Co-opting the "neuro" in neurodiversity and the complexities of epistemic injustice.

This article tackles the theoretical thinking behind PPI and inclusion, input from people with neurodiverse conditions. By providing a perspective on how the prefix "Neuro" is positioned in a neutral and authoritative way (exemplified through our brief review of articles within Cortex), we explore how "epistemic injustice" (a concept used frequently in law, politics, philosophy and social science) can potentially arise. Epistemic injustice typically refers to a pernicious power dynamic whereby oppressed groups are silenced (Fricker 2007), either because certain voices are not given weight ("testimonial injustice"), or the ways in which they are allowed to speak (e.g., interpret their own experiences) are limited ("hermeneutical injustice") (Kidd and Carel 2016). We show how, for "neurodiversity", the mainstream "neuro" narratives are often positively felt by those deemed to be neurodiverse, and the lines between oppressor and oppressed break down, as both neuroscientists and people with neurodiverse conditions co-opt and influence each other's positions.

Past, present and imaginary: Pathography in all its forms.

Diagnosis is a profoundly social phenomenon which, while putatively identifying disease entities, also provides insights into how societies understand and explain health, illness and deviance. In this paper, we explore how diagnosis becomes part of popular culture through its use in many non-clinical settings. From historical diagnosis of long-deceased public personalities to media diagnoses of prominent politicians and even diagnostic analysis of fictitious characters, the diagnosis does meaningful social work, explaining diversity and legitimising deviance in the popular imagination. We discuss a range of diagnostic approaches from paleopathography to fictopathography, which all take place outside of the clinic. Through pathography, diagnosis creeps into widespread and everyday domains it has not occupied previously, performing medicalisation through popularisation. We describe how these pathographies capture, not the disorders of historical or fictitious figures, rather, the anxieties of a contemporary society, eager to explain deviance in ways that helps to make sense of the world, past, present and imaginary.

Time trends in autism diagnosis over 20 years: a UK population-based cohort study.

BACKGROUND: Autism spectrum disorder is a diagnosis that is increasingly applied; however, previous studies have conflicting findings whether rates of diagnosis rates continue to grow in the UK. This study tested whether the proportion of people receiving a new autism diagnosis has been increasing over a twenty-year period, both overall and by subgroups. METHOD: Population-based study utilizing the Clinical Practice Research Datalink (CPRD) primary care database, which contains patients registered with practices contributing data to the CPRD between 1998 and 2018 (N = 6,786,212 in 1998 to N = 9,594,598 in 2018). 65,665 patients had a diagnosis of autism recorded in 2018. Time trend of new (incident) cases of autism diagnosis was plotted for all, and stratified by gender, diagnostic subtypes, and developmental stage: infancy and preschool, 0-5 years old; childhood, 6-11 years old; adolescence, 12-19 years old; adults, over 19 years old. RESULTS: There was a 787%, exponential increase in recorded incidence of autism diagnoses between 1998 and 2018; R2 = 0.98, exponentiated coefficient = 1.07, 95% CI [1.06, 1.08], p < .001. The increase in diagnoses was greater for females than males (exponentiated interaction coefficient = 1.02, 95% CI [1.01, 1.03], p < .001) and moderated by age band, with the greatest rises in diagnostic incidence among adults (exponentiated interaction coefficient = 1.06, 95% CI [1.04, 1.07], p < .001). CONCLUSIONS: Increases could be due to growth in prevalence or, more likely, increased reporting and application of diagnosis. Rising diagnosis among adults, females and higher functioning individuals suggest augmented recognition underpins these changes.

Autism diagnosis as a social process.

