Three-year course of behavioral/emotional problems in a national sample of 4- to 16-year-olds: I. Agreement among informants

Specificity of relations between adolescents’ cognitive emotion regulation strategies and Internalizing and Externalizing psychopathology

OBJECTIVE

Of the study was to examine the extent to which cognitive emotion regulation strategies were 'common determinants' of Internalizing and Externalizing problems and/or 'specific determinants' distinguishing one problem category from the other.

METHOD

The sample comprised 271 12- to 18-year-old secondary school students. Internalizing and Externalizing problems were measured by the Youth Self-Report (YSR) and Cognitive Emotion Regulation Strategies were measured by the Cognitive Emotion Regulation Questionnaire (CERQ), in a cross-sectional design.

RESULTS

First, adolescents with Internalizing problems, Externalizing problems, comorbid Internalizing and Externalizing problems and a control group were compared on their specific cognitive emotion regulation strategies. Results showed that adolescents with Internalizing problems (both pure and comorbid) scored significantly higher on the cognitive emotion regulation strategies of self-blame and rumination than those with Externalizing (pure) problems or the control group. Unique relationships between the separate cognitive strategies and Internalizing and Externalizing problems were tested by means of Multiple Regression Analyses. Specific relationships were found between Internalizing problems and self-blame, rumination and positive reappraisal and between Externalizing problems and positive refocusing. No 'common' correlates were found.

CONCLUSIONS

Theoretical models designed for the prediction of Internalizing problems might not simply be used for the prediction of Externalizing problems. Different (cognitive) intervention strategies should be used for adolescents with Internalizing problems and Externalizing problems.

Chemical dependency and psychiatric services for adolescents in private managed care: implications for outcomes

BACKGROUND

Many adolescents with alcohol and drug problems have mental health comorbidities. The literature suggests that patients entering chemical dependency (CD) treatment with co-occurring problems have less successful outcomes, including treatment dropout and relapse. We examined the impact of psychiatric services on treatment initiation, retention, and alcohol and drug abstinence outcomes for adolescents in CD treatment.

METHODS

Participants were 419 adolescents aged 12-18 years who were seeking treatment at four CD programs of a nonprofit, managed care, group model health system and a parent or guardian for each adolescent. We surveyed participants at intake and 6 months and examined clinical and administrative data on diagnoses and CD and psychiatric utilization. Six-month response rates were 91% for adolescents and 93% for parents.

RESULTS

Fifty-five percent of the patients with treatment intakes had at least one psychiatric diagnosis in addition to a substance use disorder. Compared with matched controls, patients with CD intakes had higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder, and conduct disorder including oppositional defiant disorder. Thirty-one percent of the full sample had psychiatric visits in the 6 months after intake; among those with a psychiatric diagnosis, 54% had a psychiatric visit. Girls and those with higher Youth Self-Report internalizing scores were more likely to have a psychiatric visit (OR = 2.27, p < 0.001 and OR = 1.05, p < 0.0001, respectively). Adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving these services (OR = 1.57, 95% CI = 0.98-2.5) and more likely to be alcohol abstinent (OR = 1.68, 95% CI = 1.00-2.85). Those adolescents at colocated clinics had higher odds of abstinence from both alcohol and drugs (OR = 1.57, 95% CI = 1.03-2.39) and drugs (OR = 1.84, 95% CI = 1.87-2.85) and of returning after intake to initiate CD treatment (OR = 2.28, 95% CI = 1.44-3.61, p < 0.001) than others.

CONCLUSIONS

Our results demonstrate the need for psychiatric treatment of adolescents in CD treatment and highlight the importance of their receiving such services.

Contributions of Genes and Environments to Stability and Change in Externalizing and Internalizing Problems During Elementary and Middle School

We examined longitudinally collected behavioral reports by teachers on a unique twin sample at the ages of 7, 8, 9, 10, 11, and 12 years. As twin and adoption studies implicate the role of genetic influence on behavioral problems found to be stable in epidemiological samples, the current study employs a developmental behavior genetic model to examine the extent to which genetic and environmental contributions to problem behaviors are stable and/or change during development. In this sample of 410 monozygotic (MZ) and 354 dizygotic (DZ) twins, MZ twins were rated as more similar than DZ twins on average. In general, boys were more frequently rated as displaying externalizing behaviors than were girls across each of the six observations, while girls' internalizing problems were found not to be significantly different from boys'. For both sexes, stability in externalizing problem behaviors was due to a single common genetic factor whose effects acted pleiotropically at each age in the presence of unique environmental influences that were transmitted from age-to-age. Change was largely due to uncorrelated age-specific non-shared environmental and additive genetic effects. Contributions to stability for internalizing problems were due to age-to-age transmission of earlier expressed genetic effects. Change for girls and boys internalizing problems were largely due to environmental experiences unique to siblings along with uncorrelated age-specific genetic effects. These results further inform the notion that individual environments are important factors in the etiology of problem behaviors, but suggest that heritable contributions to phenotypic stability are largely the same across middle childhood and early adolescence. Clinical implications of these findings are discussed.

