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Publisher Summary Depression is part of a category of more common, complex disorders where several or many genes are implicated, each of which has only a modest effect on its own but collectively … Expand. Coming to terms with the terms of risk. View 2 excerpts, references background.
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Highly Influential. View 8 excerpts, references background. Relation between economic disadvantage and psychosocial morbidity in children. View 1 excerpt, references background. Externalizing symptoms included subscales for oppositional defiance, conduct problems, inattention, impulsivity, overt aggression, and relational aggression. The first goal was to develop a model of third-grade symptom severity. To select an appropriate cut point to define the subgroups, we used parental education because it is more easily interpreted than the SES composite.
We initially defined subgroups where 1 neither parent, 2 only 1 parent, or 3 both parents had a college education, then compared the regression lines predicting symptom severity from preschool child behavioral dysregulation Figure 1.
To illustrate the within-time analyses step 3 , we provide a detailed example for the preschool period Figure 2. Within the domain of child emotions and behaviors, maternal report and observations of child approach-related negativity were proxies to maternal report and observations respectively of child behavioral dysregulation and were omitted from further analyses; and maternal report and observed child behavioral dysregulation were overlapping and combined into a single measure.
Within the family domain, maximum parental distress overlapped with maternal distress. This was the only situation in which overlapping factors contained the same variable maternal distress ; because maternal distress was more strongly associated with the outcome, we selected it and omitted maximum parental distress from further analysis.
Next, in the across-domain analyses, observed maternal negativity toward the child was omitted because it was proxy to child behavioral dysregulation. Maternal distress and child behavioral dysregulation were overlapping and were combined into a final composite variable tapping maternal and child distress and dysregulation.
Within the school transition period, we followed a similar process. All within-time analyses step 3 are summarized in Table 4 , which shows the original 13 identified risk factors and distinguishes those demonstrated to be proxies omitted from further analyses or overlapping combined , from the final 3 independent risk factors that were included in the across-time analyses.
The results of the across-time analyses step 4 are shown in Figure 3. Maternal distress in the infancy period leads to maternal and child distress and dysregulation in preschool, which is partially mediated by child social and academic impairment during the school transition. Using the same principles as described above, within-time analyses were conducted to define the risk factors within each time period as proxies, overlapping, or independent step 3. The results are summarized in Table 5.
The results of the across-time analyses step 4 are shown in Figure 4. Maternal lifetime history of depression, maximum parental depression symptoms, and maternal family history of psychopathology were each partially mediated by family distress in infancy; and the latter 2 prenatal factors were totally mediated by maternal and child distress and dysregulation in preschool.
The results for symptom directionality were quite simple. The within-time analyses step 3 showed that there were no proxy risk factors, and the only overlapping risk factors were the maternal report and observed measures of child withdrawal-related negativity in preschool, which were combined. The results of the across-time analyses step 4 are shown in Figure 5.
Child sex high score, girls was partially mediated by child prosocial behaviors during the school transition. Child withdrawal-related negativity in preschool was partially mediated by child social inhibition during the school transition. This is an exploratory study intended to generate hypotheses to be tested in future longitudinal studies of this and other populations of children about the paths leading to the severity and directionality of third-grade mental health symptoms.
Of the multitude of risk factors in the literature, represented herein by 56 potential risk factors, few constructs are identified in the model as risk factors for symptom severity. This might be because many previously reported factors are not reproducible, and those that are reproducible are often proxy or overlapping to others, as illustrated herein.
The results generate the hypothesis that family SES defines different pathways to children's later symptom severity ie, it is a moderator. Previous studies have shown associations of SES, child or contextual factors, and mental health outcomes. On the other hand, being born into a high SES family may be protective as shown by mean differences in the symptom severity levels of the 2 SES subgroups but also defines a different mediational chain beginning prenatally with parental and family histories of psychopathology, which are often regarded as genetic risk indicators that would identify a subset of particularly vulnerable children.
The results also contribute to the 2 large literatures on internalizing problems and associations with child temperament 19 , 73 , 74 and sex 12 , 75 , 76 by generating the hypothesis that these risk factors define distinct pathways to the internalizing vs externalizing nature of children's later symptoms.
One pathway to a preponderance of internalizing symptoms begins with temperamentally inhibited preschoolers who, when faced with the social challenges inherent in the transition to primary school, exhibit socially reticent, withdrawn, and anxious behaviors associated with the development of internalizing disorders.
The second pathway is defined by girls who express more prosocial behaviors than boys during the school transition, suggesting that symptom directionality is partly the product of biological sex and socially constrained gender roles. Importantly, the distinction of symptom severity and directionality clarifies some of the ambiguities in studies that have focused on internalizing or externalizing problems.
The fact that only child temperament and sex were found to be major risk factors for symptom directionality supports our earlier contention that the risk factors for childhood internalizing and externalizing problems may be much the same.
These 2 broad-band problem domains are highly comorbid during childhood and, thus, finding common risk factors is expected. However, more specific risk factors might be identified later in childhood and adolescence when comorbid symptom patterns tend to crystallize into distinct psychiatric disorders. The results have 2 major implications for prevention and treatment strategies.
First, if some of the risk factors for symptom severity are eventually demonstrated to be causal, preventive interventions focused on those factors might prevent or reduce both internalizing and externalizing problems. To show that some of the risk factors are causal, preventive interventions ideally would be directed to those identified at high risk.