LAY ABSTRACT: When a child or adult is referred for an autism diagnosis, clinicians from different backgrounds work together to make a diagnostic decision. A few studies have asked clinicians in interview how they feel about diagnosis and what the challenges are. We interviewed clinicians in child and adult assessment services in England, and from different professional backgrounds, about the challenges of autism diagnosis and the factors that might influence the assessment process. We found that there were a number of challenges in autism diagnosis, especially when someone coming for diagnosis was considered to be near the diagnostic threshold. Clinicians told us that making a diagnosis was like creating a 'narrative': looking at many different factors that told a story about a person, rather than just looking at the results of diagnostic tests. Clinicians do not always agree with the results of those tests and have to use their specialist clinical judgement to make decisions. Clinicians were concerned about the amount of time people have to wait for an autism assessment, and the resulting pressure on the assessment process. The findings of this work can help us to understand how diagnosis happens and consider ways in which it can be improved for adults, children and families coming for assessment, as well as clinicians.

Factors in Psychiatric Admissions: Before and During the Covid-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has impacted community mental health, but the effect on psychiatric admissions is unknown. We investigated factors contributing to acute psychiatric admissions, and whether this changed during the first UK lockdown. METHOD: A retrospective case-note review study with an exploratory mixed-methods design to examine factors for psychiatric admissions following the first UK 2020 lockdown compared to the same time periods in 2019 and 2018. RESULTS: Themes of psychopathology, risk, social stressors, community treatment issues, and physical health concerns were generated. The mean number of codes per case was 6.19 (s . d. = 2.43), with a mean number of categories per case of 3.73, (s. d. = 0.98). Changes in routines and isolation were common factors in the study year; accommodation and substance abuse were more prominent in the control year. Relationship stressors featured strongly in both groups. There were significantly more women (χ2(1, N = 98) = 20.80, p < 0.00001) and older adults (χ2(1, N = 98) = 8.61, p = 0.0033) in the study group than the control. Single people, compared to those in a relationship (χ2(1, N = 45) = 4.46, p = 0.035), and people with affective disorders compared to psychotic disorders ((χ2(1, N = 28) = 5.19, p = 0.023), were more likely to have a COVID-19 related admission factor. CONCLUSIONS: Early stages of the COVID-19 pandemic amplified pre-existing psychosocial vulnerabilities with a disproportionate psychiatric admissions impact on the mental health of women, older adults and those with affective disorders.

'Not at the diagnosis point': Dealing with contradiction in autism assessment teams.

Social science literature has documented how the concept of diagnosis can be seen as an interactive process, imbued with uncertainty and contradiction, which undermines a straightforward notion of diagnosis as a way to identify underlying biological problems that cause disease. We contribute to this body of work by examining the process of resolving contradiction in autism diagnosis for adults and adolescents. Autism is a useful case study as diagnosis can be a complex and protracted process due to the heterogeneity of symptoms and the necessity to interpret behaviours that may be ambiguous. We audio-recorded and transcribed 18 specialist clinical assessment meetings in four teams in England, covering 88 cases in two adult, one child and one adolescent (14+) setting. We undertook a qualitative analysis of discursive processes and narrative case-building structure utilised by clinicians to counteract contradiction.We identified a three-part interactional pattern which allows clinicians to forward evidence for and against a diagnosis, facilitates their collaborative decision-making process and enables them to build a plausible narrative which accounts for the diagnostic decision. Pragmatism was found to operate as a strategy to help assign diagnosis within a condition which, diagnostically, is permeated by uncertainty and contradiction. Resolution of contradiction from different aspects of the assessment serves to create a narratively-coherent, intelligible clinical entity that is autism.

Drawing a line in the sand: affect and testimony in autism assessment teams in the UK.

Diagnosis of autism in the UK is generally made within a multidisciplinary team setting and is primarily based on observation and clinical interview. We examined how clinicians diagnose autism in practice by observing post-assessment meetings in specialist autism teams. Eighteen meetings across four teams based in the south of England and covering 88 cases were audio-recorded, transcribed and analysed using thematic analysis. We drew out two themes, related to the way in which clinicians expressed their specialist disciplinary knowledge to come to diagnostic consensus: Feeling Autism in the Encounter; and Evaluating Testimonies of Non-present Actors. We show how clinicians produce objective accounts through their situated practices and perform diagnosis as an act of interpretation, affect and evaluation to meet the institutional demands of the diagnostic setting. Our study contributes to our understanding of how diagnosis is accomplished in practice.