Pathways to chemical dependency treatment for adolescents in an HMO

This study examines pathways to chemical dependency (CD) treatment for adolescents in a prepaid health plan, including factors influencing treatment referral and access. Data were collected from 419 adolescent CD treatment intakes ages 13 to 18 in a large, private health plan. The study examines predictors of referral from different sources and of mental health treatment prior to CD treatment. Referral patterns, problem severity, and psychiatric comorbidity differed by gender. Being male (p < .05) and higher scores on the Youth Self-Report (YSR) externalizing scale (p < .01) predicted a justice system referral. Using more types of substances predicted referral by medical and mental health providers (p < .05) and self-referral (p < .01). Higher YSR internalizing scores predicted referral from mental health (p < .01) and self-referral (p <.01). Being White versus African American (p < .05) or Latino (p < .01), older (p < .05), and having higher YSR internalizing scores (p < .05), a conduct disorder (p < .01), or a family member with a substance use problem (p < .01) predicted a mental health visit prior to CD intake. The findings raise questions regarding the role of health plans, clinicians, families, schools, and community agencies in referring and treating adolescents with substance use problems. They suggest that improved coordination of care may promote more integrated treatment practices, which could decrease substance use, mental health, and medical problem severity.

Tobacco and alcohol use as an explanation for the association between externalizing behavior and illicit drug use among delinquent adolescents

The prevalence and persistence of adolescent substance use and abuse is a national health issue, and substance use among adolescents is frequently comorbid with other psychiatric disorders. Most studies in this area utilize samples of middle or high school students or from inpatient settings. Less is known about substance use and psychiatric comorbidity among delinquent adolescents. The present study examined data from two cohorts of juvenile offenders collected over a 2-year period (n = 245, n = 299). Participants reported frequency of cigarette, alcohol, marijuana, and other substance use. Participants' parents completed a measure of behavior problems. Path analyses suggested that parental reports of externalizing problems were significantly related to self-reported substance use while parental reports of internalizing problems were not. Results also suggested that smoking and alcohol use act as mediators between externalizing problems and marijuana and other drug use. Although there were some mean differences by gender, the pattern of relationships amongst the variables did not differ by gender. Implications of the findings and future directions are discussed.

Agreement between parent and teacher reports on behavioral problems among chinese children

Research has consistently shown low to moderate correlations between parent and teacher reports on children's behavioral problems in Western samples. Little is known about the agreement between parent and teacher reports on behavioral problems among Chinese children. The authors examined the agreement on behavioral and emotional problems in a community sample of 2836 Chinese children aged 6 to 11 years from Mainland China. Children's behavioral problems were assessed by the Child Behavior Checklist (CBCL) and Teacher Report Form (TRF). Consistent with most previous studies in Western samples, our results indicated that parent-teacher agreement was low to moderate for attention, externalizing, and internalizing problems. Parent-teacher agreement was higher for attention and externalizing problems than for internalizing problems and decreased with increased behavioral problems. Child's gender, age, and academic performance and father's age were correlated with parent-teacher agreement on ratings of behavioral problems.

Maternal distress, child behaviour, and disclosure of psychosocial concerns to a paediatrician

BACKGROUND

Despite the availability of effective screening measures, primary care providers continue to fail to identify and manage many children with psychosocial problems. One of the best predictors of identification by a primary care physician is whether mothers disclose concerns about their child's psychosocial functioning to their child's physician. This study examined if maternal distress and child behaviour predicted whether mothers had and discussed concerns about their child's behaviour and emotions with paediatricians.

METHODS

Participants were 138 mothers who accompanied their 4-12-year-old children to a health supervision visit at an urban teaching hospital. Mothers completed a demographic questionnaire, the Pediatric Symptom Checklist, the Beck Depression Inventory, and an exit questionnaire. Results Logistic regression correctly classified 97.3% of mothers who did not disclose child problems. Only 34.5% of mothers who did disclose were correctly classified.

CONCLUSIONS

The results supported the hypothesis that mothers' psychosocial functioning is significantly related to concern about child behaviour and disclosure of concerns to the paediatrician. The inability of child behaviour and maternal functioning to predict which mothers were concerned and disclosed concerns supports the hypothesis that disclosure and identification of psychosocial problems in primary care is complex and requires a multifactor model.

Are foster parents reliable informants of children's behaviour problems?

BACKGROUND

Clinicians and researchers primarily measure behavioural and emotional problems of children in foster care from carer-report checklists. Yet the reliability of these reports is not adequately established. The present study examines one indicator of reliability for foster parent checklist reports: interrater agreement between foster parents and teachers.

METHODS

Estimates of interrater agreement of foster parent and teacher responses on the cross-informant scales of the Child Behaviour Checklist (CBCL) and the Teacher Report Form (TRF) were obtained for 47 children in long-term foster care, aged 5-11 years. The estimates included calculations of agreement for continuous measures of problem behaviour, as well as for categorical determinations of clinically significant behaviour.

RESULTS

Correlations of CBCL and TRF mean raw scores for the total problems (r = 0.71) and externalizing (r = 0.78) scales exceeded those described in prior studies of parent-teacher agreement, while correlation for internalizing scores (r = 0.23) was similar to that found previously. Teachers and foster parents demonstrated moderate to good agreement (kappa = 0.70-0.79) in identifying clinically significant total problems and externalizing problems, but poor agreement in identifying internalizing problems.

CONCLUSIONS

Discrepancies between these and prior findings are discussed. For children in long-term foster care, foster parents or teachers may be used as informants for total problems, externalizing problems, and social-attention-thought problems. The reliability of data on internalizing symptoms is less certain.

