Family Relationship Influences on Family Relationship Influences on Children’s Psychopathology: Revisiting the Children’s Psychopathology: Revisiting the Developmental Interface between Nature Developmental Interface between Nature

and Nurtureand Nurture

Kick off Workshop for AU Network of Public Child Mental Health, Aarhus, Denmark, December 12th 2014.

Gordon HaroldAndrew and Virginia Rudd Professor of Psychology

Director, Rudd Centre for Adoption Research and PracticeUniversity of Sussex

MRC Centre for Neuropsychiatric Genetics and GenomicsCardiff University

Overview of PresentationOverview of Presentation• Family relationship influences on children’s mental health

o A brief review of theory and research • A focus on the inter-parental and parent-child relationships

o Unpacking nature from nurture in examining family relationship influences on children’s mental health

• Examining the role of the inter-parental and parent-child relationships on childhood psychopathology

o Study 1: Inter-parental conflict, negative parenting practices and children’s externalising (conduct) problems

o Study 2: Intergenerational transmission, adoptive mother depression and mother-child hostility and children’s ADHD – conduct

problems

o Study 3: Family process intervention aimed at reducing psychopathology (depression) among a high risk sample

• Implications for practice and policyo Applications of research to practice and policy contexts

Children and Mental HealthChildren and Mental Health• How are children affected by

family factors – Emotional problems

– Depression (2020)– Behaviour problems

– Conduct Dis (£22B/year)– Social competence

– Peer relationships– Academic attainment

– Performance, behaviour– Physical health

– Substance abuse

• What family factors affect children– Economic pressure/poverty– Parent mental health– Parenting behaviour/practices– Inter-parental conflict,

domestic violence– Parental separation-divorce

Economic or Work pressure

Paternal Depression

Maternal Depression

Parent-Child

Problems

Interparental Conflict

Child Symptoms

A Process Model of Family A Process Model of Family Relationship Influences on Relationship Influences on Children’s Mental HealthChildren’s Mental Health

Conger and colleagues 1989-2007

Caveats of Past ResearchCaveats of Past Research• Salience of the family

environment ?– Predominantly conducted with

biologically related parents-children – Limited examination of maternal

versus paternal parenting influences on children

• What if it is all in the genes?– Associations between parental

behaviour (e.g. parenting) and child behaviour is BECAUSE children share genes with their parents??

– Passive rGe; Evocative rGE

• Disentangling genetic factors from rearing environment factors – Traditional twin, sibling, adoption– Unique research designs (UK, US)

Early Growth and Development Early Growth and Development StudyStudy

(Adoption at Birth Design)(Adoption at Birth Design)Sample• 561 sets of adopted children, adoptive parents, and birth

parentso Sample retention: Adoptive family = 90% Birth parent = 92%o Families assessed at child age 9-, 18-, 27-months of age; ongoing

assessments at 4.5 years, 6 years, 7 years, 8 years, 9 yearso Present sample included 341 linked families assessed at 27 months,

4.5 years, and 6 years• Nationally-representative sample of families who made domestic

infant adoption placements in the United States between 2003-2009Method• Videotaped Observation – adoptive families

o Child temperament, parent-child interactions, marital interactions video recorded in the home during 3-hour home visits at each wave. Coding for these tasks is on-going

• Questionnaire – adoptive parentso Couple relationship, parent-child relationship, symptoms of

depression and anxiety, family economic conditions, styles of family interaction, parenting style, children’s emotional and behavioural well-being, child sleep problems

• Questionnaire – birth parentso Couple relationship, diagnosis and symptoms of psychopathology,

drug use, economic conditions, life stress, temperament

Cardiff In Vitro Fertilization StudyCardiff In Vitro Fertilization Study(An Adoption at Conception Design)(An Adoption at Conception Design)

• Children born through in-vitro fertilisation (IVF)o 20 fertility centres within the UK (1 in US)

• 888 families– Homologous IVF N = 444– Sperm donation N = 210– Egg donation N = 175– Embryo donation N=36– Gestational surrogacy N=23

o Families who had a live birth (1994 – 2002) • Children aged between 4 – 10 years (mean = 6.80 yrs,

