first year of the child’s life: at child age 0-2 weeks, 2-3 months,
4 -6 months and 8-10 months. Accordingly, the health nurse record
was standardized to cover these four stages.
Information of infant mental health 0-10 months
recorded by health nurses (see Appendix 2)
In addition to the recordings of data on child health and develop-
ment, the CCC 2000 record comprises the nurses’ recordings of
parents information concerning the child and the family, and
recordings regarding the parent’s own observations of the child.
In accordance with the health nurses’ practices, each variable
was recorded dichotomized as being in the normal range or not.
The home visits customary takes 30 to 60 minutes. At the end of
the visit, the health nurse concludes whether the child or the family
needs extraordinaire visits from her or any particular intervention.
Children of health nurse concern: By tradition, Danish health
nurses describe children at risk as “concern children”. This concept
reflects an overall worry with regard to the health and the develop-
ment of the child or regarding the caregiver environment.
Accordingly, the CCC 2000 health nurse record included the record-
ing of any concern from each home visit, and the traditional differ-
entiation of health nurse concern into areas of 1) child development,
2) mother-child relationship and 3) family functioning was used as
separate variables in the CCC 2000 record (see Appendix 3).
Furthermore, it was recorded whether intervention had been
suggested and carried out, e.g whether the child or the family had
been offered extended health nurse support or had been referred to
treatment or support in the health care system or in the municipality.
Variables obtained by health nurses at home visits
(see Appendix 3)
A manual to the CCC 2000 record was prepared including guidelines
on how to obtain and record the data, and a pilot study was
conducted to establish the face validity of the variables in the record
and to test the applicability in the daily routines at home visits.
After revision, the record was implemented in the routines at
home visits of a total of 170 child health nurses from the 16 partici-
pating municipalities.
From the 1st of January to the 31st of December 2000 the
record was used to collect data on all CCC 2000 children.
Overall, records from 5.624 children (91 %) who have received
at least one home visit from a health nurse were used at data
source.
MEASURES
PAPER II: ASSESSMENT AND CLASSIFICATION OF PSYCHOPATHOLOGY
IN EPIDEMIOLOGICAL RESEARCH OF CHILDREN 0ͳ3 YEARS OF AGE
͵ A REVIEW OF THE LITERATURE
Based on experiences from epidemiological research in older
children and increasing knowledge about methods to assess and
classify mental health problems in infants and toddlers in primarily
clinical settings, the following methodologically requirements to
Fig.1 Copenhagen Child Cohort CCC2000
6090 children born in 16 municipalities I Copenhagen county 1.1- 31.12 2000
Follow-up
1½ years
6072 (99.7%) Medical Birth Register
Sub-cohort of 6 municipalities (only children with 4 health nurse visits)
(N= 1896)
5624 (91%) H ealth Nurse Records
Baselinedata
0-11 months
Case-control study
134 cases (65 %)
162 controls (79 %) 211 (69 %)
6065 National Register of Patients (incl 34 from Psychiatric Central Register)
Register
follow-up
0-36 months
Non participants/
excluded (n=95)
No health nurse data (448)
3469 children in
10 control municipalities -
(not studied at present)
Non-cases/ controls (N= 206)
Random sample (N= 304)
Cases of health
nurse concern
(N=205)
Non participants/
excluded (n=71)
Random sample study
*Reliability study in CC 1½ : 18 children from case-control sample
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the diagnostic classification of 0-3 year old children in an epidemi-
ological context can be suggested:
1. Standardized instruments that have been validated in epidemi-
ological research, or are validated during the research process.
2. In-dept assessment by experienced clinicians to ensure face-
validity of case-definition (in accordance to clinically recognis-
able patterns of psychopathology).
3. Developmentally appropriate assessment procedures with
known psychometric properties e.g validity and reliability for the
age group in question.
4. Investigation of several domains of mental development.
5. Inclusion of the relationship between child and parents in the
assessment and classification.
6. Classification of cases according to clinically relevant diagnoses
with appropriate diagnostic criteria and categories for age.
7. Inclusion of multi-axial classification of individual child psycho-
pathology as well as relational aspects.
8. Inclusion of information from different sources: E.g psychomet-
ric measures, parent’s questionnaires, clinical observations.
9. Use of methods that optimise cooperation of parents and
children, e.g methods that are not too time consuming and not
stressing the child and the parents.
From a review of the literature on methods to assess and classify
psychopathology in children aged 0-3 in epidemiological research
(Paper II) the following main categories of measures were identified:
a) tests of child development, b) measures based on parent’s
information: interviews, questionnaires and rating scales,
c) assessment measures of parent-child relationship, e) diagnostic
classification schemes, and f) instruments to identify specific
diagnostic categories.
It could be concluded from the review, that methodological
progresses seen in the last decades, make it possible to assess and
identify cases of psychopathology in children 0-3 years of age with
psychometric properties corresponding to what has been seen in
epidemiological research of older children two or three decades ago
(Skovgaard et al 2004).
In accordance with the reviewed literature, the methodological
requirements to an epidemiological study of 0-3 year old children
can be met by a combination of established research instruments,
e.g. Child Behaviour Check List, CBCL, (Achenbach & Rescorla 2000)
and standardized and clinical methods of in-depth assessment of
child mental health functioning, known from both clinical practise
and research: developmental tests, such as the Bayley’s Scales of
Infant Development BSID (Bayley 1993) and relationship assessment
as the Parent-Child Early Relational Assessment, PC-ERA (Clark 1985,
Clark 1999).
Regarding diagnostic assessment of children 0-3 years, it was
concluded, that the challenges of case-identification and diagnostic
classification, at an age where the developmental changes are so
rapid and the dependency of the relations to parents so pervasive,
can be met by the inclusion of Diagnostic Classification Zero-to
Three, DC: 0-3 (Zero to Three 1994). DC: 0-3 is an age specific classi-
fication scheme that complements customary classification by ICD-
10 (WHO 1992) and DSM- IV (APA 1980) with developmentally ap-
propriate diagnostic categories and diagnostic guidelines, and the
possibility to classify disordered parent-child relations in a multi-
axial framework (Zero to Three 1994).
Child assessment at age 1½ years (see paper V)
Procedure
The mental health functioning and symptoms of psychopathology at
child age 1½ years were assessed by experienced child psychiatrists
and child psychologists by the following: 1) assessment of child
development and psychopathology by standardised tests and clinical
measures, 2) parent interview with standardized questions com-
bined with open-ended and semi-structured questions and 3) clinical
observations and videotape recordings of the child in interaction
with the attending parent in semi-structured activities during play
and feeding/ eating, and 4) observation of spontaneous behaviour
and free play of the child, including in relation to a foreigner (the
investigator).
The child assessment lasted two-hours. At the end of the ses-
sion, the parents were given a feed back regarding the development
and mental health of the child, with regard to strengths as well as
possible difficulties. Parents were informed that they would be con-
tacted if the further analyses of the assessments disclosed areas of
concern and any need of intervention regarding child mental
health.
Diagnostic assessment (see papers II and V)
The measures of diagnostic assessment at 18 months (See Appendix
4) were selected according the conclusions of the literature review
and included:
1. The CC 1½ parent interview
A semi-structured parent interview was developed to include the fol-
lowing: The Child Behaviour Check List CBCL1 ½-5 (Achenbach &
Rescorla 2000), Checklist for Autism in Toddlers CHAT (Baird et al,
2000) and The Infant Toddler Symptom Check List ITSCL (De Gangi et
al 1995).
The interview was complemented with items from the
Manheim Eltern Interview MEI (Esser et al 1989, Laucht et al 1993)
and with thirteen adverse temperament characteristics elaborated
from The Temperament Scales of Thomas and Chess (Thomas et al
1963). Questions dealing with the physical and mental health and
development of the child and the psycho-social background of the
family were also applied.
2. Child assessment
The psycho-motor and cognitive development and functioning of the
children were assessed by the Bayley’s Scales of Infant Development
BSID II (Bayley 1993).
3. The parent-child relationship assessment
The relation between parent and child was examined by the Parent-
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Child Early Relationship Assessment PC ERA (Clark 1985, Clark 1999)
and rated regarding impact by the Parent-Infant Relationship Global
Assessment Scale: PIR-GAS (Zero to Three1994, Aoki et al 2002).
4. Classification of mental health problems and psychopathology
in ICD-10 and DC: 0-3
Psychopathology was classified through a standardized diagnostic
process where mental health problems and psychiatric phenomeno-
logy were identified and rated after clinical observations and
videotape recordings. The diagnostic process included a categorisa-
tion of developmental problems by the subscales of BSID II,
categorisation of mental health problems according to the subscale
score of CBCL/ ½-5 and according to specific questions from the
parent interview, e.g regarding attachment behaviour and traumatic
stress reactions.
Evaluation of impact was included in the overall assessment,
and classification was done according to the research diagnostic cri-
teria of ICD-10 (World Health Organization 1992, World Health
Organization 1993) and diagnostic guidelines in the DC 0-3 (Zero to
Three 1994).
The DC: 0-3 diagnoses of regulatory disorders were diagnosed
according to the ITSCL and with the inclusion of clinical cut-off scores
(DeGangi et al 1995, 2000). Relationship disturbances were classified
according to guidelines in DC: 0-3 and PIR-GAS cut-off score below
40 (Zero to Three 1994).
No forced choice between diagnoses was done, and one child
could thus be given more than one diagnosis of a psychiatric syn-
drome at axis one, both in ICD-10 and DC: 0-3. In case of diagnostic
uncertainty, the videotape recordings of the child were blindly as-
sessed by the investigators and afterwards discussed in the study
team in order to reach consensus diagnoses.
The psychometric properties of case-identification at 1½ year
Validity
Validity of diagnostic assessment was optimized by standardized
measures whenever possible and by employment of experienced
clinicians as investigators.
The face validity and applicability of assessment procedures and
diagnostic instruments was tested in a pilot study of six children
from an infant psychiatric clinic and six not-referred children from
the general population.
RELIABILITY
PAPER III: THE RELIABILITY OF THE ICDͳ10 AND THE DC: 0ͳ3 IN AN
EPIDEMIOLOGICAL SAMPLE OF CHILDREN 1½ YEARS OF AGE
The inter-rater reliability and test-retest reliability in the diagnostic
classification according to ICD-10 and DC: 0-3 was investigated in 18
children as a part of the CC 1½ study. The raw material from the
child assessment inclusive videotape recordings, were re-diagnosed
3-12 months after the initial assessment by the three child psych-
iatrists, who made the initial diagnostic assessment in the study. The
investigators were naïve with regard to diagnostic conclusions at the
primary assessment.
