Comorbidity of Externalizing and Internalizing Problems

Involuntary delayed retirement and mental health of older adults

OBJECTIVE

This study examined the association of multiple mental health measures with involuntary delayed retirement (IDR) in working older adults (≥ 65 years) in the USA.

METHODS

Data were derived from the Health and Retirement Study, focusing on two combined waves of working older adults in 2010 and 2012. IDR was measured as the desire to stop working but the inability to do so due to financial constraints. In addition, mental health outcomes included depression, anxiety, anger-in, and anger-out. Using Stata 16.0, primary analyses were conducted for descriptive statistics and multivariable logistic regression. The odds ratios were reported with 95% confidence intervals (CIs).

RESULTS

Older adults who reported IDR were more likely to have depression (OR = 3.20, CI = 1.03-9.88), anxiety (OR = 2.12, CI = 1.00-5.18), and anger-in (OR = 1.71, CI = 1.12-2.60) compared to those who did not report IDR. However, IDR was not significantly associated with anger-out in older adults who worked past the traditional retirement age.

CONCLUSION

The findings suggest that IDR is likely to act as a stressor and affects the mental health of older adults aged 65 and more. Policymakers should pay more attention to helping older adults maintain positive mental health even if they are required to work past retirement age.

Treating children's aggressive behavior problems using cognitive behavior therapy with virtual reality: A multicenter randomized controlled trial

This multicenter randomized controlled trial investigated whether interactive virtual reality enhanced effectiveness of Cognitive Behavioral Therapy (CBT) to reduce children's aggressive behavior problems. Boys with aggressive behavior problems (N = 115; Mage  = 10.58, SD = 1.48; 95.7% born in Netherlands) were randomized into three groups: CBT with virtual reality, CBT with roleplays, or care-as-usual. Bayesian analyses showed that CBT with virtual reality more likely reduced aggressive behavior compared to care-as-usual for six of seven outcomes (ds 0.19-0.95), and compared to CBT with roleplays for four outcomes (ds 0.14-0.68). Moreover, compared to roleplays, virtual reality more likely enhanced children's emotional engagement, practice immersion, and treatment appreciation. Thus, virtual reality may be a promising tool to enhance CBT effectiveness for children with aggressive behavior problems.

Joint developmental trajectories and correlates of internalizing and externalizing problems among Chinese adolescents

BACKGROUND

Internalizing and externalizing problems are the most prevalent health problems among adolescents. However, few studies have examined co-occurring internalizing and externalizing problems from a longitudinal perspective.

METHODS

A total of 1051 seventh-grade students from two junior high schools were recruited at baseline. Among them, 932 valid participants were reassessed 1 year and 2 years later. Data were analyzed using parallel-process latent class growth analysis and multinominal logistic regression.

RESULTS

Four joint trajectories of internalizing and externalizing problems were identified. Compared with the low-risk group, adolescents in the moderate and chronic co-occurring group had lower resilience, higher levels of insecure attachment, family conflicts, and academic pressure. Adolescents in the pure internalizing group had higher levels of family conflicts and academic pressure compared with the low-risk group.

CONCLUSIONS

Co-occurrence of symptoms is very high in adolescents. More individualized intervention programs should be provided to these specific groups.

Submissive behavior as a transdiagnostic construct: Associations with internalizing symptoms and distress intolerance

OBJECTIVE

Submissive behavior is associated with significant impairment and negative life outcomes. The goal of the present study was to determine the transdiagnostic nature of submissive behavior by observing its association with internalizing symptoms (i.e., social anxiety, depression, and worry) and distress intolerance. Additionally, we sought to determine the moderating role of gender in these relationships.

METHOD

We used a community sample (N = 208) to evaluate the hypothesized relationships between submissive behavior and internalizing symptoms.

RESULTS

All three internalizing symptoms were uniquely associated with greater submissive behavior when covarying for each other. Distress intolerance was also uniquely positively related to submissive behavior respective of general distress. Moderation analyses revealed that the associations between social anxiety, worry, and distress intolerance with submissive behavior were stronger in men rather than women.