Parents' postnatal depressive symptoms and their children's academic attainment at 16 years: Pathways of risk transmission.

The aim of the study was to examine whether parents' increased postnatal depressive symptoms predicted children's academic attainment over time and whether the parent-child relationship, children's prior academic attainment, and mental health mediated this association. We conducted secondary analyses on the Avon Longitudinal Study of Parents and Children data (12,607 mothers, 9,456 fathers). Each parent completed the Edinburgh-Postnatal Depression Scale at 8 weeks after the child's birth (predictor) and a questionnaire about the mother-child and father-child relationship at 7 years and 1 month (mediator). The children's mental health problems were assessed with the teacher version of the Strengths and Difficulties Questionnaire at 10-11 years (mediator). We used data on the children's academic attainment on UK Key Stage 1 (5-7 years; mediator) and Key Stage 4 (General Certificate of Secondary Education 16 years) (outcome). We adjusted for the parents' education, and child gender and cognitive ability. The results revealed that parents' depressive symptoms at 8 weeks predicted lower academic performance in children at 16 years. Mothers' postnatal depressive symptoms had an indirect effect through children's mental health problems on academic outcomes at 16 years via negative mother-child relationship, and prior academic attainment. There was a significant negative indirect effect of fathers' postnatal depressive symptoms on academic attainment at 16 years via negative father-child relationship on child mental health. The findings suggest that the family environment (parental mental health and parent-child relationship) and children's mental health should be potential targets for support programmes for children of depressed parents.

Is disclosing an autism spectrum disorder in school associated with reduced stigmatization?

Evidence suggests disclosing an autism diagnosis is associated with reduced stigmatization for autistic adults. However, it is unknown whether this is true for autistic adolescents. We used a vignette-and-questionnaire design to study stigmatizing attitudes with adolescents (aged 11-12 and 14-16 years, total N = 250) in a UK school. We investigated the effect of disclosing that a fictional adolescent had an autism diagnosis on stigmatizing attitudes of peers by testing the effect of disclosure of diagnosis on the social and emotional distance pupils wanted to maintain from the autistic adolescent. We also tested the effect of disclosure on peers' assessment of the adolescent's responsibility for their own behaviour. We checked to see if the effects were moderated by gender and age-group. Disclosing autism did not affect the social and emotional distance peers wanted to maintain from the autistic adolescent, but was associated with significant reduction in personal responsibility attributed to the adolescent's behaviour. Boys attributed more personal responsibility to the autistic adolescent than girls, but this gender effect was reduced when autism was disclosed. These findings suggest that disclosing autism to other pupils may be of limited use in reducing stigmatization by peers in UK schools.

Deconstructing Diagnosis: Four Commentaries on a Diagnostic Tool to Assess Individuals for Autism Spectrum Disorders.

Diagnostic assessment tools are widely used instruments in research and clinical practice to assess and evaluate autism symptoms for both children and adults. These tools typically involve observing the child or adult under assessment, and rating their behaviour for signs or so-called symptoms of autism. In order to examine how autism diagnosis is constructed, how diagnostic tools are positioned, and how their trainings are delivered, we paid for four places on a training course for a diagnostic tool. We asked the attendees (the first four authors) to each produce a critical commentary about their impressions of the training and the diagnostic tool itself. Their commentaries are published here in full. They have various disciplinary backgrounds: one is a social scientist, one an ethicist, one a psychiatrist, and one a developmental psychologist. The commentaries are followed by a concluding section that summarises the themes, commonalities, and differences between their accounts of the training course. Authors differed as to whether the diagnostic tool is a useful and necessary endeavour. Nevertheless, all critiqued of the tool's lack of transparency, recognizing context, emotion, and differences in interpretation and power imbalances as playing an unidentified role in the assessment process. Based on this project, we recommend that training for raters for such tools should be accessible to a wider group of people, and incorporate more explicit recognition of its own limitations and commercialisation.