Main findings
The inter-rater and test-retest agreement among investigators in the
identification of children with disorders, e.g the differentiation
between children with a mental health diagnosis, and children with
no diagnosis, was 96 %. In the differentiation between parent-child
relationship with DC: 0-3 relationship disturbances and healthy
relationships, the agreement was 100% and kappa= 1, with regard to
both inter-rater and test-retest reliability. In the classification of
psychopathology at Axis I, the kappa values of inter-rater reliability
and test-retest reli ability were respectively 0.66 and 0.57 with ICD
10, and 0.72 and 0.74 respectively, with DC: 0-3.
In conclusion, reliability of case-identification and parent-child
relationship disturbances was high. Diagnostic classification of
mental health problems was good and classification by DC: 0-3
resulted in improved test-retest reliability compared to ICD-10.
Clustering of mental health diagnoses at child age 1½ years
Child psychiatric outcome was measured as ICD-10 and DC: 0-3
diagnoses. Analyses of associations were done for ICD-10 diagnoses,
and those DC: 0-3 diagnoses, which are not directly comparable to
ICD- 10 diagnoses: Multisystem developmental disorders MSDD,
regulatory disorders and relationship disorders.
The ICD-10 diagnoses were clustered in two major groups in or-
der to get a sufficient number for the analyses of associations.
The one group included the neurodevelopment disorders from the
ICD-10 section F 80-F89 (disorders of psychological development), R
62.0 (psycho-motor retardation), and F 90 (hyperactivity/ attention
deficit disorders). The ICD-10 diagnoses F 80-F 89 (disorders of psy-
chological development) include F 80.1 (expressive language disor-
der), F 82.9 (specific developmental disorder of motor function), and
the category F 88.0-F88.9 (other disorders of psychological develop-
ment). The latter category covers specified disorders of psycho-
logical developmental, which do not fulfil the diagnostic criteria of
the other subcategories in F 80-F84 (WHO 1992).
The other main group clustered for analysis contained all other
ICD-10 F-diagnoses given in the study. These included the following:
F 92 (mixed disorders of conduct and emotions), F 93 (emotional dis-
orders), F94.1 (reactive attachment disorder), F 98.2 (feeding disor-
der), F 51 (sleeping disorder), and F 43 (adjustment disorder).
Definition of risks
Biological and psycho-social risk factors recorded at parent interview
at child age 1½ years were clustered according to the Manheim Risk
Index into groups of high, moderate and no risk (see Appendix 5).
Statistics
The majority of data are presented as descriptive statistics. Univari-
ate analyses were performed using the likelihood ratio Chi-square
test and Fisher’s exact test, if cell count was less than 5. Multivariate
analyses (cross sectional data) were done by logistic regression with
child mental health disorder as dependent variable and biological
and psychosocial risks as independent variable.
Odds ratios (OR), 95 % confidence interval (CI) and P-values
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(two-sided) were calculated for basic and multivariate analyses.
Kappa statistics was used to assess reliability.
The potential of screening for mental illness was evaluated as
sensitivity, specificity, predictive value of positive test (PV pos), and
predictive value of negative test (PV neg) (Altman1991).
RESULTS
MENTAL HEALTH PROBLEMS IN INFANCY
PAPER IV: MARKERS OF MENTAL HEALTH PROBLEMS BASED ON
PUBLIC HEALTH NURSES’ ASSESSMENTS OF 0ͳ1ͳYEARͳOLD CHILDREN:
THE COPENHAGEN COUNTY CHILD COHORT 2000
Based on data from child health nurses’ assessments and recordings
at home visits at child age 0-2 weeks, 2-4 months, 4-6 months and
8-10 months, variables were created with regard to core aspect of
child development and parent-child relationship (Appendix 3).
Main findings
In Table 4, the distribution of problems in different areas of health
and development was reconstructed in the age periods: 0-2 months,
2-6 months and 6-10 months.
Problems of feeding and eating were the most frequent prob-
lems recorded by health nurses and across the first 10 months of liv-
ing, and 30 % of these children exhibit feeding/ eating problems at
one or more health nurse visit. Health nurses reported problems re-
garding the overall development of the child at least once between
birth and 10 months in 13 % of the children, and abnormal develop-
ment of verbal and non-verbal communication was reported in 11.7
% of the children. In 4 % of the children, the health nurse reported
that the parents had an experience of deviant contact with the child.
Problems in the interaction between mother and child were re-
ported for 10 % of the children, and these problems and other prob-
lems in the relationship between parents and child, such as deviant
handling and deviant expectations to the child, were most frequent
at 2-6 months.
Discussion
No other general population studies have published data on
developmental and relational aspects of mental health in infancy and
direct comparisons with other studies are thus not possible. But with
regard to the high frequency, 30 %, of problems of feeding and eating
found in the present study, the results corresponds to results from
other studies of children at corresponding age (Benoit 2000), inclusive
a general population study of Swedish children (Lindberg et al 1991).
THE PREVALENCE AND ASSOCIATES OF
PSYCHOPATHOLOGY AT 1½ YEARS
PAPER V: THE PREVALENCE OF MENTAL HEALTH PROBLEMS
IN CHILDREN 1½ YEARS OF AGE ͵ THE COPENHAGEN CHILD
COHORT 2000
The prevalence and associates of mental health problems, measured
as ICD-10 and DC: 0-3 diagnoses, were investigated in a random
sample study of 211 children at age 1½ years (see Fig 1).
Co-morbidity was studied with regard to primary child (axis I)
diagnoses in ICD-10 and DC: 0-3 and parent-child relationship dis-
turbances (axis II) in DC: 0-3.
Data on biological and psychosocial risks were obtained from
parents at the interview in relation to the diagnostic assessment of
the child. Putative child psychiatric risk factors were analysed ac-
cording to the Manheim Risk Index of no, moderate and high bio-
logical and psycho-social risk (Se Appendix 5).
Main findings
The prevalence of axis I diagnoses of a primary child psychiatric
syndrome was 16 % (CI 11.9-22.1) with ICD-10 and 18 % (CI 13.5-
24.4) with DC: 0-3 (Table 5). Most frequent child diagnosis was the
DC: 0-3 diagnoses of regulatory disorders, which were diagnosed in
7.1 % (CI 4.0-11.5). Parent child-relationship disturbances were the
most frequent diagnoses of all, found in 8.5 % (CI 5.1-13.2).
When including ICD-10 axis II diagnoses (specific developmental
disorders) and axis III diagnoses (mental and psycho-motor retarda-
tion) the overall prevalence of children with one or more ICD-10 di-
agnoses was 18 % (CI 13.4-23.6).
ICD-10 neurodevelopment disorders, including general and spe-
cific developmental disorders and attention deficit hyperactivity dis-
Table 4: Problems of health and development at child age 0-10 months recorded by child health nurses
(N=5624)
0-2 months 2-6 months 6-10 months 0-10 months Area of infant health and functions
Variables Recorded
n (%) Problems
% Recorded
n (%) Problems
% Recorded
n (%) Problems
% Recorded
n (%) Problems
%
Feeding/ eating 5521 (98.2) 13.2 4812 (85.6) 10.0 5050 (89.8) 15.9 5622 (99.9) 30.0
Sleep 5393 (95.9) 4.4 4749 (84.4) 12.9 4927 (87.6) 9.8 5611 (99.8) 20.0
Defecation 5524 (98.2) 3.3 4825 (85.8) 9.7 5050 (89.8) 7.5 5623 (99.9) 16.0
Infant language 5524 (98.2) 2.0 4825 (85.8) 7.0 5050 (89.8) 5.7 5623 (99.9) 11.7
Tactile reactions 5226 (92.9) 0.5 4675 (83.1) 1.8 4833 (85.9) 0.3 5598 (99.5) 2.1
Gross-motor functions 5265 (93.6) 1.9 4747 (84.4) 10.4 4968 (88.3) 6.0 5614 (99.8) 14.1
General development 5524 (98.2) 3.4 4825 (85.8) 7.2 5050 (89.8) 7.1 5623 (99.9) 13.0
Parents perception of contact with the child 5524 (98.2) 2.7 4825 (85.8) 1.2 5050 (89.8) 0.6 5623 (99.9) 4.0
Parents way of speaking about the child 5524 (98.2) 1.0 4825 (85.8) 2.2 5050 (89.8) 1.7 5623 (99.9) 3.7
Parents handling and care 5524 (98.2) 1.9 4825 (85.8) 2.5 5050 (89.8) 1.5 5623 (99.9) 4.2
Mother-child relation 5411 (96.2) 3.7 5166 (91.9) 7.0 5337 (94.9) 6.1 5604 (99.6) 10.1
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order, ADHD, were diagnosed in a total of 7 % (CI 3.6-10.8) of the
children, of whom ADHD were diagnosed in 2.4 % (CI 0.8-5.4). No
children fulfilled the criteria of an ICD-10 diagnosis of a pervasive de-
velopmental disorder (F84), whereas 3.3 % (CI 1.3-6.7) were diag-
nosed in DC: 0-3 with a multi system developmenttal disorder,
MSDD. ICD-10 emotional and behavioural disorders were diagnosed
in 4.3 % (CI 2.0-5.4) and eating disorders in 2.8 % (CI 1.1-2.8).
Significant comorbidity was found between DC: 0-3 parent-child
relationship disorder and child mental health disorders, OR 10.6 (CI
3.8-29.8). In particular ICD-10 emotional and behavioural disorders
and ADHD and the DC: 0-3 diagnosis of a regulatory disorder were
associated with relationship disorders (Table 6).
Associations of risk at child age 1½ years (Table 7)
Biological risk were associated with an increased risk of a mental
health disorder, but only significant with regard to neurodevelop-
ment diagnoses, OR 4.9 (CI 1.4-16.9). A non-significant lower risk of
relationship disturbances with high biological risk was seen.
Psychosocial risk were significantly associated with a mental
heath disorder in the child, OR 3.1 (CI 1.2-8.1) and with a parent-
child relationship disorder OR 5.0 (CI 1.6-16.0).
The strongest risk associations were found between relation-
ship disorders and child mental health disorders in the area of emo-
tional, behavioural, eating and sleeping disorders, and this associ-
ation persisted when the confounding effect of both biological and
psycho-social risks were corrected for, OR 11.6 (3.8-370.5).