SD=1.23)• Demographics (family income, parent education, ethnicity)• Present sample included children aged 5-8 years old (m =

6.49, sd = .85)• Genetically related versus unrelated groups

o Genetically Related• Mothers (N=546):Homologous, sperm donation, surrogacy• Fathers (N=531): Homologous, egg donation, surrogacy

o Genetically Unrelated• Mothers (N=160): Egg and embryo donation• Fathers (N=173): Sperm and embryo donation

Inter-Parental Conflict, Hostile Inter-Parental Conflict, Hostile Parenting and Children’s Parenting and Children’s

Conduct Problems Conduct Problems

Harold, G. T., Leve, L. D., Elam, K., Thapar, A., Neiderhiser, J., Natsuaki, M., Shaw, D., Reiss, D. (2013). The Nature of Nurture: Disentangling Passive Genotype-Environment Correlation from Family Relationship Influences on Children’s Externalizing Problems. Journal of Family Psychology, 27(1), 12-21.

Economic or Work pressure

Paternal Depression

Maternal Depression

Parent-Child

Problems

Interparental Conflict

Child Symptoms

A Process Model of Family A Process Model of Family Relationship Influences on Relationship Influences on

Children’s PsychopathologyChildren’s Psychopathology

Conger and colleagues 1989-2007

Study Measures (IVF/EGDS)Study Measures (IVF/EGDS)• Inter-parental Conflict

o Self report of hostility towards spouse• IVF & EGDS: Behavior Affect Rating Scale (mothers,

=.89/.88; fathers, =.91/.90, Melby et al., 1993)

• Parent-Child Relations (Hostile Parenting) o Mother & Father report of hostility toward child

• IVF & EGDS: IYFP Ratings Scales (mother, =.70/82; father, =.75/.80, Melby et al., 1993).

• Child Conduct Problemso Mother & Father report of child externalising behavior

• Cardiff IVF: Strengths and Difficulties Questionnaire (mother, =.80; father, =.78)

• EGDS: Externalizing subscale, Child Behavior Check List, (mother, =.88; father, =.90)

Theoretical Model (Theoretical Model (IVF-HIVF-H / /

EGDSEGDS))

Mother-Child

Hostility

Father rated Child

Conduct Prob

Father-Child

Hostility

Mother rated Child

Conduct Prob

Interparental Conflict

.23**/.17*

.33**/.19*

.32**/.31**

.39**/.44**

.24**/.34**

.10*/.21**

*p <.05, ** p < .01

Relevance of Genetic Relatedness (IVF Relevance of Genetic Relatedness (IVF

Sample)Sample)

Mother-Child

Hostility

Father rated Child

Conduct Prob

Interparental Conflict

.33**a/.37*b .31**/.28**

*p <.05, ** p < .01

Father-Child

Hostility

Mother rated Child

Conduct Prob

Interparental Conflict

.45***a/.58***b .37**/.38**

.33**/.37*

.45**/.58**

Summary and Considerations Summary and Considerations

• Family relationship influences on children o Inter-parental conflict affects children’s conduct problems

through disrupted mother-child and father-child relationships • Confound of passive rGE controlled• Inter-parental conflict as context may have greater

disruptive influence on father-child compared to mother-child relationship

o Implications for intervention (promoting positive maternal and paternal parenting practices in the context of inter-parental conflict)

• Limitations and considerations o Cross-sectional analyses; Rearing (adoptive) parent reports

• Past longitudinal and experimental evidence; Opposite parent report of child externalizing

o Role of evocative gene-environment correlation (rGE)??• Genetically informed attributes in the child may evoke

disrupted family relationship behaviours/patterns

Intergenerational Transmission: Intergenerational Transmission: Biological versus Adoptive Mother-Biological versus Adoptive Mother-Child Processes, Children’s ADHD Child Processes, Children’s ADHD

and Conduct Problems and Conduct Problems

Harold, G. T., Leve, L. D., Thapar, A., et al., (in preparation). Adoptive mother-to-child hostility and children's ADHD symptoms and conduct problems: Examining the role of genetically-informed child attributes on pathways to psychopathology.