Mapping the Autistic Advantage from the Accounts of Adults Diagnosed with Autism: A Qualitative Study.

Background: Autism has been associated with specific cognitive strengths. Strengths and weaknesses have traditionally been conceptualized as dichotomous. Methods: We conducted 28 semi-structured interviews with autistic adults. Maximum variation sampling was used to ensure diversity in relation to support needs. We asked which personal traits adults attributed to their autism, and how these have helped in the workplace, in relationships, and beyond. Data were collected in two stages. Responses were analyzed using content and thematic techniques. Results: The ability to hyperfocus, attention to detail, good memory, and creativity were the most frequently described traits. Participants also described specific qualities relating to social interaction, such as honesty, loyalty, and empathy for animals or for other autistic people. In thematic analysis we found that traits associated with autism could be experienced either as advantageous or disadvantageous dependent on moderating influences. Moderating influences included the social context in which behaviors occurred, the ability to control behaviors, and the extent to which traits were expressed. Conclusions: Separating autistic strengths from weaknesses may be a false dichotomy if traits cannot be isolated as separate constructs of strengths or deficits. If attempts to isolate problematic traits from advantageous traits are ill conceived, there may be implications for interventions that have reduction in autistic traits as a primary outcome measure. LAY SUMMARY: Why was this study done?: The study was done to find out what autistic adults could tell us about their own abilities. They told us about their abilities and how these abilities had helped them in their everyday lives: at work, in their relationships with other people, and at home.What was the purpose of this study?: To tell a story about what aspects of their autism adults thought were of benefit, when going about their daily lives.What did the researchers do?: The researchers interviewed 24 adults who had an autism diagnosis. Some lived in residential care and others lived alone in rented apartments. Some people were interviewed twice. Most people said they enjoyed the experience of being interviewed.Once the interviews were done, they were typed up and the researchers tried to figure out what were the common themes over all the stories they had heard. They thought about the themes, then did some more interviews with autistic adults to check they were on the right lines. After discussing them, they wrote the story.What were the results of the study?: Hyper focus, attention to detail, and the ability to remember were the abilities that autistic people said benefitted them most often. But autistic adults who were interviewed said although their autistic traits were sometimes helpful, at other times they hindered their progress. So the same trait might be useful in some circumstances and unhelpful in other situations. For example, hypersensitivity led one person to enjoy nature, but was difficult to cope with in crowded streets. The study highlights this interchangeability.What do these findings add to what was already known?: Before, autistic people were known to have both strengths and challenges, but studies tended to separate autistic strengths and weaknesses as different things. We theorize that some traits are expressed as behaviors that may serve to improve or hinder autistic people's progress, but this depends on their situation (context).What are potential weaknesses in the study?: Because the researchers used interviews, they did not include any nonverbal autistic people in the study.How will these findings help autistic adults now or in the future?: It could be useful to think about autism in a way that does not focus on deficits and this study will help us to do that. Plus, if an autistic trait can give people an advantage or a disadvantage, interventions aimed at reducing autistic behaviors might risk dampening advantageous traits as they seek to help with difficulties. That means, autistic adults and children might lose useful abilities when and if they are treated for traits that can also be problematic. The researchers hope their study will lead to more discussion about these types of ideas.

Selection bias on intellectual ability in autism research: a cross-sectional review and meta-analysis.