Discussion
The prevalence of mental health disorders at child age 1½ years. The
most frequent single child diagnosis was the DC: 0-3 diagnosis of
Table 5 Prevalence of mental health diagnoses at 1½ years (ICD 10 and DC: 0-3)
(N = 211)
DC 0-3 diagnoses
ICD 10 diagnoses
Axis 1 n % CI 95 % Axis 1 n % CI 95%
Disorders of psychological development
(F 88-89, R 62) 6 2.8 1.1-6.1 Multisystem Developmental Disorders MSDD
(700) 7 3.3 1.3-6.7
Hyperactivity/ Attention deficit disorders
(F 90) 5 2.4 0.8-5.4 Regulatory disorders
(400) 15 7.1 4.0-11.5
Disorders of behaviour and emotions
(F 92-93) 9 4.3 2.0-5.4 Disorders of affect
(200) 6 2.8 1.1-6.1
Reactive attachment disorder
(F 94) 2 0.9 0.1-3.4
Reactive attachment disorder
(206) 1 0.5 0.0- 2.6
Eating disorder
(F 98.2) 6 2.8 1.1 – 6.1 Eating disorder
(600) 5 2.4 0.8-5.4
Sleeping disorder
(F 51) 3 1.4 0.3-4.1 Sleeping disorder
(500) 3 1.4 0.3- 4.1
Adjustment disorder
(F 43) 2 0.9 0.1- 3.4 Adjustment disorder
(300) 2 0.9 0.1-3.4
One or more ICD 10 axis 1 diagnoses 34 16 11.9- 22.1 One or more DC:0-3 axis 1 diagnoses 39 18 13.5-24.4
Axis I, II and III diagnoses
One or more ICD 10 mental health diagnosis 37 18 13.4- 23. 6
Axis 2
Relationship disorders (902-905) 18 8.5 5.1-13.2
Table 6
Co- morbidity between relationship disturbances and child mental health disorder in a
random sample of 211 children at the age of 18 months
(Odds Ratio 95 % CI)
Child diagnoses
(ICD 10/DC 0-3) N
Relationship
disturbance
(DC 0-3)
No Yes
193/ 211 18/ 211
OR
(95 % CI)
Developmental disorders
ICD 10: F 88-89
6
5 1
2.2 (0.2-20.0)
Hyperactivity/Attention Deficit Disorder
ICD 10: F 90 5 2 3 19.1 (13.0-123.3)*
Disorders of conduct and emotions
ICD 10: F 92-93 9
4 5 14.5 (3.7-56.4)*
Reactive attachment disorder
ICD 10: F 94 2 0 2 -
Disorders of eating and sleeping
ICD 10: F 51, F 98.2
9
8 1 1.3 (0.2-11.5)
Regulatory Disorders
DC 0-3: 400 15 10 5 6.3 (1.9-21.1)*
All ICD 10 child mental health diagnoses
36 25 11 10.6 (3.8-29.8)*
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regulatory disorder, found in 7.1% of general population children.
Regulatory disorder is a diagnostic concept from DC: 0-3, defined by
disturbances in the regulation of neurophysiological and emotional-
behavioural reactions, which at one end reflect maturity-based and
transient deviances in an otherwise normal development and at the
other end, more persistent neuro-regulatory disturbances (Zero to
Three, 1994, Barton & Robins 2000, DeGangi et al 2000). The latter
has been suggested to be an early manifestation of attention deficit
and hyperactivity disorder, ADHD (Barton& Robins 2000). In the
present study, children diagnosed with regulatory disorder with
DC: 0-3, show a spectrum of diagnoses in ICD-10, ranging from no
diagnoses in one third, to ADHD in another third, which concerts
with these considerations.
DC: 0-3 relationship disorders were the most frequent mental
health problem of all, diagnosed in 8.5 % of parent-child pairs.
Furthermore, relationship disorders were significantly associated
with a mental health disorder in the child, in particular ADHD, reac-
tive attachment disorders and emotional and behavioural disorders.
For comparison, no other general population studies of children
at this age have investigated prevalence and co-morbidity of mental
health diagnoses. A comparison of the diagnostic distribution and
prevalence of single diagnoses found in the present study, with the
results from other studies at the same age, is thus not possible.
However, studies of parent-reported behavioural and social-emo-
tional problems in non-selected populations below the age of three
years (Table 2) have demonstrated rates of prevalence ranging from
7% to 24 %, with the majority falling between 10% and 15 %
(Richmann et al, 1975; Earls, 1980; Larsson, Pless & Miettinen, 1988;
Koot & Verhulst 1991; Stallard et al 1993, Sourander, 2001; Briggs-
Gowan & Carter, 2001; Egger &Angold 2006). In a study of psychiatric
diagnoses in children from a paediatric population, Lavigne et al
found an overall prevalence of best estimate DSM-III R diagnoses of
7.1-13.6 % in children aged 2 years. Children with general or perva-
sive developmental disorders were not included in this study, and
furthermore, the participation rate was low, 45 %. Accordingly, direct
comparison with the present general population study is not possible.
However, studies of children aged 5 years or more, have found
a mean general population prevalence of mental disorder at 16 %
(Roberts et al 1998, Costello et al 2005), which corresponds to the
prevalence we have found in the 1½ year old children. Additionally,
studies of older children have shown an overall distribution of diag-
nostic categories which are comparable to the results from the
present study, with emotional, - behavioural- and adjustment dis-
orders being the most common, and neurodevelopment disorders,
including attention deficit hyperactivity disorders, affecting a minor
proportion of disordered children (Rutter1989; Fombonne 2002,
Costello et al 2005, 2006).
Associations of risk at child age 1½ years: The significant associ-
ations between biological risks and neurodevelopment disorders,
and between psycho-social risks and disorders of emotions and be-
haviour found in the present study, correspond to results from stud-
ies of older children (Rutter et al 1989, 2005, Costello et al 2005,
2006). Furthermore, the findings of significant associations between
psycho-social adversities, relationship disorders and child mental
Table 7
Risk associations
Associations of biological and psycho-social risks (Appendix 5) with mental health disorder and relationship disturbances
in a random sample of 211 children at the age of 1½ year. Logistic regression
Child Mental Health Disorder (ICD 10 diagnose, N=37)
Yes No % OR CI (95 %)
Relationship disturbances (DC 0-3, axis 2 N= 18)
Yes No % OR CI (95 %)
Sex (female) (N=101/211) 15 95 13.6 1.6 (0.8-3.4) 10 91 9.9 1.2 (0.4-3.6)
Biological Risk
(MRI- A)
Low (N= 151) 20 131 13.2 - 12 139 7.9 -
Moderate (N= 34) 10 24 29.4 1.9 (0.7-3.8) 4 30 11.8 1.1 (0.3-3.8)
High (N= 26) 7 19 26.9 1.6 (0.6-4.7) 3 24 7.7 0.4 (0.1-2.2)
Psycho-social Risk
(MRI- B)
Low (N= 113) 12 101 10.6 - 7 106 6.2 -
Moderate (N= 56) 12 44 21.4 1.9 (0.8-4.6) 2 54 3.6 0.1 (0.1-2.8)
High (N= 42) 13 29 31.0 3.1(1.2-8.1)* 9 33 21.4 5.0 (1.6-16.0)*
* p< 0.05
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health disorders in the present study of general population children,
are in line with empirical data from clinical populations of infants of
psycho-socially disadvantaged parents, e.g parents with mental ill-
ness, alcohol/ drug abuse, low education etc (Zeanah et al 1997 a,
1997 b, 2000, Seifer et al 2000).
INFANCY PREDICTORS OF PSYCHOPATHOLOGY
PAPER VI: PREDICTORS Έ0ͳ10 MONTHSΉ OF PSYCHOPATHOLOGY
AT AGE 1½ YEARSͳ A GENERAL POPULATION STUDY IN THE
COPENHAGEN CHILD COHORT 2000
Predictors of child mental disorder were investigated in prospective
data recorded by child health nurses from birth to ten months and
with the outcome at 1½ years in the CC 1½ random sample study of
211 children from the general population (see Fig 1). The predictor
variables (see Appendix 3) were grouped in the following cardinal
domains of infant mental health: neurodevelopment, cognitive
functions, language, social interaction/ communication, regulation of
physical functions, emotional functioning and parent-child relations,
and further divided into early (0-6 months) and late (8-10 months)
problems.
Main findings
Impairments in neuro-cognitive functioning, deviant language
development, disturbances in the child’s contact and communica-
tion and parent-child relationship problems were all significant
infancy predictors of a child mental disorder at 1½ years (Table 8).
Predictors of neuro-developmental disorders (Table 9): Impaired
social interaction and communication recorded already in the first
six months of the child’s life, predicted all the neurodevelopment
disorders investigated, inclusive attention deficit hyperactivity dis-
orders, ADHD. Delays in cognitive functioning and language impair-
ment predicted all neurodevelopment disorders but ADHD. The
latter however, was predicted by the parent’s perception of deviant
contact with the child recorded in the first ten months of living.
Predictors of other child mental disorders: No single infancy pre-
dictor was found regarding the clustered group of emotional-, behav-
ioural-, eating and sleeping disorders. Among the separate diagnoses,
however, eating disorder at 1½ years was significantly predicted by
eating problems recorded at 8-10 months, OR 6.1 (CI 1.2-31.7).
Relationship disorders: No single child factor recorded from
birth to ten months seems to predict a relationship disturbance at
1½ year, but several parent related factors did: Unwanted pregnancy
and the parent’s negative expectations of the child and deviant han-
dling and reactions to the child recorded in the first months of the
child’s life, were significant predictors of a relationship disturbance
at 1½ year (Table 10).
Discussion
Prospective data recorded by health nurses between birth and child
age 11 months showed significant predictors of neurodevelopment
disorders at child age 1½ years. These infancy predictors of neurode-
velopment disorders correspond to childhood predictors of neuro-
psychiatric disorders, that have been demonstrated in longitudinal
studies of adolescents and adults (Mc Gee et al 1995, Isohanni et al
2004, Rutter et al 2006), e.g predictors of schizophrenia found in the
Dunedin study (Cannon et al 2002).
Table 8
Infancy predictors of psychopathology
Associations of health nurse recorded mental health problems (0 - 10 months) with ICD 10 psychiatric disorders at 1½ years in a random sample of 210* children.