Contextualising Family RelationshipContextualising Family RelationshipInfluences on Children Influences on Children

• Direction of effectso Parent effects on children

• Harsh (or positive) family experiences affect children’s psychological development

• Parental depressive symptoms may affect children’s psychopathologyo Child effects on parents

• Child behaviour/disorder/disability may affect parent’s parenting behaviour and family relationship experiences

• Child behaviour/disorder/disability may affect parent’s mental health (depression)

• Attention Deficit Hyperactivity Disorder (ADHD)o Neurodevelopmental disorder (highly heritable)o Families of children with ADHD report higher rates of family conflict and

more negative parent-child relationships• Role of ADHD on family relationship patterns??• Children’s ADHD symptoms relative to conduct problems??

o Intervention/family support programme implications?

Study Measures Study Measures EGDS Sample and Maternal Focused Influences

•Birth Mother & Adoptive Mother ADHD symptoms: Barkley’s Adult ADHD Scale (Barkley & Murphy, 1998; BM: =.90, AM: 85).

•Child Impulsivity: Impulsivity scale of Children’s Behavior Questionnaire (Rothbart, Ahadi, Hershey, & Fisher, 2001)(=.78); Child Activation: Drive, Reward Responsiveness, and Fun Seeking scales of BIS/BAS (Carver & White, 1994; =.81, .71, .70).

•Adoptive Mother-to-Child Hostility, Adoptive Mother Depression: Iowa Family Interaction Scales (Melby, 1995; =.91); Beck Depression Inventory (BDI; =.92).

•Child ADHD and Conduct Problems: Conner’s Abbreviated Parent Questionnaire(Conners,1997; =.89); CBCL Aggression Subscale (Achenbach, 1991; =.91).

Child ADHD – Conduct Child ADHD – Conduct

ProblemsProblems

Birth Mother ADHD

Symptoms

Child Impulsivity and Activation

Adoptive Mother

Hostility

Adoptive Mother

Depression

Child ADHD Symptoms

(Father Report)

Child Conduct Problems

(Father Report)

Genetically Related Genetically Unrelated

.15*

.01

..42**

.12*

.02

.01.19*

.14*

.32**

18 mths – 4.5 yrs 4.5 years 6 years

.22* .30**

Summary and Implications Summary and Implications • Primary Summary Points/Findings

o Passive rGE: Evidence for environmental effects (adoptive mother-to-child hostility) on child ADHD and Conduct problems

o Evocative rGE: Adoptive mother-to-child hostility evoked by genetically informed child impulsivity which predicts child ADHD and conduct problems

• Not depression, a focus on parentingo Phenotype specificity (ADHD); parenting influences, stronger

association with conduct problems (early coercive family process theories; Patterson et al., 1980s)

• Bottom-Line Take-Home Messages/Implicationso Evidence-based guidance as to intervention focus

• Genetic risk for ADHD as risk factor for disrupted family environment (mother-child relationship), mother-child relationship as risk factor for ADHD development AND conduct problems

• Early child behaviour influences on parenting, not just the other way around

• Identification of mechanisms, key to early intervention (prevention)

• Importance of family ‘process’ approach

Putting Research into Practice: Implementing Putting Research into Practice: Implementing an Evidence-Based Approach an Evidence-Based Approach

Assessing Children’s Psychological Welfare Assessing Children’s Psychological Welfare in the Context of Parental Separation and in the Context of Parental Separation and

Divorce Divorce

Harold, G. T., (2009). Development and Implementation of the CAFCASS Cymru Child and Adolescent Welfare Assessment Checklist (CC-CAWAC). Welsh Government.

A Practice and Policy ContextA Practice and Policy Context• Parental separation and divorce

o Over 50% of new marriages end in divorce (UK, USA)• 28% of children (>1 in 4) will have lived through their parents

divorce before the school leaving age of 16 yearso 68% under the age of 10 yrs

o Divorce as cause??• Conflict that occurs before, during and after divorce may

explain more about children’s adaptation than actual divorce (Kelly, 2000)

• Legislative contexto Adoption and Children Act (2002)

• Definition of significant harm emanating from exposure to domestic violence has been extended to include ‘impairment suffered from seeing or hearing the ill treatment of another

• Supporting children in the context of parental separation and divorce in the UK o Children and Family Court Advisory Support Service in