Three informants' reports of child behavior: parents, teachers, and foster parents

OBJECTIVE

To evaluate whether disagreements in reporting child behavior problems between biological parents and foster parents and teachers are related to depressive symptoms in the biological parent.

METHOD

Child Behavior Checklists and Teacher's Report Forms were completed by parents, foster parents, and teachers on 95 foster children between ages 5 and 16 during 1990-1991. Depressive symptoms in biological parents were assessed using the Center for Epidemiologic Studies Depression Scale. Structural equation modeling was used to estimate the relation between parental depressive symptoms and the discrepancies between their reports and those of two other informants.

RESULTS

In both the internalizing and externalizing behavior models, a significant relation was found between parents' depressive symptoms and their discrepancies in reporting, but not with child behavior. This relation was stronger for internalizing than externalizing models.

CONCLUSIONS

Using foster parents (and teachers) as informants offered a unique opportunity to view the reports of biological parents in comparison to two independent reports. Foster parents have a similar observational situation as biological parents but bring a less emotionally invested perspective to behavior observation, even when they are relatives. It is likely that depressive symptoms in parents distort their reports of their children's behavior. Clinicians would be wise to supplement parental with other informant reports.

Defenses in school age children: children's versus parents' report

We tested a questionnaire assessing defenses in school age children and compared the results with their mothers' reports of the same. Thirty-four children (56% male, mean age 8.5) completed the Response Evaluation Measure for Youth (REM-Y) twice over three weeks. Simultaneously, mothers completed the parent version of this measure (REM-P) about their children. In these questionnaires, factor 1 defenses (less adaptive; broken down into intrapersonal and interpersonal defenses) are assessed separately from factor 2, or more adaptive, defenses. Only lower level, interpersonal defenses, such as acting out, were recognized by mothers in their children. The children's intrapersonal defenses, along with factor 2 reactions, were reported less by mothers than by children.

The 4 year stability of psychopathic traits in non-referred youth

One significant limitation in research extending the construct of psychopathy to youth has been the absence of longitudinal studies testing the stability of psychopathic traits prior to adulthood. To begin to address this limitation, the current study estimated the stability of psychopathic traits over a 4 year period in a sample of non-referred children in the third, fourth, sixth, and seventh grades at the first assessment. For parent ratings of psychopathic traits, stability estimates using intra-class correlation coefficients ranged from 0.80 to 0.88 across 2-4 years, with a stability estimate of 0.93 across all four assessments. There were also distinct trends in the patterns of stability found in the sample. Specifically, children rated as being initially high on these traits were more likely to be rated lower at later assessments than was the case for children rated initially low on these traits. Finally, the child's level of conduct problems, the socioeconomic status of the child's family, and the quality of parenting the child received were the most consistent predictors of stability of psychopathic traits.

Long-term stability of the Child Behavior Checklist in a clinical sample of youth with attention deficit hyperactivity disorder

Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.

Behavioral and emotional problems in Chinese adolescents: parent and teacher reports

OBJECTIVE

This study examined behavioral and emotional problems in Chinese adolescents.

METHOD

A sample of 1,694 adolescents aged 12 to 16 years participated in this study in 1997. Parents completed the Child Behavior Checklist (CBCL), and teachers completed the Teacher's Report Form (TRF).

RESULTS

For both parent and teacher reports, internalizing syndromes were scored higher in girls and externalizing syndromes were scored higher in boys. Scores on most of the CBCL and TRF subscales were higher for the older adolescents. The overall prevalence rates of parent- and teacher-reported behavioral problems were 23.1% and 19.2%, respectively. The eight cross-informant syndromes were highly comorbid, with a significant association across syndromes (mean odds ratio = 16.1 for CBCL and 22.5 for TRF). Correlations between parent and teacher reports were 0.51 for eight subscales and 0.68 for Total Problems.

CONCLUSIONS

These findings demonstrate that behavioral and emotional problems tend to increase with age and cluster in the same individuals. The prevalence rates of behavioral problems in Chinese adolescents are comparable to those reported in Western countries. In contrast to findings for Western samples, parent reports of behavioral problems were highly correlated with teacher reports.

Mother and child perceptions of child functioning: relationship to maternal distress

The relationship between maternal distress and mother's reports of psychosocial problems in their children has been well-documented. However, relatively little research has investigated the relationship between maternal and family distress and young children's perception of their own functioning. Using a brief questionnaire designed for use with children, data were collected from 166 mothers and their children aged 5-12 years. Children provided information about their own daily functioning, and mothers provided information about their own, their child's, and their family's psychosocial functioning. Findings indicated that while children generally agreed with the reports of their mothers, children of distressed mothers self-reported better daily functioning than their mothers did. Distressed mothers tended globally to report negatively about themselves, their child, and their family. The present findings suggest that when assessing mothers or children, the reports of children should be considered as well as the reports of mothers.

Patterns and correlates of agreement between parent, teacher, and male adolescent ratings of externalizing and internalizing problems

The authors examined how well 394 triads of male youths, caregivers, and teachers agreed about youth problems reported on the Achenbach checklists. Dyadic agreement was measured through difference scores (subtracting the raw score of youth self-report from the caregiver's or teacher's score for shared items), q correlations between pairs of raters across items, and D2 (generalized distance between item profiles) for both externalizing and internalizing items. Teachers reported fewer internalizing and externalizing problems than did caregivers or youths. Teacher-youth disagreement was higher for African American than European American males about externalizing criteria. Caregiver depression and stress (but not paternal antisocial behavior or maternal substance abuse) correlated with higher disagreement with other informants about all criteria. These factors appear to increase disagreement about the level of problems but not about specific symptom patterns.