(Odds ratio 95 % CI)
Area of abnormal development or function
Neurodevelopmental disorders
(R 62, F 80-89, F90)
No Yes OR CI 95%
(n=196) (n=14)
Emotional-, behavioural-, eating and sleeping
disorders (F 92, F93, F 94, F 98.2, F 51, F 43)
No Yes OR CI 95%
(n=187) (n=23)
Any mental health disorder**
No Yes OR CI 95%
(n=174) (n=36)
Neuro-developmental problems
Deviant language development (28/ 210)
Neuro-cognitive functions (incl language) (50/210)
One or more developmental problems (70/ 210)
22 6 5.9 (1.9-18.7)
41 9 6.8 (2.2– 21.4)
61 9 4.0 (1.3- 12.4)
24 4 1.4 (0.5-4.6)
45 5 0.9 (0.3-2.5)
63 7 0.9 (0.3- 2.2)
18 10 3.3 (1.4-8.0)
36 14 2.4 (1.1- 5.2)
54 16 1.8 (0.9-3.7)
Feeding/ eating problems (61/ 210) 55 6 1.9 (0.6- 5.8) 52 9 0.7 (0.3- 1.8) 47 14 1.7 (0.8-3.6)
Sleeping problems (35/210) 33 2 8.8 (0.2- 3.9) 28 7 2.5 (0.9- 6.6) 26 9 1.9 (0.8- 4.5)
Emotional state/ regulation (17/ 208) 15 2 2.0 (0.4- 9.7) 15 2 1.1 (0.2- 5.1) 13 4 1.5 (0.5- 5.0)
Disturbances in child’s contact and communication
(48/ 210) 41 7 3.8 (1.3- 11.4)
41 7 1.6 (0.6 4.0)
34 14 2.6 (1.2- 5.6)
Relationship problems
Disturbances in parents relations to the child
(34/ 210) 30 4 2.2 (0.7- 7.5) 28 6 2.0 (0.7- 5.5)
24 10 2.4 (1.0- 5.6)
(* One child of 211 children in random sample was excluded because of missing data)
** One child had a diagnosis both of the two main groups
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Taken together, the present study confirms the significance of
pre- and perinatal risks in the pathogenesis of neurodevelopment
disorders and points to the existence of global predictors of neuro
psychiatric disturbances that can be identified as early as in the first
year of living.
Predictors of a parent-child relationship disorder at child age 1½
year could be tracked back to the first months of the child’s life and
manifest disturbances in the parent’s relations to the child recorded
by health nurses between birth and 10 months significantly pre-
dicted a mental disorder at child age 1½ years.
Studies of children older than 6-7 years of age, have demon-
strated different influences on mental health whether exposed to
biological or psycho-social risks (Rutter 1989, Friedman et al 2002,
Rutter et al 2003, 2005, Costello et el 2005, 2006, Rutter et al 2006).
For comparison with the present study of 1½ year old children,
only the Manheim Study of Risk Children have investigated both
biological and psychosocial risks simultaneously and prospectively
from infancy (Laucht et al 1997) and furthermore, with measures
compar able to those used in the present study.
The Manheim Study investigated children in respectively high,
moderate and low/ no risk regarding biological as well as psycho-so-
cial risk factors, and found significant and different impact of biologi-
cal risk and psycho-social risk on respec tively psycho-motor develop-
ment and psycho-social functioning at age 3 months (Laucht et al
1993).
A decrease in influence of biological risk recorded at birth was
seen at follow up at child age 24 months, whereas the importance of
psycho-social risks had become more prominent (Laucht et al 1997,
2000). These findings are in accordance with the results from the
present study of 1½ years old children.
Table 10
Risk factors of parent-child relationship disorder
Associations of child and family variables recorded from birth to 10 months and
a relationship disorder diagnosed at child age 18 months in a random sample of 210 children*
(Odds Ratio CI 95 %)
(* One child of 211 children in random sample was excluded because of missing data)
Risk factor (Prenatal / 0-10 months)
N (%)
Relationship disorder (DC: 0-3 902-905)
No Yes OR CI 95%
(n=192) (n=18)
Child variable
Female sex 101 (48.1)
Birth complications 73 (34.8)
Congenital disorder/ malformations 4 (1.9)
Neuro-developmental delay 50 (23.8)
Feeding/ eating problems 60 (28.5)
Sleeping problems 35 (16.7)
Emotional state/ regulation 17 (8.1)
91/101 10/8 1.4 (0.5-3.7)
71 2 3.8 (0.9-16.5)
4 0 -
44 6 1.6 (0.6– 4.7)
54 6 0.8 (0.3- 2.2)
33 2 0.6 (0.1- 2.8)
14 3 2.5 (0.7- 9.7)
Parental factors
Low / lacking education 20 (9.5)
Mental illness in parents 18 (8.6)
Parental conflicts 38 (18.1)
Lack of social network 14 ( 6.7)
15 5 3.6 (1.5- 9.2)
16 2 1.3 (0.2-3.5)
30 8 3.6 (1.5 8.5)
9 5 5.4 (2.3-12.9)
Relationship variables
Unwanted pregnancy 8 ( 3.8)
Parental perception of deviant contact
with the child 6 ( 2.9)
Deviant expectations, handling or
reactions to the child (0-1 month) 14 (6.6)
5 3 5.0 (1.8-13.9)
3 3 12.6 (2.3- 67.9)
10 4 5.1 (1.4- 18.5)
Table 9
Infancy predictors of neuro-developmental disorders
Associations of health nurse recorded problems (0-10 months) and neuro-psychiatric disorders at child age 1½ years
(ICD 10 and DC 0-3 diagnoses) in a random sample of 210* children (Odds Ratio OR CI 95 %)
Mental health problems
Assessed at age (months)
n/N (%)
Psycho-motor retardation
(ICD 10 R 62.0)
N= 3
OR CI 95%
Disorders of Psychological
Development (ICD 10 F 88-89)
N= 6
OR CI 95%
Attention Deficit Hyperactivity
Disorders (ICD 10 F 90)
N=5
OR CI 95%
Multi- system Developmental
Disorders (DC 0-3:701-703)
N=7
OR CI 95%
Delay in cognitive functioning
(0-6 months)
27/209 (12.9)
1.1 (1.0-1.3)
7.5 (1.4-39.1)
1.7 (0.2-15.9)
10.4 (2.2-49.3)
Language delay/ impairment
(0-10months )
28/ 210 (13.3)
13.9 (1.2-159.0) 7.2 (1.3-37.4) 1.7 (0.2-15.3)
5.3 (1.1-25.3)
Impaired social interaction and com-
munication
(0-6 months)
14/210 (6.7)
32.5 (2.8-384.3) 8.0 (1.3-48.2) 10.7 (1.6-70.4)
6.4 (1.1-36.3)
Deviant contact perceived by parents
(0-10 months)
6/ 210 (2.9) 0.97 (0.95-0.99)
7.8 (0.8-81.3) 33.5 (4.3-258.8) 6.6 (0.7-65.5)
(
* One child of 211 children in random sam
p
le was excluded because of missin
g
data
)
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The present CCC 2000 results point to the importance of parent-
child relationship problems in the risk mechanisms of emotional, be-
havioural and eating and sleeping disorders, both when recorded be-
tween birth and 10 months and when diagnosed as parent-child
relationship disorder at 1½ years.
For comparison, the Manheim Study found significant associa-
tions between relationship problems recorded at three months and
symptoms of social-emotional withdrawal at 4½ and 8 years of age
(Gerhold et al 2002).
MENTAL HEALTH SCREENING IN INFANCY
PAPER VII: CAN A GENERAL HEALTH SURVEILLANCE BETWEEN BIRTH
AND 10 MONTHS IDENTIFY CHILDREN WITH MENTAL DISORDER AT
1½ YEAR? ͵ A CASEͳCONTROL STUDY NESTED IN COHORT CCC 2000
A global concept of concern, concluded at home visits regarding
child development, parent-child relations or family functions, was
used as “screening-measure”, and the potential of screening for
mental health problems in infancy was investigated in 296 children
in a case -control study nested in a sub-cohort of CCC 2000 (Fig 1)
and with child mental disorder or parent-child relationship disorder
at 1½ year as the outcome.
Children of any health nurse concern were the cases and chil-
dren of no-concern were the controls in the study.
Main findings
Community health nurses concern about the development of the
child recorded between birth and ten months was significantly
associated with the child having a neuro-developmental disorder at
1½ year (Table 11).
Concern about mother-child relationship was associated with
the child having a disorder of emotional-, behavioural, eating and
sleeping disturbance and this association was seen already in the
first 6 months of the child’s life OR 2.7 (CI 1.1-6.5).
A tendency towards inverse associations between concern of
child development (0-10 months) and relationship disturbances at
1½ year was found: concern of child development at child age 8-10
months was thus associated with a significantly 10 % lower risk of a
mother –child relationship disturbance at 1½ year.
The predictive value of health nurse concern with regard to the
child having a mental disorder at age 1½ years (PV pos: true posi-
tive/ true positive +false positive) was highest when concern was
concluded regarding mother-child relations, PV pos 34.2 % (CI 20.6-
50.7) and child development, PV pos, 26.6 % (CI 17.6-37.9). The
highest sensitivity (true positive/ true positive + false negative) was
seen with health nurses’ overall conclusion regarding concern or
no-concern within the whole period 0-10 months, 56.1 % (CI 42.4-
69.0). Across all areas of concern, but in particular regarding moth-
er-child relations and family function, the predictive value of a neg-
ative test was high, more than 80 %, which indicate that the
majority of children concluded of no-concern at age 0-10 months,
were truly iden tified as not in risk of a mental disorder at age 1½
year.
Table 11
Associations of health nurse’s concern stratified on periods in infancy and mental health disturbances at child age 18 months in a
general population sample of 296 children from CCC 2000
(ICD 10: Neuro-developmental disorder (F 80-89, F 90 and R 62) and Emotional-, behavioural-, eating and sleeping disorder (F 43, F 51,F 92-93, F 94.1 and F 98.2) and DC: 0-3 rela-
tionship diagnoses 902-905)
Area of concern Age period
Neuro-developmental disorder
(N=25)
OR CI 95 %
Emotional-, behavioural-, eating
and sleeping disorder
(N=35)
OR CI 95 %
Relationship disorders
(N=25)
OR CI 95 %
Any disorder
(N=57)
OR CI 95 %
Child development
0 - 6 months
8- 10 months
Any period
2.0 (0.8-5.19
3.8 (1.5-9.5)
2.8 (1.2-6.5)
1.5 (0.6-3.5)
0.9 (0.3-2.6)
1.3 (0.6-2.8)
0.6 (0.2-2.2)
0.9 (0.8-0.9)
0.4 (0.1-1.2)
1.6 ( 0.8-3.1)
2.2 (1.0-4.7)
1.8 (1.0-3.4)
Mother-child relationship
0- 6 months
8-10 months
Any period
1.1 (0.3-3.7)
3.5 (0.9-13.6)
1.6 (0.6-4.6)
2.7 (1.1-6.5)
1.3 (0.3-6.5)
2.5 (1.1-5.8)
1.1 (0.3-3.7)
1.9 (0.4-9.1)
1.2 (0.4-3.7)
2.3 (1.0-4.9)
2.7 (0.9-8.7)
2.6 (1.2-5.3)
Family relations
0-6 months
8-10 months
Any period
1.3 (0.5-3.6)
1.6 (0.4-5.8)
1.6 (0.6-4.0)
2.7 (0.5-3.1)
1.3 (0.3-6.5)
1.4 (0.6-3.3)
0.9 (0.3-2.9)
1.9 (0.6-5.9)
1.6 (0.6-4.0)
1.3 (0.6-2.6)
1.6 (0.6-3.9)
1.5 (0.8-3.0)
Any concern
0 -6 months
8-10 months
Any period
1.1 (0.5-2.7)
2.6 (1.1- 6.1)
2.3 (1.0-5.3)
1.4 (0.7-2.8)
0.9 (0.4-2.1)
1.3 (0.7-2.7)
1.1 (0.5-2.7)
0.8 (0.3-2.2)
1.1 (0.5-2.5)
1.2 (0.7-2.2)
1.7 (0.9-3.2)
1.7 (0.9-3.1)
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Discussion
Health nurses’ conclusions of concern respective no-concern
between birth and ten months were predictive of mental health
outcome at child age 1½ years in more than half of the children.