CONCLUSION

The present study provides novel evidence for the relevance of submissive behavior to internalizing symptoms and distress intolerance. We discuss clinical implications and directions for future research.

Contextual predictors of internalizing and externalizing problems among adolescents from high-achieving private schools in Hong Kong

Emerging research suggests that adolescents at high-achieving schools (HAS) in Western societies are at elevated risk for problem behaviours. This cross-sectional study explored whether adolescents attending HAS in a non-Western setting show similar risk patterns and if contextual (school-, family-, and peer-based) factors typically associated with the excessive pressures to achieve predict these problems. Participants were 237 adolescents (14–18 years old), and one of their parents, who were recruited from high-achieving private schools in Hong Kong. The parent-child dyads completed questionnaires on youth internalizing and externalizing problems and perceived stressors. Multiple linear regressions were conducted to test whether academic demands, parent-related stressors, and social status among peers were associated with youth problem behaviours, after controlling for age and gender. The study found that nearly half of the female adolescents and over a third of the males met borderline-clinical levels (≥ 86%ile) of internalizing problems; moreover, more females than males met clinical criteria (≥ 98%ile) for self-reported externalizing problems and parent-reported internalizing problems. Academic demands, parent-related stressors, and social status among peers predicted youth-reported internalizing problems; and the latter two factors contributed parent-reported internalizing problems. However, only parent-related stressors significantly predicted youth- and parent-reported externalizing problems. The findings provide preliminary indication that HAS adolescents from Hong Kong may be an “at risk” group, highlighting the need for increased awareness and targeted interventions.

Development of the gut microbiota in healthy children in the first ten years of life: associations with internalizing and externalizing behavior

BACKGROUND

Increasing evidence indicates that psychopathological disorders are associated with the gut microbiota. However, data are largely lacking from long-term longitudinal birth cohorts, especially those comprising low-risk healthy individuals. Therefore, this study aims to describe gut microbiota development in healthy children from birth till age 10 years, as well as to investigate potential associations with internalizing and externalizing behavior.

RESULTS

Fecal microbial composition of participants in an ongoing longitudinal study (N = 193) was analyzed at 1, 3 and 4 months, and 6 and 10 years of age by 16S ribosomal RNA gene sequencing. Based on these data, three clusters were identified in infancy, two of which were predominated by Bifidobacterium. In childhood, four clusters were observed, two of which increased in prevalence with age. One of the childhood clusters, similar to an enterotype, was highly enriched in genus-level taxon Prevotella_9. Breastfeeding had marked associations with microbiota composition up till age 10, implying an extended role in shaping gut microbial ecology. Microbial clusters were not associated with behavior. However, Prevotella_9 in childhood was positively related to mother-reported externalizing behavior at age 10; this was validated in child reports.

CONCLUSIONS

This study validated previous findings on Bifidobacterium-enriched and -depleted clusters in infancy. Importantly, it also mapped continued development of gut microbiota in middle childhood. Novel associations between gut microbial composition in the first 10 years of life (especially Prevotella_9), and externalizing behavior at age 10 were found. Replications in other cohorts, as well as follow-up assessments, will help determine the significance of these findings.

An examination of the moderating role of growth mindset in the relation between social stress and externalizing behaviors among adolescents

INTRODUCTION

Experiencing elevated stress increases the risk of further difficulties in mental health, including externalizing behaviors in adolescents. There is a need for understanding the factors that help adolescents mitigate social stress to prevent problematic externalizing behaviors. Growth mindset has been found to be a promising protective factor in adolescent development including mental health. This study aimed to examine the potential buffering role of growth mindset of thoughts-emotion-and-behaviors in the context of two types of social stress (i.e., family and peer) to reduce externalizing behaviors among adolescents.