Four-year course of teacher-reported internalising, externalising and comorbid syndromes in preadolescent children

The aim of this study was to elucidate the nature of comorbidity between internalising and externalising syndromes and its meaning in the course of these syndromes from 8 to 12 years of age in a school setting. The children in the cohort (N = 1320) were born in 1981. They were first surveyed in second grade (N = 1284) and followed up in sixth grade (N = 906). Teachers were the informants, and the study was carried out by means of a questionnaire. Data from both points of time were available on 861 subjects. The Rutter Teacher Questionnaire (RB2) measured behavioural and emotional symptoms at Time 1, and the Teacher Report Form (TRF) at Time 2. Comorbidity was more prevalent in boys than girls. Childhood comorbidity predicted externalising syndrome and comorbidity, but not internalising syndrome in early adolescence. It changed the course of boys' internalising syndromes to an externalising direction over time. The data suggest a gender difference in the pattern of comorbidity. When comorbidity was partialled out, it was very rare for internalising and externalising syndromes to develop into contrasting syndromes over time. The recovery rate for childhood comorbidity was poor. Special attention should be paid to making schools recognise and help these children.

Dimensions of early childhood behavior problems: stability and predictors of change from 18 to 30 months

The prevalence, structure, stability, and predictors of change in early behavior problems were examined in a population-based sample of Norwegian children at 18 and 30 months of age (N = 750). A clear factor structure involving four dimensions emerged at both assessment times: Two factors were characterized by externalizing behaviors and were labeled Social Adjustment and Overactive-Inattentive; one factor tapped internalizing problems and was labeled Emotional Adjustment; and the fourth, related to general immaturity, was labeled Regulation. Specific patterns of child and family risk factors were associated with stability and change over the two time points for each factor. Children with stable problems had the most problematic characteristics on all significant predictors, followed by children with problems at one, but not both, time points. The data suggest that it is possible to identify risk factors for stable problems at 18 months, allowing some prediction of those children whose problems will persist over early childhood. Since specific risk factors emerged for specific types of behavior problems, the results may provide some much-needed guidance to early intervention efforts.

Competence and behavioral/emotional problems among Taiwanese adolescents as reported by parents and teachers

OBJECTIVE

To investigate competence and behavioral/emotional problems among nonreferred adolescents in Taiwan, using a Chinese version of the Child Behavior Checklist (CBCL-C) and the Teacher's Report Form (TRF-C). The psychometric properties of these instruments and cross-cultural differences were also examined.

METHOD

Parents of 854 junior high school students aged 12 to 16 years in Taipei, Taiwan, were asked to complete the CBCL-C. Among these students, 162 had their teachers' ratings of the TRF-C.

RESULTS

The internal consistency and 1-month test-retest reliability were satisfactory for both the CBCL-C and TRF-C, which were moderately correlated. Both exploratory and confirmatory factor analysis provided some support for the validity of Achenbach's cross-informant model. Parents' reports showed that compared with their American counterparts, Taiwanese adolescents tended to have lower scores on most competence scales, higher scores on scales that reflect covert behavior problems, and lower scores on scales that reflect more overt behavior problems. However, teachers' reports showed no significant differences on most competence and behavior problem scales.

CONCLUSION

The CBCL-C and TRF-C are useful tools for assessing the mental health status of Taiwanese adolescents. The cross-cultural differences in adolescent behavior problems are discussed.

Long-term stability of Child Behavior Checklist profile types in a child psychiatric clinic population

OBJECTIVE

To study the long-term stability of Child Behavior Checklist (CBCL) profile types, which represent children's overall patterns of single and comorbid scale elevations.

METHOD

Profile types were determined for 623 outpatient children at referral and then at mean follow-up 4.8 years later, and their continuity was determined.

RESULTS

At baseline 37.5% of the children were classified by a profile type, and 41.9% of these originally classified children continued to be classified at follow-up. The average odds ratio for a child continuing as a specific CBCL profile type from baseline to follow-up was 8.2. When children changed from one specific profile type to another, they usually continued in the same broad externalizing or internalizing category. Children who were not classified by a profile type at baseline generally remained unclassified.

CONCLUSIONS

Stability findings for CBCL profile types appeared good and were similar to past longitudinal results for CBCL scales and DSM diagnoses. These profile types may prove an important empirical method for addressing the problem of comorbid clinical pictures.

Behavioral and emotional problems among children of cocaine- and opiate-dependent parents

OBJECTIVE

To test associations between parental drug abuse and children's problems, children of cocaine- and opiate-dependent parents were compared with demographically matched referred and nonreferred children.

METHOD

Cocaine- and opiate-dependent parents in treatment completed the Child Behavior Checklist for 410 children (218 boys, 192 girls) from ages 2 through 18 years (mean = 7.9 years). Children of drug abusers (CDAs) were demographically matched to referred (RCs) and nonreferred children (NRCs).

RESULTS

RCs scored lower than CDAs and NRCs on most competence scales, and higher than CDAs and NRCs on all problem scales. CDAs scored lower than NRCs on most competence scales, and higher than NRCs on Withdrawn, Thought Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problems. Group status also predicted clinical range scores on most competence and all problem scales.