Bearing in mind, that the screening measure investigated was a
global concept of risk or concern, and the health nurses have no
formalized training in infant mental health assessment, it is note-
worthy, that nearly a fourth of children with a mental health disorder
at 1½ years were identified. The predictive value depended on the
age of the child and the area of concern, and the strongest associa-
tion was seen, when concern about child development was conclud-
ed at 8-10 months, being associated with a more than three fold
increase in risk regarding a neurodevelopment disorder at 1½ years.
In their customary routines Danish health nurses perform a
standardized test of hearing, attention and communication, the
BOEL test, at child age 8-10 months. Another study in CC 1½ has in-
vestigated the predictive value of abnormal reactions at the BOEL
test and compared to health nurses’ global assessment of child de-
velopment with neurodevelopment disorders as outcome (Jacobsen
et al 2007). The results point to the improvement in predictive valid-
ity of a mental health screening, when a standardized measure as
the BOEL test is applied.
To the author’s knowledge, no other studies have been pub-
lished which investigate the screening potential in the general infant
population and with regard to the whole spectrum of mental illness
in such young children. Studies of screening for autism spectrum dis-
orders, ASD (Baird et al 2000, Dietz et al 2006) have shown, that
even when a specific screening tool as Checklist for Autism in
Toddlers, CHAT, is applied at child age 18 months, the sensitivity and
the predictive validity of a positive test, PV pos, is relatively low,
whereas specificity and predictive value of negative test, PV neg, is
high (Baird et al 2000, 2001, Chairman et al 2005).
Taken together, the present study of unspecific “screens” and
the studies of CHAT both illustrate the problems of low predictive
value of a positive test, when screening a general population for rel-
atively rare disorders in preschool age, as relatively many children
are being screened as false positive (Costello et al 2005).
A REGISTER STUDY OF THE INCIDENCE OF MENTAL
HEALTH DISORDERS IN 0ͳ3 YEAR OLD CHILDREN
ΈUNPUBLISHED DATAΉ
For this overview, a register study was carried out on CCC 2000
children diagnosed at hospitals within their first three years of life.
For all cohort children, their unique identification was searched
within the National Register of Patients (LPR) and the Psychiatric
Central Register (PCR). For details see Appendix 1.
The age of the child was calculated from the birthday and the
first day of treatment at hospitals. The incidence of mental health
disorders was calculated as first time diagnosis of a disorder of men-
tal health in the population for each year.
Main findings
During their first three years of life a total of 87 children from the
CCC 2000 were recorded in the registers (LPR and PCR) with 118 first
time diagnosis of an ICD-10 mental health F-diagnosis or the
diagnosis R 62.0 of psycho-motor retardation. Of these, 64 had a
first time mental health F-diagnosis corresponding to an overall
incidence of 10.7/ 1000 (Table 12).
Diagnoses of mental retardation and psycho-motor retardation
were the most frequent of all, accounting for more than half of all first
time diagnoses between birth and 36 months. The majority of children
with mental retardation and psycho-motor retardation were diag-
nosed in the first year of life at paediatric departments/ hospitals. Also
eating disorder was most often diagnosed at paediatric departments
during the first year of life, with an incidence of 1.5/ 1000. Attachment
disorders were also most frequently diagnosed in the first year of life,
whereas 3 of 4 children with pervasive development disorders, includ-
ing autistic disorders, were diagnosed in their third year of life.
The distribution on gender shows a higher rate of boys com-
pared to girls regarding developmental disorders and behavioural-
emotional disorders, whereas girls were more frequently diagnosed
with eating -, attachment- and adjustment disorders.
Discussion
The overall incidence of a child mental disorder diagnosed at
hospital from birth to 36 months and including all F-diagnoses and R
62.0 was 1.9 %, while the general population prevalence of the
corresponding diagnoses was 18 % (CI 13.4-23.6) at child age 18
months. A comparison with regard to the diagnostic areas, show a
higher proportion of neurodevelopment disorders compared to
emotional and behavioural disorders in children treated at hospitals,
probably due to early referral to paediatric departments of children
with developmental delay and co-morbid physical illness. As children
with severe physical illness or handicaps, e.g profoundly retarded
children, were not included in the general population study, the
overall prevalence of neurodevelopment disorders at child age 1½
years was underestimated.
For all diagnostic categories investigated, a pattern of consider-
able higher prevalence in the general population was seen at child
age 1½ years, when comparing to the incidence of disorders diag-
nosed at hospitals in the first 3 years of life. Thus, ADHD was diag-
nosed at hospital in 0.03 %, whereas the general population preva-
lence of the disorder was 2.4 %. Eating disorders were diagnosed at
hospital in 0.15 % in the first three years of life, whereas 2.8 % of the
children in the general population met the criteria of an eating dis-
order at 1½ years, e.g within the same period of age.
Discrepancies between the prevalence of disorders in the gener-
al population and the incidence of children exceeding the threshold
to referral to hospital services, are well known from epidemiological
studies of older children (Costello et al 2005), and currently discussed
in the context of reluctance to diagnose mental illness in children and
the inappropriate resources to assessment and treatment.
With regard to infants and very young children as investigated
in the present study, a relatively low incidence could also be ex-
plained by limitations in knowledge about infant and toddler psycho-
pathology in the primary health services.
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GENERAL DISCUSSION
A general population birth cohort was established to study psycho-
pathology prospectively from birth in order to fill in the gap in
knowledge regarding core epidemiological aspects of mental illness
in early life.
THE HYPOTHESES INVESTIGATED IN THE STUDY WERE:
1Ή INFANTS AND TODDLERS SUFFER FROM MENTAL
ILLNESS LIKE OLDER CHILDREN DO
Psychiatric phenomenology regarding 0-3 year old children was
investigated in a general population prevalence study of 1½ years
old children, and supplied with a register study of first time diag-
noses in children referred to hospital, and diagnosed with a mental
health disorder at age 0-3 years. Based on in-depth child psychiatric
assessment by experienced clinicians using standardized measures
and clinical assessments, it was shown that mental health disorders
according to the diagnostic categories in ICD-10 and DC: 0-3, can be
detected in the general population of children as young as 1½ years.
The frequency and distribution of diagnostic categories correspond
in several aspects to what has been found in studies of older
children (Roberts et al 1998, Costello et al 2005).
Among children diagnosed at hospital, the whole spectrum of
ICD-10 mental health diagnoses were represented, with general de-
velopmental disorders and eating disorders as the most frequent. An
age and gender specific pattern was seen, with pervasive develop-
mental disorders diagnosed more frequent the older the age, and
eating disorders and attachment disorder more frequently diagnosed
in the youngest children. The gender distribution known from studies
of older children was seen already in children 0-3 years of age, with
neuro-developmental disorders diagnosed more frequent in boys and
eating disorders more frequent in girls (Rutter et al 2003).
Table12
Incidence of mental health diagnoses in children aged 0-3 years in CCC 2000 (N=6090)
Frequency of children (N=87) diagnosed with a first time mental health diagnosis in their first 3 years of life-
Based on register data (LPR and PCR) recorded from paediatric and child psychiatric departments 2000-2004
and stratified on age and gender
ICD-10- mental health diagnoses
(F- diagnoses and R 62.0)
1. year
(N= 6090)
n / 1000
2. year
(N=6074)
n / 1000
3. year
(N=6073)
n / 1000
0-3. year
(N=6073)
n / 1000
Ratio
boys: girls
Mental Retardation (F70-F 77, F78-F 79) 4 (0.66) 4 (0.66) 5 (0.82) 13 (2.15) 1.2
Psycho-motor retardation (R 62) 32 (5.25) 14 (2.31) 6 (0.99) 52 (8.56) 1.4
Specific developmental disorders (F80-83) - 3 (0.49) 4 (0.66) 7 (1.31) 1.3
Pervasive Developmental disorders (F84) 1 (0.16)
- 3 (0.49) 4 (0.66) 1
Hyperactivity Disorders (F90) 1 (0.16) 1 (0.16) - 2 (0.33) 1
Disorders of conduct and emotions (F91, 92, F 93) 1 (0.16) 2 (0.33) 2 (0.33) 5 (0.82) 1.5
Attachment disorders (F94.1-F94.9) 7 (1.15) - 1 (0.16) 8 (1.31) 0.1
Eating disorders (F98.2-F50) 13 (2.15) 2 (0.33) - 15 (1.48) 0.7
Sleeping disorders (F51) 1 (0.16) 1 (0.16) 2 (0.33) 4 (0.66) 1
Adjustment disorders (F43) 2 (0.33) 2 (0.33) 2 (0.33) 6 (0.99)
no boys
Other F-diagnoses (F 18) 1 (0.16) - 1 (0.16) 2 (0.33) 1
All F-diagnoses 31 (5.1) 15 (2.47) 18 (3.03)
64 (10.7)
0.7
All diagnoses 63 (10.4) 29 (4.7) 26 (4.28) 118 (19.4) 0.9
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Together these findings point to a far earlier emergence of
manifest psychopathology than has been described hitherto.
2Ή DISORDERS OF NEURODEVELOPMENT: MENTAL RETARDATION,
PERVASIVE DEVELOPMENTAL DISORDERS PDD AND ADHD MANIFEST
IN THE FIRST YEARS OF LIFE
Disorders of neurodevelopment were identified in 7 % of the
children from the general population at child age 1½ years. Of these,
ADHD was found in 2.8 %, whereas no children were diagnosed with
an autism-spectrum disorder at age 1½ years. Among referred
children aged 0-3 years, ADHD showed an incidence of 0.03%. The
overall incidence of PDD was 0.1 %, with incidence increasing with
age.
Neurodevelopmental disorders were associated with biological
risk factors similar to what has been found in studies of older chil-
dren (Costello et al 2006). Significant early predictors of deviant neu-
rodevelopment were identified between birth and 10 months by
community health nurses.