Background: Current global estimates suggest the proportion of the population with autism spectrum disorder (ASD) who have intellectual disability (ID) is approximately 50%. Our objective was to ascertain the existence of selection bias due to under-inclusion of populations with ID across all fields of autism research. A sub-goal was to evaluate inconsistencies in reporting of findings. Methods: This review covers all original research published in 2016 in autism-specific journals with an impact factor greater than 3. Across 301 included studies, 100,245 participants had ASD. A random effects meta-analysis was used to estimate the proportion of participants without ID. Selection bias was defined as where more than 75% of participants did not have ID. Results: Meta-analysis estimated 94% of all participants identified as being on the autism spectrum in the studies reviewed did not have ID (95% CI 0.91-0.97). Eight out of ten studies demonstrated selection bias against participants with ID. The reporting of participant characteristics was generally poor: information about participants' intellectual ability was absent in 38% of studies (n = 114). Where there was selection bias on ID, only 31% of studies mentioned lack of generalisability as a limitation. Conclusions: We found selection bias against ID throughout all fields of autism research. We recommend transparent reporting about ID and strategies for inclusion for this much marginalised group.

'People should be allowed to do what they like': Autistic adults' views and experiences of stimming.

'Stereotyped or repetitive motor movements' are characterised as core features in the diagnosis of autism, yet many autistic adults (and the neurodiversity movement) have reclaimed them as 'stimming'. Supported by a growing body of scientific research, autistic adults argue that these behaviours may serve as useful coping mechanisms, yet little research has examined stimming from the perspective of autistic adults. Through interviews and focus groups, we asked 32 autistic adults to share their perceptions and experiences of stimming, including the reasons they stim, any value doing so may hold for them and their perceptions of others' reactions to stimming. Using thematic analysis, we identified two themes: stimming as (1) a self-regulatory mechanism and (2) lacking in social acceptance, but can become accepted through understanding. Autistic adults highlighted the importance of stimming as an adaptive mechanism that helps them to soothe or communicate intense emotions or thoughts and thus objected to treatment that aims to eliminate the behaviour.

The agreement between the referrer, practitioner and research diagnosis of autistic spectrum conditions among children attending child and adolescent mental health services.

We aimed to explore the levels of agreement about the diagnoses of Autistic Spectrum Conditions between the referrer, CAMHS practitioner and a research diagnosis, as well as the stability of the practitioner's diagnosis over time in a secondary analysis of data from 302 children attending two Child and Adolescent Mental Health Services over two years. Kappa coefficient was used to assess the agreement between the referrer and research diagnosis. Kendall's tau b coefficient was used to assess the agreement between the practitioner and the research diagnosis assigned using the Development and Well-Being Assessment, as well as the agreement between the referrer's indication of presenting problems and the practitioner diagnosis. Diagnostic stability was explored in children with and without a research diagnosis of Autistic Spectrum Condition. There was a moderate level of agreement between the referrer and research diagnosis (Kappa = 0.51) and between practitioner's and research diagnosis (Kendall's tau = 0.60) at baseline, which reduced over the subsequent two years. Agreement between the referrer and practitioner's diagnosis at baseline was fair (Kendall's tau = 0.36).The greatest diagnostic instability occurred among children who practitioners considered to have possible Autistic Spectrum Conditions but who did not meet research diagnostic criteria. Further studies could explore the approaches used by practitioners to reach diagnoses and the impact these may have on diagnostic stability in Autistic Spectrum Conditions. Standardised assessment using a clinically rated diagnostic framework has a potential role as an adjunct to standard clinical care and might be particularly useful where practitioners are uncertain.

Clinical practice guidelines for diagnosis of autism spectrum disorder in adults and children in the UK: a narrative review.