Wales (CAFCASS CYMRU)• How do practitioners assess “psychological risk” to children

Assessing the psychological effects of Assessing the psychological effects of witnessing inter-parental conflict on witnessing inter-parental conflict on

childrenchildren• Child and Adolescent Welfare Assessment Pack

(CAWAC) o Psychological impacts of family process assessment

pack• A questionnaire and short answer instrument aimed at

allowing assessment of psychological risk/impacts to children who witness inter-parental conflict and violence for application within the family justice system

o Comprehensive research review relating to the effects of inter-parental conflict on children

• Practitioner friendly summary of bottom line findings and implications derived from comprehensive research review

• Accessible summary and practice guidelines

• Context of Useo Private and Public Law applications

• CAFCASS (Wales) 7,812 cases involving children (2009-10)

Primary Assessment Domains Primary Assessment Domains Children’s psychological symptoms, experiences of

inter-parental conflict and parenting practices (Sections 1, 2, 3)

• Psychological symptoms (e.g. SDQ)• Perceptions of inter-parental relations (e.g. CPIC)• Perceptions of parent-child relations (e.g. CRPBI)

Children’s perceptions of community, family and caregiver relationships and court expectations (Sections 4, 5 ,6)

• Profiling children’s family ‘connectedness’, kinship and support systems (peers, school, extended family)

• Implications of court request for children’s perceptions of inter-parental, parent child, sibling relations, kinship relations/connectedness and individual well being

Assessment to Recommendation Assessment to Recommendation Format of Assessment

– Questionnaire and interview format (parent, carer, practitioner, child, teacher)

– Child (age 6-11 years); Adolescent (age 12-16 years) versions – Aimed at equipping practitioners with objective assessment

materials so as to complement existing practice guidelines and individual expertise in making court based recommendations

Identifying “at risk” children (population comparison)– Applying population norms to calibrate the welfare of children

relative to children of similar age and gender in the general population

Practitioner orientated report format for application in the court context– Guidelines and report writing template– Improving objective assessment of psychological impacts of “seeing

or hearing the ill treatment of another” in the context of parental separation-divorce

Practitioner Training and Practitioner Training and

AccreditationAccreditation• Practitioner accreditation process

o Formal training (day long); Six-month practice based accreditation

o Self and software generated comprehensive reporto Equipping (training) practitioners for cross-examination

challenge

• Results to dateo CAWAC has been used in over 600 cases since April 2009

(Private Law)JUDGE: Processed application to court (request for increased access/contact by parent) in 15 mins that would have ordinarily taken six months”)

o Standardized assessment of mental health impacts of parental separation and divorce on children

• Review (North and South Wales): 60% - 80% showing significant to severe symptoms (age 5 to 16 years)

• Future Applicationo Common assessment strategy for use by health workers,

social workers, court officials, other practitioners/educatorso Developing context specific intervention (support)

programmes (Court, School, Health, adoption, foster-care)

Bringing it All TogetherBringing it All Together• Highlighting the role of family relationship influences on

children ‘s mental healtho Inter-parental relationship; Parent-child relationships

• Implications for practice and policyo Evidence-based guidance as to intervention focuso When do we target, who do we target, what do we target?o Salience of family relationship influences on children

• Irrespective of genetic relatedness

• Practice and policy implicationso Importance of utilising a complement of research designso Informing intervention targets through carefully designed

researcho Supporting parents (adoption, IVF, step-parent, carer, biological)

• Emphasising the importance of the rearing environment• Promoting resilient children by promoting and supporting

resilient parents (helping children by helping parents)• Early prevention versus late intervention (cost benefits)

AcknowledgementsAcknowledgementsEGDS and MTFC Cardiff IVF Study

Leslie Leve Anita Thapar

Jenae Neiderhiser Frances RiceMisaki Natsuaki Gemma LewisDaniel Shaw Alyson LewisDavid Reiss Dale HayLaura Scaramella Jacky BoivinRand Conger XiaoJia GeJody GanibanXiaojia GePhil FisherPatti ChamberlainJohn ReidDavid DeGarmo

The Wellcome TrustThe Nuffield Foundation

The National Institutes of Health (USA)