Among referred children, the increased risk regarding neurode-
velopmental disorders in boys, known from studies of older children,
was seen already at child age 0-3 years.
Together these findings point to the validity of neurodevelop-
mental disorders in early age.
3Ή RISK FACTORS AND PREDICTORS OF CHILD MENTAL
ILLNESS CAN BE DETECTED IN THE FIRST YEAR OF LIFE
Risks factors were investigated on cross sectional data obtained
from parents at the time of the diagnostic child assessment at age
18 months and predictors were studied on prospective data,
collected by health nurses from birth to 10 months.
The study results concerts with results from epidemiological
studies of older children regarding different pathway of risks, with
biological risks associated with neurodevelopment disorders and
psycho-social risk with emotional-, behavioural-, eating, sleeping and
adjustment disorders (Rutter 1989, Rutter 2005, Costello et al 2006).
The early influences of these risks are demonstrated by the
findings that predictors can be identified in the first 6 months of life.
The role of relationship disturbances in the early risk mechanisms
Parent-child relationship problems identified by health nurses in
the first ten months of life were associated with a more than two
fold increase in risk of a child disorder at age 1½ years, and children
with a parent-child relationship disorder had a ten fold increased risk
of a co-morbid mental disorder, in particular reactive attachment
disorder, disorders of behaviour and emotions and attention deficit
hyperactivity disorder, ADHD. Risk factors of relationship disturb-
ances at child age 1½ were manifest before the birth of the child, e.g
parent’s low education and unwanted pregnancy. These findings are
in accordance to the literature and to clinical experiences regarding
the key role of the parent-child relations in infant and toddler
psychopathology (Zeanah et al 1997 a, b).
No child risk factors at age 0-10 months were associated with
increased risk of parent-child relationship disturbances at age 1½
years. On the contrary, a tendency of inverse association was found
in children with biological risk and showing developmental impair-
ment at age 8-10 months, as these children had a 10 % reduced risk
of relationship disturbances at child age 1½ year.
ADHD was found associated with both predictors of neurodevel-
opment disorders (e.g deviances in social interaction and communi-
cation and parents perception of deviant contact between birth and
ten months) and with relationship disorders at age 1½ years.
The study results point to the early manifestation of ADHD as
regulatory disorders, a DC: 0-3 diagnostic concept of maturity based
neuro-regulatory disturbances (Zero to Three 1994) and further-
more, the results suggest a pathway of further risk exposition in
these children early in life, due to disturbances in parent-child rela-
tionship. These results are in accordance with the results from the
Bloominton Longitudinal Study of prospectively recorded early pre-
cursors of children’s self-regulatory competence (Olson et al 2002)
and in accordance with the results from the Manheim Study of
Children at Risk (Laucht et al 2000). The latter found significant asso-
ciations between difficulties in the child’s temperament and regula-
tory problems at 3 months on the one side, and ADHD symptoms at
2 years of age at the other side (Laucht et al 1993, 1994). However,
when controlling for family adversity, this association vanished
(Becker et al 2004).
Using ADHD as a model to understand the role of the parent-
child relation in developmental psychopathology, a two directional
influence on the pathogenesis can be considered: the negative influ-
ences on the relationship, given a regulatory disturbed hyperactive
child in one direction, and the aggravation of constitutional hyper-
kinetic symptoms, given a disturbed parent-child relation, e.g based
on an unwanted pregnancy and parents negative expectations to the
child and lack of resources to regulate and support the child.
Taken together, the findings from the study support the experi-
ences from clinical settings regarding the parent-child relationship as
the potential key mediator of psycho-social risks, as well as a key re-
silient factor with regard to the early promotion of child mental
health (Zeanah 2000).
The role of gender and age in the risk mechanisms
Studies of school aged children and adolescents have shown
remarkable differences in psychiatric morbidity according to sex and
age, most pronounced in clinical populations, but the same ten-
dencies have been found in general population studies. In school
aged children, neurodevelopmental and externalising disorders, e.g
behavioural disorders, have been found most prevalent in boys,
whereas internalising disorders, in particular emotional disorders
have been found more prevalent in girls. Before puberty, boys
exceed girls with regard to the prevalence of overall psychiatric
illness, whereas the pattern changes after puberty, and girls exceed
boys, partly due to increase in emotional/ affective disorders
(anxiety disorders and depressive disorders) and eating disorders
(Rutter et al 2003).
In the present general population study of children aged 1½
years, no significant differences in gender distribution were seen.
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However, among children referred to hospital within age 0-3 years,
the same pattern of gender distribution as described in older chil-
dren was seen, with boys more frequently diagnosed with a neu-
rodevelopment disorder and girls more often with eating disorders.
In the age period investigated, 0-3 years, differences according to
age were seen regarding eating disorders and attachment disorders
being predominantly diagnosed in the first year of life, and perva-
sive developmental disorders diagnosed more frequent, the older
the child. The same tendency was seen in another study of children
aged 0-3 years, referred from the same geographic area, but diag-
nosed in the period 1996-1998 (Elberling et al 2002). Taken togeth-
er, these findings suggest that gender and age specific differences
in the manifestations and identification of psychopathology, known
from studies of older children, are seen already in very early child-
hood.
The role of early feeding and eating problems
Nearly one third of all general population children were reported to
have feeding problems between birth and ten months, which
corresponds to results from other general population studies
(Lindberg et al 1991, Reilly et al 1999).
Studies of eating disorders in 0-3 year old children have been re-
stricted to small clinical samples, and no other studies have published
data on prevalence at this young age. We found a general population
prevalence of eating disorders of 2.8 % in children aged 1½ years and
an incidence of eating disorders diagnosed at hospitals in the same
study population of 0.15 % in children aged 0-23 months.
The findings suggest differences in severity of the most com-
mon infant problem, problems of feeding and eating: From develop-
mentally normal variations in establishing feeding in the first ten
months at one end, across manifest symptoms of feeding and eating
problems with increasing impact on weight to, at the other end:
manifest eating disorder, exceeding the threshold to referral to
treatment at hospital, and possibly due to weight faltering/ failure to
thrive. The data on children diagnosed with an eating disorder at
hospital show, that these were most often referred in the first year
of life, indicating the early manifestation of severe feeding and eat-
ing problems.
A study of failure to thrive in CCC 2000 children with the defin-
ition of FTT as the slowest growing 5 % of the infant population
(Olsen et al 2006) showed significant associations between health
nurse’s report of feeding problems and contemporary FTT. FTT with
onset within the first two months of life was associated with pre-
and perinatal adversities (preterm birth, low birth weight) and devel-
opmental impairment reported after birth, whereas FTT with onset
after 3 months seemed to be associated to no other risk factors but
feeding problems (Olsen et al 2007).
In the present study of infancy predictors, feeding problems re-
corded by health nurses at child age 8-10 months was the only sig-
nificant predictor of eating disorders at age 1½ years.
Taken together, the findings from the CCC 2000 studies point to
different psychopathological mechanisms in the development of eat-
ing disorders in infancy, and at least two, in principle different, risk
mechanisms can be suggested: One characterized by pre-/ perinatal
adversities, weight faltering/ failure to thrive FTT within the first two
months of life, in children with early signs of neurodevelopment im-
pairment and, probably early oral-motor conditioned feeding prob-
lems as discussed by Reilly et al (Reilly et al 1999). In the other type,
the pathway from feeding problems within the normal range, to the
development of an eating disorder with weight faltering, could be
suggested to be the result of a compromised parent-child interac-
tion, developing over time in an otherwise healthy child . The latter
suggested type corresponds to the subtypes of feeding behaviour
disorders characterized by parent-child relationship problems pro-
posed by Chatoor (Chatoor et al 2004).
Overall, the suggested hypotheses of different routes of risk
mechanisms in early feeding problems are in accordance with clin-
ical experiences and the literature on feeding and eating disorders in
infants and toddlers (Benoit 2000, Chatoor et al 2004), and also in
accordance with the proposed classification of feeding and eating
disorders in DC: 0-3 R (Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood, Revised
0-3, DC: 0-3 R 2005).
4Ή GENERAL HEALTH PROFESSIONALS ARE ABLE TO SCREEN
FOR MENTAL HEALTH DISORDERS IN INFANCY
The possibilities of mental health screening were investigated in the
general child health surveillance with the traditional measure of risk
among Danish health nurses, “concern” as the “screening instru-
ment”.
The results show, that within their ordinary routines, child
health nurses manage to perform an unspecific mental health
screening which is demonstrated by the identification of a fourth of
those children diagnosed with a mental health disorder at age 1½
years. Even though no specific screening instrument was applied,
and the health nurses were not specifically trained in child mental
health screening, they were able to identify children diagnosed with
neurodevelopment disorders at age 1½ years, by the recognition of
developmental impairment e.g in the area of language or communi-
cation, already in the first 10 months of life. However, the predictive
validity of positive test was low, which point to the need of develop-
ing more specific and standardized measures to ensure the validity
of screening for neurodevelopment disorders in infancy.
Considerations of infant mental health screening in a public
health system have to include considerations regarding intervention.
Disorders of neurodevelopment (e.g pervasive developmental dis-
orders, attention deficit hyperactivity disorders and psychomotor re-
tardation) are all characterized by persistent problems and a high
risk of complicating mental and social disabilities. Intervention to-
wards these disorders, e.g by parent counselling and psycho-educa-
tion, have the potential benefit of reducing the risk of exceeding
mental health problems, by reducing inappropriate demand on the
child and facilitation of the general development.
Early intervention as described has potentially long lasting per-
spectives regarding prevention of the emotional and behavioural
complications of these disorders (Offord & Bennet 2002).
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Screening and intervention towards children
in risk of parent-child relationship disorders
The results from the present study point to parent-child relationship
disturbances as the core mediator of psycho-social risks, which can
be identified before the birth of the child (e.g unwanted pregnancy)
or in the first months after birth (e.g negative expectation towards
the child, negative handling and reaction to the child). Accordingly,
the results both point to the need of developing screening instru-
ments to the valid identification of parents-child relationship
problems, as well as the need to develop and test strategies of
intervention directed towards the parent-child relationship, e.g.
concerning pregnant women and infant-mothers of psycho-social
risk as described in the European Early Promotion Project EEPP
(Puura et al 2005).
STRENGTHS AND LIMITATIONS
The research presented is based on a general population study of
mental health and psychopathology in a developmental perspective,
starting with birth.
The main strengths of the research concern: 1) the prospective
collection of data relevant to infant mental health 2) in a compre-
hensive study population, 3) in-depth assessment of psychiatric phe-
nomenology at child age 1½ years, 4) the investigation of develop-
mental psychopathology in the first years of life in a cohort from the
general population and furthermore, 4) the investigation of mental
health screening in the existing child health surveillance programme.