METHODS

The sample is composed of 399 adolescents (age range 14-18 years, M = 16.22, SD = 1.21; 56.4% female, 42.3% male, 1.3% gender-nonconforming or variant) from a large, urban, diverse high school in the United States. Adolescent self-reports were administered at one time.

RESULTS

Moderation analyses revealed that growth mindset of thoughts, emotion, and behaviors moderate the association between family stress and externalizing behaviors. The magnitude of this association weakened as the level of growth mindset increased, supporting the buffering effect of the moderator. Neither the moderation effect of growth mindset nor the main effects of peer stress and growth mindset were significant in predicting externalizing behaviors.

CONCLUSION

Taken together, the findings suggested that growth mindset has protective effects in reducing externalizing behaviors when adolescents experience family stress. Future directions and implications are discussed.

Teacher-rated aggression and co-occurring behaviors and emotional problems among schoolchildren in four population-based European cohorts

Aggressive behavior in school is an ongoing concern. The current focus is on specific manifestations such as bullying, but the behavior is broad and heterogenous. Children spend a substantial amount of time in school, but their behaviors in the school setting tend to be less well characterized than at home. Because aggression may index multiple behavioral problems, we used three validated instruments to assess means, correlations and gender differences of teacher-rated aggressive behavior with co-occurring externalizing/internalizing problems and social behavior in 39,936 schoolchildren aged 7-14 from 4 population-based cohorts from Finland, the Netherlands, and the UK. Correlations of aggressive behavior were high with all other externalizing problems (r: 0.47-0.80) and lower with internalizing problems (r: 0.02-0.39). A negative association was observed with prosocial behavior (r: -0.33 to -0.54). Mean levels of aggressive behavior differed significantly by gender. Despite the higher mean levels of aggressive behavior in boys, the correlations were notably similar for boys and girls (e.g., aggressive-hyperactivity correlations: 0.51-0.75 boys, 0.47-0.70 girls) and did not vary greatly with respect to age, instrument or cohort. Thus, teacher-rated aggressive behavior rarely occurs in isolation; boys and girls with problems of aggressive behavior likely require help with other behavioral and emotional problems. Important to note, higher aggressive behavior is not only associated with higher amounts of other externalizing and internalizing problems but also with lower levels of prosocial behavior.

Resilience in adolescence: Prospective Self moderates the association of early life adversity with externalizing problems

INTRODUCTION

Early life adversity (ELA) can result in negative behavioral outcomes, including internalizing and externalizing problems. Evidence suggests that adolescence is a critical developmental period for processing ELA. Identity formation, which is crucial to this developmental period, may moderate the effect between ELA and these problems. One potential moderating variable associated with identity formation is the latent construct Prospective Self, comprised of future-oriented attitudes and behaviors.

METHODS

Participants are from the first wave of an ongoing longitudinal study designed to characterize behavioral and cognitive correlates of risk behavior trajectories. A community sample of 10th and 12th grade adolescents (N = 2017, 55% female) were recruited from nine public school districts across eight Southeastern Michigan counties in the United States. Data were collected in schools during school hours or after school via self-report, computer-administered surveys. Structural equation modeling was utilized to assess Prospective Self as a latent construct and to evaluate the relationship between ELA, internalizing and externalizing problems, and Prospective Self.

RESULTS

Preliminary findings indicated a satisfactory fit for the construct Prospective Self. The predicted negative associations between Prospective Self and internalizing and externalizing problems were found and evidence of moderation was observed for externalizing problems, such that the effects of ELA (i.e., childhood maltreatment) on externalizing problems were lower for individuals with higher levels of Prospective Self.

CONCLUSIONS

These results indicate that Prospective Self may play a role in supporting resilience against externalizing problems associated with ELA among adolescents.