CONCLUSIONS

CDAs showed more internalizing and externalizing psychopathology relative to matched NRCs, but they showed significantly less psychopathology than shown by matched RCs. CDAs are an important group to target for preventive interventions.

Relationships among parental reports of child, parent, and family functioning

Most children with psychosocial problems do not present for treatment in mental health settings. They are managed by primary care physicians. Children with psychosocial problems often have parents and/or families with psychosocial distress. The present study measured associations between parental reports of child, parent, and family functioning in individuals in the general population. Participants were 226 parents of children, aged 2-16 years, who presented for routine primary care. Parents reported on the psychosocial functioning of themselves, their child, and their family. All correlations of measures were significant, ranging from .55 to .23. Similar to data from psychiatric samples, the psychological functioning of children, parents, and families were significantly correlated. Unlike in psychiatric settings, child mental health problems were not as closely related to parent or family distress as parent and family distress were related to each other and to child behavior problems.

Concordance between mothers' and children's reports of somatic and emotional symptoms in patients with recurrent abdominal pain or emotional disorders

Mother-child concordance regarding children's somatic and emotional symptoms was assessed in children with recurrent abdominal pain (n = 88), emotional disorders (n = 51), and well children (n = 56). Children between 6 and 18 years of age and their mothers completed questionnaires assessing the children's somatic symptoms, functional disability, and depression. Mothers of children with recurrent abdominal pain reported more child somatic and depressive symptoms than did their children, and mothers of children with emotional disorders reported more child depressive symptoms than did their children. Higher levels of maternal distress were associated with greater mother-child discordance in the direction of mothers reporting more child symptoms than did their children. No significant child age or sex differences were found in concordance patterns.

The persistence of psychiatric disturbance among children

This study assessed the persistence of psychiatric disturbance and factors associated with it. The material consisted of the Rutter A2 Scale the Rutter B2 Scale and the Children's Depression Inventories (CDI) of 1268 children completed respectively by parents, teachers and the children themselves. Three questionnaires were filled out twice, with an interval of 4 years. The mean scores obtained from the questionnaires were lower for both boys and girls in study 2 than in study 1. Differences between genders in both studies were most prominent when information given by teachers was used. Children screened as disturbed in study 1 were clearly more prone to be disturbed in study 2 as well. The risk varied between 5- and 8.8-fold when the same assessment method was used in both studies. Another variable clearly connected with disturbance in study 2 was psychiatric consultation reported by the parents. The sex of the child also proved to be important when the disturbance was assessed using the information given by the teacher.

A prospective study of childhood emotional and behavioural problems in Port Pirie, South Australia

OBJECTIVE

To describe the extent to which emotional and behavioural problems experienced by 5-year-old children living in or around Port Pirie, South Australia, persisted when the children were aged 11-12 years.

METHOD

Childhood emotional and behavioural problems were identified at the age of 5 years using Child Behaviour Checklists completed by mothers. When the children were aged 11-12 years, problems were identified using checklists completed by mothers, children and teachers.

RESULTS

Attention problems, aggressive behaviour and anxious/depressed problems were the most persistent problems over this period of the children's lives. In general, the strongest relationship over time occurred when reports were obtained from mothers on each occasion. A weaker relationship existed between earlier mother-reported problems and later teacher-reported problems, while the relationship between mother-reported problems and later self-reported problems occupied an intermediate position.

CONCLUSION

The course of problems among children in Port Pirie appeared similar to that previously reported for children in Holland and North America. To better understand the aetiology of psychiatric disorders and to plan for effective interventions, more information is needed about the natural course of childhood emotional and behavioural disorders in Australia.

Predictors of cross-informant syndromes among children and youths referred for mental health services

This study sought to identify which syndromes of initial problems predicted later syndromes among children and youths referred for mental health services. Standardized parent reports on the Child Behavior Checklist obtained at intake were compared to standardized parent, teacher, and self-reports obtained at follow-up. There were 1,103 subjects (774 males and 329 females) 4 to 18 years old, followed up an average of 6 years after referral. High quantitative and categorical stability was found for cross-informant syndromes within samples of younger and older subjects. Throughout childhood and into young adulthood, parent ratings of most syndromes at the time of referral predicted the counterpart cross-informant syndrome construct at follow-up, controlling for other types of problems at referral. There were multiple additional independent predictors of many syndromes, including Delinquent Behavior, Aggressive Behavior, and Shows Off for young adult males. Time 1 Social Problems and Attention Problems independently predicted diverse problems at Time 2 for younger males. A wide variety of problems also predicted younger males' self-ratings of withdrawal, anxiety, and depression. The stability of problems for the referred sample was similar to that found for demographically matched nonreferred subjects drawn from a national sample.

Attention problems versus conduct problems as six-year predictors of problem scores in a national sample

OBJECTIVE

To test the extent to which attention problems, the continuation of early comorbid conduct problems, and overall initial problems account for poor outcome scores on the Child Behavior Checklist and related measures 3 and 6 years after initial assessment.

METHOD

The course of attention and conduct problems was investigated in a nationally representative US sample assessed three times over 6 years, using standardized ratings of attention, conduct, and other problems and gender-specific scores for defining deviance.

RESULTS

Subjects deviant on both attention and conduct problems scored significantly higher on behavior problems at outcome than did those deviant on only attention problems or conduct problems. After controlling for initial conduct problems, initial attention problems made little unique contribution to later conduct problems. Predictive patterns were similar across gender and age groups.