Data from the Danish National registers ensured a) a high cover-
age of data, e.g on child physical and mental health and putative risk
factors in the families, b) a broad description of core epidemiological
data including socio-demographic variables and c) option for analyses
of non-participants on several relevant parameters from registers.
The study profits by an established and well accepted general
child health surveillance programme by health nurses as source of
information on development, health and psycho-social environment,
ensuring a high participation at baseline (91%) and low cost data
generation. The health nurses’ perform their functions at home
visits, thus data collection was done in the natural setting of children
and parent. Information on child health consisted of both observa-
tions and assessments by child health nurses and the parent’s struc-
tured information of the nurses.
These strengths also imply one of the limitations in the study:
The unknown psychometric properties of the same data collection,
even though optimizing the validity was aimed through the creation
of standardized record.
Identification of psychiatric conditions in children aged 1½ years
is controversial as the concept of mental illness at this age is still de-
bated, and the validity of diagnostic categories not as well estab-
lished as in older age groups (Emde et al 1993, Zeanah et al 1997,
American Academy of Child and Adolescent Psychiatry 1997).
However, as pointed out by Egger & Angold: the present situation in
epidemiological research on psychopathology in preschool aged chil-
dren can be compared to the situation thirty years ago, where epi-
demiological research in older children’s mental illness opened the
way for the understanding and conceptualizing of mental health
problems and psychopathology in school aged children, at a time
where the psychometric qualities of the diagnostic classification
were questioned (Egger & Angold 2006). In accordance with this,
Egger & Angold point to the need of a dual approach where the ap-
plicability of current diagnostic criteria for identifying disorders in
very young children is tested while exploring the validity and clinical
utility of developmentally specific criteria/ or diagnostic algorithms.
In the child psychiatric assessments at child age 1½ years, we
have followed this approach: to search for a case-definition with the
optimal psychometric properties given “the state of art”, while en-
suring that the measures of psychopathology made it possible to
generalize findings to clinical settings (Verhulst 1995, 2002,
Fombonne 2002). Accordingly, the whole diagnostic spectrum of
psychopathology was investigated, both with regard to ICD-10 diag-
noses and the infant-toddler specific classification, DC: 0-3. Validity
was optimized by the use of standardized measures, research diag-
nostic criteria and criteria of impact available. Additionally, face val-
idity was optimized by the use of experienced child psychologists
and child psychiatric specialists as investigators.
A high reliability of the identification of children with mental
health disorders was demonstrated by 96 % inter-rater agreement in
the differentiation between children with or without psychopath-
ology, and 100 % agreement in the diagnostic classification of par-
ent-child relationships with disturbances. The reliability of the diag-
nostic classification of child mental health disorder present kappa
values of 0.6 (ICD -10) and 0.7 (DC:0-3), corresponding to results
from studies of clinical samples regarding DC: 0-3 diagnoses
(Guedeney et al 2003, Emde & Weise 2003, Frankel et al 2004) and
DSM-IV diagnoses (Frankel et al 2004). Furthermore, when compar-
ing the reliability of the separate diagnostic categories found in the
present study to studies of older aged children in clinical settings,
corresponding figures of reliability is seen (Skovgaard et al 1988,
Taylor & Rutter 2003, Egger et al 2006).
The methodologically strength of a thorough child psychiatric
investigation also implies a limitation, given the relatively small sam-
ple size possible to investigate. The statistical power of associations
is limited and for some analyses condensation of group has been
necessary.
MAIN CONCLUSIONS
The research presented in this thesis demonstrates that very young
children, 0-3 years of age, may suffer from the same kind of mental
health disorders as older children do. The risk factors seem to be
similar to findings from studies of older children, with seemingly spe-
cific psychopathological pathways of biological and psycho-social
risks. Furthermore, the results point to the key role of parent-child
relationship disturbances in early childhood as mediator of psycho-
social adversities.
Prospective data from the first year of living with the outcome
regarding mental disorder at 1½ years, suggest a pattern of pan-de-
velopmental predictors of neuropsychiatric disorders similar to what
has been described in studies with outcome in adult age.
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A general child health surveillance programme offers a frame to
screen for mental health problems in the first year of living, condi-
tioned the development of appropriate psychometric screening
measures and education of the involved health professionals.
Data on children treated for psychiatric conditions in the health
care system indicates that only a minor group of the children, which
might potentially profit from it, are identified and treated.
PERSPECTIVES
The results from the study contribute to the understanding of
developmental psychopathology early in life and point to the
possibilities of early identification of parent- child relationship
disorder and mental health disorders in the child.
The results suggest, that intervention should be done at a far
earlier stage in the child’s life than has been effectuated until now,
and underscore the importance of developing and assessing specific
and focused strategies directed towards children in biological risks
and parents in psycho-social risks, optimally effectuated already in
pregnancy and early infancy.
The implications for the health care system concern the neces-
sity of an increased focus at infants and toddlers mental health, re-
garding psychiatric symptoms. Due to their role in the child health
surveillance, both community health nurses and the general practi-
tioners should be educated in the identification of early symptoms
of mental health disturbances in infants and toddlers, and trained in
small scale strategies of intervention.
Finally, the results point to the demand for an extension in child
psychiatric services to include the youngest children and hereby en-
sure the early assessment and treatment of infants and toddlers
with manifest mental health disorder. The perspectives of early diag-
nosis followed by appropriate parent counselling and specific treat-
ment imply a reduced risk of progressions and complications of
mental illness in childhood.
Overall, identification of risk factors, predictors and manifest
mental disorder in the first years of life have the perspectives of re-
ducing the burden of mental health disorder, at the level of the indi-
vidual child and the family, as well as at the society level.
SUGGESTIONS FOR FUTURE RESEARCH
Follow-up studies of the whole CCC 2000 cohort are needed to
investigate the longitudinal course of mental health problems and
developmental psychopathology.
Standardized instruments of mental health screening in infancy
should be developed and tested regarding psychometric properties.
Furthermore, strategies of specific intervention in the general child
health surveillance should be investigated, e.g by controlled studies
of systematic intervention based on parent counselling, psycho-edu-
cation and short-term psychotherapy conducted by health profes-
sionals, e.g. child health nurses.
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SUMMARY
The thesis includes seven published papers and an overview
concerning the epidemiological aspects of mental health problems
and psychopathology in children aged 0-3 years.
The research behind the thesis focuses at psychopathology in
the first years of life. The aim has been to investigate phenomen-
ology, prevalence, risk factors and predictors, in order to contribute
to the knowledge about early developmental psychopathology, and
improve the scientific foundation for identification and treatment of
mental illness of infants and toddlers, and optimize the foundation
for prevention of psychiatric illness in early life.
The Copenhagen Child Cohort CCC 2000 was established with
inclusion of 6090 children born in year 2000. The cohort was de-
scribed at baseline with data from Danish National registers and pro-
spective data on mental health and development collected by health
nurses at home visits.
At 1½ years of age a subpopulation was thoroughly investigated
regarding child psychiatric illness, in a random sample prevalence
study and a case-control study nested in cohort, with cases being
children of health nurse concern in the first ten months of living.
Mental health disorders were identified in 18 % of 1½ year old
children from the general population. The prevalence and distribu-
tion of main diagnostic categories correspond to results from studies
of older children. Disorders of neurodevelopment (mental retarda-
tion, disorders of psychological development and ADHD) were asso-
ciated with pre-and perinatal biological risks and predictors were de-
viant language development and impaired communication, recorded
by health nurses in the first ten months of life. The findings corre-
spond to results from studies of older children and adolescents and
point to an earlier emergence of neurodevelopmental psychopath-
ology than has been described hitherto.
Risk factors of emotional, behavioural and eating and sleeping
disorders were psycho-social adversities in parents, and parent-child
relationship disturbances seem to be the key mediator in the risk
mechanisms. Risk factors of relationship disorders at child age 1½
years can be identified before the birth of the child, and predictors
can be identified by health nurses from birth to 10 months.
In the general child health surveillance between birth and ten
months, community health nurses are able to identify risk factors
and predictors of child mental disorders at 1½ years, and by a global
and unspecific screen, health nurses identify one fourth of children
diagnosed with a mental disorders at age 1½ year.
The incidence of mental health disorders including mental
retard ation diagnosed at hospital in the first three years of life was 2
%. Sex differences known from studies of older children were dem-
onstrated in children referred to hospitals, with neurodevelopment
disorders more often diagnosed in boys, and eating disorders more
frequent in girls.
Conclusions: For the first time it is shown in a general popula-
tion study, that children as young as 1½ years may suffer from men-
tal illness as older children do. Risk factors and predictors of mental
illness can be identified in the first ten months of life, and the associ-
ation of risks found in studies of older children seem to operate al-
ready from birth. The results point to the potentials of mental health
screening and intervention in the existing child health surveillance.
Perspectives: The current longitudinal study of CCC 2000 in pre-
school and school age will expand the present findings and further
elucidate the significance of the first years of life regarding child
mental health. Future research in this area should include the study
of measures to screen and intervene towards mental health prob-
lems in infancy within the general child health surveillance.
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DANSK RESUMÉ
Afhandlingen omfatter 7 artikler og en sammenfattende oversigt
vedrørende epidemiologiske aspekter ved psykiske helbredsproble-
mer og psykopatologi hos 0-3 årige børn.
Forskningen bag afhandlingen fokuserer på psykopatologi i de
første leveår med udgangspunkt i data indsamlet prospektivt fra fød-
slen. Formålet har været at udforske fænomenologi, forekomst,
risikofaktorer og prædiktorer, for herved at bidrage med viden til
forståelsen af tidlige psykopatologiske mekanismer, og øge det vi-
denskabelige grundlag for diagnostik og behandling af spæde og
småbørn, og grundlaget for forebyggelse af psykisk sygdom.
Studiepopulation er en uselekteret fødselskohorte, Copenhagen
Child Cohort CCC 2000, CCC 2000, bestående af 6090 børn født i
2000. Ved baseline blev kohorten beskrevet ud fra nationale registre
og data vedrørende psykisk helbred og potentielle risikofaktorer de
første 10 måneder efter fødslen, indsamlet prospektivt ved sund-
hedsplejerskernes hjemmebesøg.
Ved 1½ års alderen er gennemført dybtgående studier indenfor
kohorten med henblik på at identificere psykopatologi hos små børn
fra normalpopulationen og fastlægge hyppighed af psykisk sygdom
og prædiktorer herfor. Desuden er potentialet for psykisk helbredss-
creening i barnets første leveår undersøgt med udgangspunkt i sund-
hedsplejerskernes undersøgelser ved hjemmebesøg i den eksister-
ende småbørnsprofylakse. Studiet er suppleret med ikke-tidligere
publicerede data fra en registerundersøgelse af psykiatriske diag-
noser hos hospitalsbehandlede 0-3 årige i CCC 2000 kohorten.