BACKGROUND: Research suggests that diagnostic procedures for Autism Spectrum Disorder are not consistent across practice and that diagnostic rates can be affected by contextual and social drivers. The purpose of this review was to consider how the content of clinical practice guidelines shapes diagnoses of Autism Spectrum Disorder in the UK; and investigate where, within those guidelines, social factors and influences are considered. METHODS: We electronically searched multiple databases (NICE Evidence Base; TRIP; Social Policy and Practice; US National Guidelines Clearinghouse; HMIC; The Cochrane Library; Embase; Global health; Ovid; PsychARTICLES; PsychINFO) and relevant web sources (government, professional and regional NHS websites) for clinical practice guidelines. We extracted details of key diagnostic elements such as assessment process and diagnostic tools. A qualitative narrative analysis was conducted to identify social factors and influences. RESULTS: Twenty-one documents were found and analysed. Guidelines varied in recommendations for use of diagnostic tools and assessment procedures. Although multidisciplinary assessment was identified as the 'ideal' assessment, some guidelines suggested in practice one experienced healthcare professional was sufficient. Social factors in operational, interactional and contextual areas added complexity to guidelines but there were few concrete recommendations as to how these factors should be operationalized for best diagnostic outcomes. CONCLUSION: Although individual guidelines appeared to present a coherent and systematic assessment process, they varied enough in their recommendations to make the choices available to healthcare professionals particularly complex and confusing. We recommend a more explicit acknowledgement of social factors in clinical practice guidelines with advice about how they should be managed and operationalised to enable more consistency of practice and transparency for those coming for diagnosis.

Maternal thyroid hormone insufficiency during pregnancy and risk of neurodevelopmental disorders in offspring: A systematic review and meta-analysis.

BACKGROUND: In the last 2 decades, several studies have examined the association between maternal thyroid hormone insufficiency during pregnancy and neurodevelopmental disorders in children and shown conflicting results. AIM: This systematic review aimed to assess the evidence for an association between maternal thyroid hormone insufficiency during pregnancy and neurodevelopmental disorders in children. We also sought to assess whether levothyroxine treatment for maternal thyroid hormone insufficiency improves child neurodevelopment outcomes. METHODS: We performed systematic literature searches in MEDLINE, EMBASE, PSYCinfo, CINAHL, AMED, BNI, Cochrane, Scopus, Web of Science, GreyLit, Grey Source and Open Grey (latest search: March 2017). We also conducted targeted web searching and performed forwards and backwards citation chasing. Meta-analyses of eligible studies were carried out using the random-effects model. RESULTS: We identified 39 eligible articles (37 observational studies and 2 randomized controlled trials [RCT]). Meta-analysis showed that maternal subclinical hypothyroidism and hypothyroxinaemia are associated with indicators of intellectual disability in offspring (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.20 to 3.83, P = .01, and OR 1.63, 95% CI 1.03 to 2.56, P = .04, respectively). Maternal subclinical hypothyroidism and hypothyroxinaemia were not associated with attention deficit hyperactivity disorder, and their effect on the risk of autism in offspring was unclear. Meta-analysis of RCTs showed no evidence that levothyroxine treatment for maternal hypothyroxinaemia or subclinical hypothyroidism reduces the incidence of low intelligence quotient in offspring. LIMITATIONS: Although studies were generally of good quality, there was evidence of heterogeneity between the included observational studies (I2 72%-79%). CONCLUSION: Maternal hypothyroxinaemia and subclinical hypothyroidism may be associated with intellectual disability in offspring. Currently, there is no evidence that levothyroxine treatment, when initiated 8- to 20-week gestation (mostly between 12 and 17 weeks), for mild maternal thyroid hormone insufficiency during pregnancy reduces intellectual disability in offspring.

The relationship between financial difficulty and childhood symptoms of attention deficit/hyperactivity disorder: a UK longitudinal cohort study.