CONCLUSIONS

Both boys and girls who show a combination of attention and conduct problems are at particular risk for the persistence of conduct problems.

Prevalence and correlates of psychopathology in pregnant adolescents

PURPOSE

To investigate the prevalence and correlates of psychopathology, as measured by the Youth Self-Report Scale, in pregnant adolescents so that interventions during pregnancy may be tailored to treat the psychopathology and thereby improve maternal and child outcomes.

METHODS

Scores on seven psychologic syndromes (withdrawn, delinquent, aggressive behaviors; anxiety/depression; and social, thought, and attention problems) were compared for groups of pregnant adolescents (n = 185), never pregnant teenagers (n = 126), and previously published normative samples of clinically referred (n = 518) and nonreferred (n = 518) female adolescents using chi-square, Student's t-tests, analysis of covariance, or multiple logistic regression. Correlates of psychopathology were identified for the pregnant sample using odds ratios and 95% confidence limits.

RESULTS

Pregnant adolescents exhibited less serious or lower rates of psychopathology than groups against which they were compared. Correlates of psychopathology included substance use during pregnancy, prior assault, maternal childbirth before age 18 years, ethnicity, > or = 3 sexual partners, and absence of a relationship with the baby's father.

CONCLUSIONS

Although the prevalence of psychopathology was lower among pregnant patients, those who exhibit psychopathology are likely to engage in risky health behaviors that contribute to poor perinatal outcome.

Kindergarten predictors of boys' stable behavior problems at the end of elementary school

This study predicted stable social maladjustments of ages 10, 11, and 12 from teacher behavioral ratings in kindergarten and a measure of family demographics. Kindergarten teachers rated 1,034 boys on hyperactivity, aggression, inattention, anxiety-withdrawal, and prosocial behavior. Sociodemographic information was collected from the parents. At ages 10, 11, and 12, teacher, parent, peer, and self-report behavior ratings were collected on 743 boys. School achievement was documented from school records. Boys whose average scores on each of the five behavioral ratings across ages 10, 11, and 12 were above the 90th percentile according to at least two informants were defined as having stable behavioral problems. From teacher ratings collected in kindergarten and family demographics, logistic regression analyses predicted stable social maladjustment. For each negative outcome there was a unique set of predictors. The results are discussed with reference to the early identification of children who are at risk.

Behavioral and emotional problems among Chinese and American children: parent and teacher reports for ages 6 to 13

This study compared behavioral and emotional problems reported by parents and teachers in Chinese urban and rural samples and demographically similar American samples. Parents of 469 6-to-13-year-old children of each nationality completed the Child Behavior Checklist (CBCL). Teachers completed the Teacher's Report Form (TRF). Cross-cultural differences were generally modest in magnitude. Chinese children scored higher on TRF Delinquent Behavior and Anxious/Depressed syndromes, and on Internalizing. American children scored higher on CBCL Aggressive Behavior and TRF Attention Problems syndromes. Boys exhibited more externalizing behaviors across both cultures. The mean correlation between parent and teacher ratings was .36 in the Chinese sample and .29 in the American sample, a nonsignificant difference. Findings indicate considerable similarity between problems reported for children in very different societies.

Nine-month changes of maternal expressed emotion in conduct and emotional disorders of childhood: a follow-up study

In this follow-up study, mothers of 28 children with conduct disorders (CD) and 29 children with emotional disorders (ED) of 6-11 years of age, were interviewed and rated for expressed emotion 9 months after their first clinical assessment. Mothers of children with CD expressed significantly less criticism and higher warmth after 9 months. Initial externalizing scores in the CD group and initial internalizing scores in the ED group at the first assessment predicted symptomatic change, in contrast with EE scales. Initial externalizing scores and low levels of maternal warmth predicted presence of conduct disorder at the last contact with the clinician. The implications of the findings on the development of treatment techniques are discussed.

Six-year predictors of problems in a national sample of children and youth: I. Cross-informant syndromes

OBJECTIVE

To illuminate the development of psychopathology by tracing 6-year predictive paths to outcomes assessed in terms of empirically based syndromes.

METHOD

A national sample assessed at ages 4 through 12 years via parent reports was reassessed 3 and 6 years later via parent, teacher, and self-reports.

RESULTS

For syndromes having the clearest DSM counterparts, cross-informant predictive paths revealed similar traitlike patterns for Aggressive Behavior in both sexes; Delinquent Behavior was less traitlike, with greater sex differences in predictive paths; the Attention Problems syndrome was developmentally stable, but, surprisingly, it was associated with more diverse difficulties among girls than boys; conversely, Anxious/Depressed was associated with more diverse difficulties among boys than girls.

CONCLUSIONS

Quantification of problems via empirically based syndromes can detect important sex, age, and developmental variations that may be masked by uniform diagnostic cutoff points for both sexes and diverse ages. This may be especially true for diagnostic cutoff points derived mainly from clinical cases of one sex, such as depression for girls versus attention and conduct disorders for boys.