Ved 1½ års undersøgelsen kunne psykopatologiske tilstande
svarende til ICD-10 diagnoser identificeres hos 18 %, og med en diag-
nostisk fordeling, der svarer til resultater fra undersøgelser af ældre
børn. Neuro-udviklingsforstyrrelser (mental retardering, psykiske ud-
viklingsforstyrrelser og forstyrrelser af opmærksomhed og aktivitet,
ADHD) fandtes associeret med biologiske risici påvist i tiden omkring
fødslen. Afvigende kognitiv udvikling og afvigende kommunikative
færdigheder var prædiktorer for neuro-udviklingsforstyrrelser, som
allerede kunne påvises ved sundhedsplejerskernes undersøgelser i
de første 10 levemåneder. De påviste risikofaktorer og prædiktorer
svarer til fund fra undersøgelser af ældre børn og unge og peger på
en tidligere manifestation af psykopatologien ved neuro-psykiatriske
lidelser end hidtil påvist.
Risikofaktorer for følelsesmæssige og adfærdsmæssige forstyr-
relser og forstyrrelser af spisning og søvn var psyko-sociale belast-
ninger hos forældrene, hvilket er i overensstemmelse med fund fra
undersøgelser af ældre børn. Desuden viste undersøgelsen af de 1½
årige børn, at forstyrrelser i forældre-barn relationen har en central
rolle i risikomekanismerne, og at psyko-sociale prædiktorer for
forældre-barn relationsforstyrrelser kan identificeres af sundhed-
splejerskerne allerede i tiden omkring barnets fødsel.
Inden for den eksisterende småbørnsprofylakse kan sundhed-
splejerskerne, uden specifikke screeningsinstrumenter, identificere
hvert fjerde barn, som diagnosticeres med en psykisk forstyrrelse
ved 1½ år.
Hos hospitalsbehandlede 0-3 årige i kohorten var hyppigheden
af førstegangs diagnoser for psykisk sygdomme incl mental retarde-
ring, 2 %. Kønsforskelle, som er kendt fra undersøgelser af ældre
børn, fandtes også hos 0-3 årige diagnosticeret på hospital, med
overvægt af drenge med neuro-udviklingsforstyrrelser og overvægt
af piger med spiseforstyrrelser.
Konklusion: For første gang viser en populationsbaseret under-
søgelse, at børn ned til 1½ år kan rammes af psykiske sygdomme
som ældre børn. Risikofaktorer og prædiktorer for psykisk sygdom
kan identificeres i de første ti levemåneder, og risikomekanismer
som er beskrevet ved undersøgelser af ældre børn, ser ud til at
udøve deres virkning fra den tidligste barnealder.
Undersøgelsens resultater peger på screeningsmuligheder i den
eksisterende småbørnsprofylakse.
Perspektiver: Igangværende og planlagte follow-up studier i CCC
2000 vil bidrage yderligere til at belyse risikomekanismer og prædik-
torer ved psykisk sygdom i den tidlige barnealder. Valide metoder til
psykisk helbredsscreening og effektive interventionsstrategier i bar-
nets første leveår bør udvikles og afprøves systematisk, både mht.
sundhedsplejersker og praktiserende læger. Desuden bør sundheds-
væsenets muligheder for tidlig diagnostik og behandling af 0-3 årige
med psykiske vanskeligheder udbygges.
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Appendix 1
Danish National Registers
National Registers in Denmark Area of information
The Civil Personal Registration System (CPR) All citizens in Denmark have a unique 10-digit ID- number, which follows
them throughout life. This personal CPR ID-number is stored together with
information about age, sex, places of living, nationality and the CPRID-
number of the parents
The Medical Birth Register (MBR) All children born in DK.
Parents ethnicity, marriage, mothers and fathers place of birth
Pregnancy and delivery, place of birth, birth complications,
Gestational age, birth weight, length at birth, Apgar - score.
No days treated at hospital after birth
National Register of Patients (LPR) Admissions to somatic hospitals in DK including diagnoses and treatments
The Psychiatric Central Register (PCR) Admissions to psychiatric departments in DK including diagnoses and
treatments.
The National Social Register (IDA): School, education, vocational training, and earnings as well as present and
past occupation.
The National Register of Medicinal Products Prescribed medicine
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Appendix 2
Information recorded by health nurses at home visits (CCC 2000)
Area Variables Measure
Psycho-social conditions Educational level of parents
Occupational status of parents
Housing conditions
Marital / civil status
Ethnicity*
Number of siblings
Parent’s smoking and drinking
Parental supervision and care
Parent interview
(1-5 weeks after
b
irth)
at each visit
Pregnancy and birth Complications in pregnancy*
Gestational age*
Birth complications*
Weight and length at birth*
Congenital deformities
Peri -natal problems
Parent interview
(1-5 weeks after
birth)
History Psychomotor development
Sensory functions
Inter current physical illness /
hospitalisation**
Patterns of urination and
defecation
Nutrition
Regulation of sleep and eating
Parents perception of the child
(communication/ temperament)
Parent interview
(At each visit)
Assessment of infant health
and development Weight and length
Developmental milestone:
- psycho- motor development
- language/ communication
(appropriate for age)
Social and emotional state
Clinical
observation/
examination by
health nurse
(At each visit)
Conclusions / intervention Child development
Mother-infant relationship
Family relations
Advices
Referrals
(At each visit)
* Information also obtained from Medical Birth Register (MFR)
** Information also obtained from The National Register of Patients (LPR)
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Appendix 3 Variables of infant mental health 0-10 months recorded by community health nurses in CCC 2000
Domain Function Examples of variables (age at assessment/months)
Neuro development
Reflexes
Gross motor development
Fine motor development
Oral- motor development
Activity, interest
Capacity of attention and focusing
Perception (visual, hearing, tactile)
Suckling-, searching- (0-1), grasping- (0-6), moro -reflexes (0-6)
Rolls from ventral to dorsal position (4-10) , sits alone (8-10)
Tweezers grasp (8-10)
Examines objects by putting into the mouth, bites and chews (4-10)
Observes an object and reaches for it (4-10), curious and examining (8-10)
Concentrates at the following of objects (visual and hearing) (8-10), listens to conversation (4-10)
Enjoys being touched and handled (0-6)
Language development
Receptive
Expressive (non-verbal, verbal) Reacts at mothers mimics and voice (0-10)
Babbling (2-6), dialogue babbling (3-10)
Social interaction/ communication
Social reactivity
Joint emotional involvement
Interactive intentions and reciprocity
Differentiated communication
Reacts at mothers mimics and voice (0-10), listens to conversation (4-10),
Dialogue babbling (3-10), contact smile (8-10)
Touches mothers face (4-6), reaches the hands to be taken up (8-10), waves (8-10)
Pats-a cake (8-10)
Regulation of physical functions
Sleep
Feeding, eating
Digestion
Sleep problems (0-10)
Problems with feeding (0-10)
Regurgitation (0-10), vomiting (0-10)
Emotional state/
Affective expression
Joy
Discomfort, unhappiness Smiles (2-3), chuckles (2-3), laughter (4-6), contact smile (8-10)
Differentiated crying (2-3)
Mother-infant relation
Sensitivity, responding, regulation
Affective involvement
Mother’s presentation of the child
Physical interaction´, touching
Mutuality, reciprocity
Mother’s taking care of physical and emotional demand of the child (0-10)
Love and warmth in mother’s spoken of the child (0-10)
Mother’s positive expectations of the child (0-10)
Adequate and positive handling of the child (0-10)
The quality of the contact between mother and child (0-10)
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Appendix 4
Measures of Diagnostic Assessment at 18 months
1. Parent interview Child Behaviour Check List CBCL /1½-5
Infant toddler Symptom Check List ITSCL
Checklist of Autism in Toddlers CHAT
Manheim Eltern Interview MEI
2. Child assessment Bayley Scales of Infant Development BSID II
Checklist of Autism in Toddlers CHAT
Clinical observations /videotape recordings of child behaviour
3. Relationship assessment Parent Child Early Relationship Assessment (PC-ERA)
Parent Infant Relation Global Assessment Scale PIR-GAS
4. Diagnostic classification
ICD 10: I. Psychiatric Syndrome
II. Specific Developmental disorders
III. Intellectual Level
IV. Physical Illness
IV. Psycho-social Disadvantages.
DC 0-3: 1. Primary Mental Health Diagnosis
2. Relationship disturbances
3. ICD 10 (DSM IV) Diagnoses
4. Psycho-social Stressors
5. Functional Emotional Level
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Appendix 5
Definition of Risks (Manheim Risk Index)
A. Estimation of biological risks
________________________________________________________________________________
1. Birth Weight 2500-4200
2. Gestational age GA: 38-42 weeks
3. No information of signs of asphyxia (Apgar 10/ 5 min)
4. No surgical delivery (Except elective)
5. Toxaemia of pregnancy (oedema, proteinuria and hypertension)
6. Pre-term birth, GA < 37 weeks
7. Preterm labour: Tocolytic treatment or cerclage
8. Very low birth weight BW < 1500 g
9. Clear case of asphyxia (Apgar < 5/ 5 min) and special treatment at intensive neonatal unit for > 7 days
10. Neonatal complications: Seizures, respiratory therapy (mechanical ventilation) or sepsis
________________________________________________________________________________
Groups of biological risk
Non-risk: all of items 1-4 and none of 5-10
Moderate-risk: one out of items 5-7 and none of 8-10
High-risk: one out of items 8-10
B. Estimation of psycho- social risk
________________________________________________________________________________
1. Parents low educational level Parent without completed school education or without skilled job training
2. Overcrowding More than 1.0 person/room
3. Parental psychiatric disorder Moderate or severe disorder (diagnosed at hospital)
4. Parental broken home or Institutional care of parents or more than two changes of care
history of delinquency takers in parents childhood or parental delinquency
5. Marital discord Low quality of partnership in two out of three areas
(harmony, communication, emotional warmth)
6. Teenage parents
7. One -parent family at the time of child birth
8. Unwanted pregnancy Abortion was seriously considered
9. Poor social integration Lack of friends and lack of help in child care
and support of parents
10. Severe chronic difficulties Affecting a parent more than 1 year
11. Poor coping skills in parent Inadequate coping with stressful events of the last year
_________________________________________________________________________________
Groups of psycho-social risk
Non-risk: no item fulfilled
Moderate-risk: one or two fulfilled
High-risk: more than two fulfilled
(for details see Laucht, Esser & Schmidt, 1997).