The interventions would affect the risk factor in a random subset of high-risk children, who would be compared with control subjects to demonstrate whether the risk factor is causal. Furthermore, social and academic impairment during the school transition may be prodromal expressions of subsequent symptoms.
Similarly, for symptom directionality, social inhibition during the school transition may be a prodromal expression of subsequent internalizing symptoms. This suggests that the school transition period may be too late for effective preventive interventions. Even so, interventions targeted at these child factors might prevent the emergence of later symptoms. It is important to note that what one learns in exploratory data analysis is determined by the outcome measure and the criteria set for the analysis.
If our choices were changed, the results might be different. We chose to use a dimensional rather than categorical outcome measure. It has long been known that dichotomizing dimensional outcomes entails a major reduction of power and precision.
However, for exploratory data analysis, dimensional measures are more sensitive to individual differences and more likely to detect true structural relationships. A related issue is the long-standing concern about the difficulty of detecting moderators. On the one hand, the presence of moderators would explain the low potency of risk factors found in many studies and the failure to understand who needs intervention, when, and how.
On the other hand, detecting a moderator requires splitting the sample, which decreases power to detect risk factors and especially interactions between risk factors, thereby impairing efforts to design appropriate interventions. There are 2 important limitations of this study.
First, the possibility of a sampling bias within this population, and the nonrepresentativeness of this population of the larger US population, must be kept in mind when interpreting the findings. This sample represents largely middle-class, white, and—at the outset—intact families in 2 Midwestern cities.
Nevertheless, even here, the SES gradient is of major importance. Furthermore, this is a population in which it would be expected that potent risk factors for childhood psychiatric symptoms would be particularly hard to find. Consequently, to try such exploratory approaches, this is an ideal population to study. However, we emphasize that the implications of the findings for other populations eg, higher risk and lower income are unclear.
Thus, it is our hope that the hypotheses generated herein will stimulate the hypothesis-testing studies in other populations that are critical for the development of effective prevention and treatment strategies for childhood mental health problems. Second, as with all studies, the results are limited by the measures available.
The measures used may not always be optimal eg, the assessment of child and parental mental health based on rating scales , and there are undoubtedly other risk factors not measured.
Correspondence: Marilyn J. Submitted for Publication: September 8, ; final revision received February 14, ; accepted February 23, Hyde, PhD principal investigator, , and Marilyn J. Klein, PhD, Nancy A. Smider, PhD, and Deborah L. Vandell, PhD coinvestigators. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue.
Figure 1. View Large Download. Table 1. Am Psychol ; Google Scholar Crossref. Handbook of Child Psychology. Goodman SHGotlib IH Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission.
Hinshaw SP Process, mechanism, and explanation related to externalizing behavior in developmental psychopathology. Moffitt TECaspi A Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Crick NRZahn-Waxler C The development of psychopathology in females and males: current progress and future challenges.
Raine A Annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. Not everyone who is exposed to a risk factor will have an adverse outcome.
Knowledge related to the risks for relapse is not yet well developed and it is important to realise the limitations of our understanding in this area. Furthermore, the nature of risk varies in terms of the element of choice or voluntariness of the risk factors identified, which affects the extent to which the risk is amenable to intervention.
The Canadian Association of Gerontology see Health Canada p8 identifies personal risks on a continuum of voluntary choice as follows: Risk pursued as opportunity Freely accepted risk Reluctantly assumed risk Risk with little or no choice Thirdly, Monograph states that the process of identifying risk can be biased. Risk is not a neutral concept; decisions regarding what are acceptable or unacceptable levels of risk are subjective.
The process of ascribing risk can be disempowering for consumers, as the assessment of risk factors is often carried out by services. Asking people themselves what is important for their wellbeing can generate factors very different to those determined by a service provider. Interventions can be paternalistic and at odds with the concepts of consumer empowerment and participation. You can put too much emphasis on relapse prevention and there's the risk of trying to be too overprotective; you can highlight vulnerability to the extent that it kind of restricts people's sense of wellbeing.
Addressing a single risk factor or having a short-term orientation to prevention is likely to be ineffective. These types of simplistic approaches are all too common and derive from and underlie the fragmented, sector-specific nature of many services. Structural barriers can hinder intersectoral approaches and impede more multi-focused, holistic and intersectoral prevention interventions.
If risks are improperly identified, interventions can be targeted at the wrong factors. At best such interventions may be ineffective and a waste of scarce resources; at worst they may exacerbate other risk factors. An example of an intervention that may increase risk is the premature removal of children from their families in response to perceived risk and placing them in foster care or institutions. The stolen generation of Aboriginal children resulted from a biased, misguided, paternalistic and racist decision to remove part-Aboriginal children from the 'risks' associated with growing up within Aboriginal communities and, instead, provide them with the 'benefits' of being assimilated into the 'dominant' culture.
The disastrous and multi-generational outcomes of this intervention are now evident. The overzealous application of a risk approach is all too well understood by parents who have mental illness. These people risk the removal of their children when they become acutely unwell and then may have difficulty getting them back once they are well again. Top of page DOCS doesn't consider mental illness, it's outside of their Act, if they get involved the children just disappear.
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