The Western Australian child health survey: a pilot study

A pilot survey of 200 households was undertaken to field test the survey instruments and trial the validation and calibration procedures for the Western Australian Child Health Survey (WACHS) conducted in 1992. This paper describes the background to the WACHS, the development of the instrumentation and the conduct of the pilot study. This survey aims to replicate and extend previous epidemiological surveys conducted in other countries, and to provide Australian norms for mental health morbidity in 4 to 16 year old children. The measurement of mental health was undertaken through the use of the Child Behaviour Checklist (CBCL). This screening instrument provided data on the prevalence of mental health morbidity and of specific mental disorders in 4 to 16 year olds. Its reliability and validity as a diagnostic indicator were checked through a clinical calibration technique. The pilot survey also permitted an examination of the sampling strategy adopted to ensure that the sample selected reflected "normality" in terms of expected trends and results. Modifications to the content of the questionnaires are described in light of both psychometric qualities of the data and comments from field interviewers and professionals who have examined the instrument. Finally, changes to data collection strategies are discussed.

Competencies and problems reported by parents of Greek and American children, ages 6-11

This study compared parent-reported competencies and behavioral/emotional problems in demographically-matched samples of Greek and American children, ages 6-11. Parents of 356 children of each nationality completed the Child Behavior Checklist (CBCL). Competence scores were higher for American children, except on Academic Competence, where scores were higher for Greek children. Greek scores were significantly higher than American scores on the Withdrawn, Anxious/Depressed, Attention Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problem scales. On the Anxious/Depressed syndrome, nationality accounted for 14% of the variance. There were few main effects for sex and age and fewer interactions. The higher problem scores in the Greek sample were partly due to the tendency of Greek parents to use extreme item scores. When items were scored present v. absent, Greek scores were higher only on Withdrawn, Anxious/Depressed, Internalizing, and Total Problems, while American scores were higher on Somatic Complaints and Thought Problems. Nationality differences in rates of referral for mental health services and sample differences in exclusion criteria for prior mental health services may have contributed to differences in problem scores. Results are compared to findings from other cross-cultural studies.

Differential predictive value of parents' and teachers' reports of children's problem behaviors: a longitudinal study

This study investigated the prediction of signs of disturbance in 946 children originally aged 4 to 11 years from the general population across a 6-year period. Parents' and teachers' ratings obtained via the Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF) were tested as predictors of (a) academic problems, (b) school behavior problems, (c) receipt of mental health services, (d) child's need for professional help, (e) suicidal behavior, and (f) police contacts. Total problem scores in the deviant range on the CBCL or TRF were significantly associated with poor outcomes 6 years later. The combination of deviant scores on both the CBCL and TRF was a powerful predictor of poor outcomes with 56% of the girls, and 36% of the boys with total problem scores in the deviant range on both instruments maladjusted 6 years later. The CBCL syndromes Attention Problems and Delinquent Behavior, and the TRF syndromes Delinquent Behavior, Somatic Complaints, and Social Problems significantly predicted poor outcomes. Teachers' reports predicted poor outcomes equally well or even somewhat better than parents' reports. It is important to include teacher information in the diagnostic assessment of children.

Comorbidity of empirically based syndromes in matched general population and clinical samples

Comorbidity of deviance on eight empirically based syndromes was compared in matched general population and clinical samples of 2,705 children aged 4-18, using a bidirectional formula to avoid confounding effects of differential base rates. Syndromes were assessed via parent ratings on the CBCL, teacher ratings on the TRF, and self ratings on the YSR. Significantly higher comorbidity rates were obtained for clinical than general population samples for all 28 pairings of CBCL syndromes, 15 pairings of TRF syndromes, and 22 pairings of YSR syndromes. Bidirectional comorbidity rates for empirically based syndromes were compared to pairings of comparable DSM-III diagnoses.

Behavior problems in 5- to 11-year-old children from low-income families

OBJECTIVE

The aims of the present study were to survey the Child Behavior Checklist (CBCL) scores (behavioral section) in a nonclinical population of US urban children from low-income families and to compare the distribution and pattern of scores with the normative data in the CBCL manual (1991).

METHOD

The sample consisted of 890 low-income children and a mother or female guardian selected randomly from among Seattle public school students aged 5 to 11 years.

RESULTS

In this sample the total CBCL score as well as all subscale scores were significantly higher than the norms. The proportion of children who scored in the clinical/borderline range was also higher than the norm.

CONCLUSIONS

These findings support previous work showing that poverty is a risk factor for mental distress in children. They also raise questions about the validity of the CBCL norms for screening or research purpose for low-income families.

Epidemiology of behavioral and emotional problems among children of Jamaica and the United States: parent reports for ages 6 to 11

Research on child behavior problems requires standardized methodology in order to identify similarities and differences between societies. The present study compared parent-reported behavior problems of 360 Jamaican and 946 U.S. children aged 6 to 11. It revealed few differences in individual, total, internalizing (e.g., depression), and externalizing (e.g., fighting) problem scores as a function of nationality, gender, or age. Findings from this and other studies indicate the feasibility of a common methodology in cross-national studies of children's problems, but also the need for further refinement.

Epidemiological comparisons of American and French children: Parent reports of problems and competencies for ages 6-11

We compared problems and competencies reported by parents on the Child Behavior Checklist for 1842 demographically matched nonreferred French and American children. American children tended to receive higher competence scores, while French children tended to receive higher problem scores. Scores were higher for French than American children on more Internalizing items than Externalizing items. Nearly all nationality differences were small according to Cohen's (1988) criteria. There were few main effects of sex or age group, and fewer significant interactions. Findings are compared with findings on the Child Behavior Checklist in Holland, Australia, Puerto Rico, and Thailand.