PURPOSE: Attention deficit/hyperactivity disorder (ADHD) is associated with socioeconomic status (SES), in that children who grow up in low SES families are at an increased risk of ADHD symptoms and diagnosis. The current study explores whether different levels of ADHD symptoms are associated with prior changes in the SES facet of financial difficulty. METHODS: Using the Avon Longitudinal Study of Parents and Children (ALSPAC), we examined symptoms of ADHD measured by the Strengths and Difficulties Questionnaire (SDQ) hyperactivity subscale in relation to parent-reported changes in financial difficulty, grouped into four repeated measures at four time points across childhood; (n = 6416). A multilevel mixed-effects linear regression model with an unstructured covariance matrix was used to test whether different patterns of financial difficulty were associated with subsequent changes in ADHD symptoms. RESULTS: Families who had no financial difficulty had children with a lower average ADHD symptom score than groups who experienced financial difficulty. Children whose families stayed in financial difficulty had higher mean ADHD symptom scores than all other groups (No difficulty mean SDQ hyperactivity 3.14, 95% CI 3.07, 3.21, In difficulty mean SDQ hyperactivity 3.39, 95% CI 3.28, 3.45, p < 0.001). Increasing or decreasing financial difficulty predicted mean symptom scores lower than those of the in difficulty group and higher than the no difficulty group. CONCLUSIONS: Our findings contribute to the building evidence that SES may influence the severity and/or impairment associated with the symptoms of ADHD, however the effects of SES are small and have limited clinical significance.

Selective patient and public involvement: The promise and perils of pharmaceutical intervention for autism.

BACKGROUND: Guidelines suggest the patient community should be consulted from the outset when designing and implementing basic biomedical research, but such patient communities may include conflicting views. We examined how engagement occurred in one such instance. OBJECTIVE: Our objective was to scrutinize patient and public involvement (PPI) by a pan-European biomedical consortium working to develop drugs to treat autism. We aimed to use this as an example to illustrate how PPI has been utilized in biomedical research. SETTING, PARTICIPANTS AND ANALYSIS: Two public events, one in the UK and one in Denmark were conducted as part of the consortium's on-going PPI activities in 2014 and 2015. Sixty-six individuals submitted written comments on the consortium's research after these events. The textual data produced were analysed using a thematic approach. Approximately 71% of respondents reported themselves to be adults on the autism spectrum or parents of children with autism. RESULTS: The themes identified illustrated major differences between some community concerns and the biomedical research agenda. While treating autism per se. was seen as problematic by some, treating specific co-occurring problems was seen as helpful in some circumstances. The biomedical consortium selected PPI with a limited user viewpoint at its outset and more widely once basic research was on-going. DISCUSSION: This case illustrates what we term "selective PPI" where only a sympathetic and/or limited patient viewpoint is included. Findings highlight the perils of using selective PPI to legitimise scientific endeavours, and the possibilities for constructive dialogue.

Parental depressive symptoms, children's emotional and behavioural problems, and parents' expressed emotion-Critical and positive comments.

This longitudinal study examined whether mothers' and fathers' depressive symptoms predict, independently and interactively, children's emotional and behavioural problems. It also examined bi-directional associations between parents' expressed emotion constituents (parents' child-directed positive and critical comments) and children's emotional and behavioural problems. At time 1, the sample consisted of 160 families in which 50 mothers and 40 fathers had depression according to the Structured Clinical Interview for DSM-IV. Children's mean age at Time 1 was 3.9 years (SD = 0.8). Families (n = 106) were followed up approximately 16 months later (Time 2). Expressed emotion constituents were assessed using the Preschool Five Minute Speech Sample. In total, 144 mothers and 158 fathers at Time 1 and 93 mothers and 105 fathers at Time 2 provided speech samples. Fathers' depressive symptoms were concurrently associated with more child emotional problems when mothers had higher levels of depressive symptoms. When controlling for important confounders (children's gender, baseline problems, mothers' depressive symptoms and parents' education and age), fathers' depressive symptoms independently predicted higher levels of emotional and behavioural problems in their children over time. There was limited evidence for a bi-directional relationship between fathers' positive comments and change in children's behavioural problems over time. Unexpectedly, there were no bi-directional associations between parents' critical comments and children's outcomes. We conclude that the study provides evidence to support a whole family approach to prevention and intervention strategies for children's mental health and parental depression.