Epidemiological comparisons of American and Dutch adolescents' self-reports

OBJECTIVE

To determine the cross-cultural applicability of self-reports of adolescents' problems and competencies.

METHOD

Youth Self-Reports (YSRs) were completed by 803 American and 803 Dutch nonreferred adolescents matched by gender, age, and socioeconomic status.

RESULTS

Comparisons revealed that American adolescents reported many more problems than did Dutch adolescents. This finding contrasts sharply with the American/Dutch similarities in parents' and teachers' reports of children's problem behaviors. Competence scores also were much higher for the American than the Dutch sample.

CONCLUSIONS

Cutpoints for discriminating the normal and the clinical range of YSR scores need to be adjusted to local norms for the Dutch sample. Cultural factors may be responsible for the cross-national differences.

Dopamine-beta-hydroxylase in behaviorally disturbed youth. Relationship between teacher and parent ratings

A series of neurotransmitters, metabolites, and enzymes considered relevant to emotional and behavioral disorders was studied in blood samples obtained from boys admitted to a residential setting because of disruptive or unmanageable behavior in their home environments. The youth were categorized into mainly prepubertal (under 12.0 years) and pubertal/post pubertal (12.0 years and over) groups. Behavior ratings of the younger group completed by parents revealed significant inverse correlations between several behavioral factors and dopamine-beta-hydroxylase (DBH) activity levels, notably in the aggressive behavior and antisocial domains. Teacher ratings completed after about 1 month of living in the residential setting also showed numerous significant, but positive, correlations between several behavior factors and DBH activity levels. Furthermore, teacher and parent ratings themselves often were significantly and inversely correlated. The findings related to DBH activity levels were strongest in the younger group of boys. The results are discussed in terms of the possibility that low DBH activity in boys reflects a vulnerability towards behavioral disorder, which in certain environments becomes manifested by conduct problems and antisocial behavior.

Psychological functioning of children with craniofacial anomalies and their mothers: follow-up from late infancy to school entry

Twenty-three mothers and their 5- to 7-year-old children with craniofacial anomalies (CFA) who were assessed during the child's infancy were followed. Three types of CFA were included: cleft lip and palate (CLP), isolated cleft palate (CP), and sagittal synostosis. Measures of child status focused on behavior-problem frequency and self-concept. Mothers completed self-report measures of emotional well-being, marital satisfaction, and social support. Results indicated that (1) a sizable minority (18%) of the children with CFA had clinically significant behavior-problem scores shown in concordant reports by parent and teacher of behavior problems; (2) individual differences in child functioning within the CFA group were predicted by observational measures of earlier mother-infant interaction during play and teaching situations; (3) mothers of children with CLP reported less favorable social support than mothers of children with CP or sagittal synostosis.

Two-year stability of self-reported problems in an epidemiological sample of adolescents

This study investigated the stability and change of problems reported by adolescents during a 2-year period. An epidemiological sample of 580 adolescents aged 11-16 at the initial assessment completed the Youth Self-Report on two occasions. We found high stability in the level of Youth Self-Report total problem scores. The highest stability was found for aggressive behavior. Problem scores tended to increase across time. This increase was greater for girls than for boys, especially for the somatic complaints syndrome. Of the adolescents who could be regarded as deviant at the initial assessment, 42% could still be regarded as deviant 2 years later.

Pathways of problem behaviors from childhood to adolescence

OBJECTIVE

the purpose of this study was to determine the 6-year longitudinal course of psychiatric disorders in children from the general population commencing at age 4 to 11 years.

METHOD

three groups of children were selected on the basis of Child Behavior Checklist ratings obtained at 2-year intervals: "persisters," "decreasers," and "increasers." Selected subjects and their parents were clinically interviewed, and DSM-III-R diagnoses were derived.

RESULTS

the majority of children whose overall level of psychopathology persisted over time obtained lifetime DSM-III-R diagnoses classified as externalizing: attention-deficit hyperactivity disorder, oppositional disorder, or conduct disorder. The majority of children whose overall level of psychopathology decreased obtained lifetime DSM-III-R diagnoses classified as internalizing: anxiety disorders, major depression, or dysthymic disorder. Children with initial Child Behavior Checklist scores in the normal range whose problem scores increased received lifetime diagnoses that were neither predominantly externalizing or internalizing.

CONCLUSIONS

this study showed that the majority of initially disordered children with the poorest outcome showed aggressive or antisocial behaviors, whereas disordered children whose functioning improved had problems reflecting fearful, inhibited, or depressive behavior. The findings also showed that retrospective information on the course of children's problem behaviors should be regarded with caution.

Six-year stability of parent-reported problem behavior in an epidemiological sample

An epidemiological sample of 936 Dutch children originally aged 4-11 years was assessed at 2-year intervals over a 6-year period. Parents completed the Child Behavior Checklist (CBCL) on all four occasions. Stability coefficients computed for eight CBCL syndromes, Internalizing and Externalizing dimensions, and total problems revealed considerable long-term stability. There was no significant difference in the 6-year stability of internalizing vs. externalizing scores. This finding was at odds with reports of considerably lower stability of internalizing behavior, and was consistent with findings suggesting that the stability of internalizing problems should not be underestimated. The magnitude and specificity of the long-term stability of internalizing and externalizing scores lends support to the validity of these behavioral dimensions as tapped by the CBCL. No significant sex or age differences in the stability of problem behaviors were found.