Ethnicity's Role in the Relationship Between Anxiety and Negative Interpretation Bias Among Clinically Anxious Youth: A Pilot Study

Negative interpretation bias, a correlate of anxiety, is defined as an individual's tendency to interpret ambiguous events as negative or threatening. The current study examined associations between interpretation bias and anxiety symptoms in clinically anxious youth and potential moderators of these relationships. Thirty anxious youth and their parents participated in a clinical interview and reported on child anxiety symptoms. Youth completed implicit, explicit-personally irrelevant, and explicit-personally relevant interpretation bias measures. Child-reported anxiety was only associated with negative interpretation bias on the explicit-personally relevant measure and parent-reported social anxiety was negatively associated with positive bias on this measure. Hispanic individuals displayed marginally higher anxiety symptoms and significantly more intense negative interpretation on the implicit measure. While this pilot study revealed preliminary findings that Hispanic ethnicity may play a role in relationships between interpretation bias and anxiety, future work may further elucidate associations between interpretation bias, anxiety, and ethnicity in anxious youth.

Factorial Validity of the Devereux Behavior Rating Scale-School Form

The construct validity of the Devereux Behavior Rating Scale-School Form was examined, primarily through use of factor analysis. The subjects in this study were 384 children ages 5-18 who were either receiving special education services as seriously emotionally disturbed (SED; n = 171) or receiving no special education services (non-SED; n = 213). Parents and/or teachers rated each student on the Devereux Behavior Rating Scale-School Form. Item-level factor analyses were conducted for both the 5-12 age version of the scale and the 13-18 age version. These analyses were originally conducted separately by the SED sample and the non-SED sample. Because of differences in these factor structures, the final analyses were conducted with the SED and non-SED samples combined but with the effects of group placement partialed out. These analyses did not replicate the four Devereux subscales. For both age groups, a three-factor solution was found to best represent the data. Items did group together by original subscale to some extent, but there was a substantial amount of item-crossover. Internal consistency reliabilities of the subscale scores and obtained factor scores were calculated and were consistently high. Mean differences between the SED and nonSED students on the subscale scores and factor scores were also calculated. SED students were rated as having a significantly higher level of problems on all subscale and factor scores. These results are discussed and implications related to the use of this scale are highlighted.

Emotion Knowledge and Attentional Differences in Preschoolers Showing Context-Inappropriate Anger

Some children show anger inappropriate for the situation based on the predominant incentives, which is called context-inappropriate anger. Children need to attend to and interpret situational incentives for appropriate emotional responses. We examined associations of context-inappropriate anger with emotion recognition and attention problems in 43 preschoolers (42% male; M age = 55.1 months, SD = 4.1). Parents rated context-inappropriate anger across situations. Teachers rated attention problems using the Child Behavior Checklist-Teacher Report Form. Emotion recognition was ability to recognize emotional faces using the Emotion Matching Test. Anger perception bias was indicated by anger to non-anger situations using an adapted Affect Knowledge Test. 28% of children showed context-inappropriate anger, which correlated with lower emotion recognition (β = -.28) and higher attention problems (β = .36). Higher attention problems correlated with more anger perception bias (β = .32). This cross-sectional, correlational study provides preliminary findings that children with context-inappropriate anger showed more attention problems, which suggests that both "problems" tend to covary and associate with deficits or biases in emotion knowledge.

Childhood aggression, depressive symptoms, and peer rejection: The mediational model revisited

The goals of the current study were to investigate whether peer rejection mediated the relation between aggression and depressive symptoms in childhood, and if so, whether this mediational pathway was specific to the reactive subtype of aggression. Participants were 57 second-grade children (22 girls and 35 boys). Data on reactive aggression, proactive aggression, depressive symptoms, and peer rejection were collected from four sources (parents, teachers, peers, and self). Results revealed that reactive aggression, but not proactive aggression, was positively related to depressive symptoms. Furthermore, peer rejection partially mediated the relation between reactive aggression and depressive symptoms.

Inherited and environmental influences on a childhood co-occurring symptom phenotype: Evidence from an adoption study

Risk factors for the childhood development of co-occurring internalizing and externalizing symptoms are not well understood, despite a high prevalence and poor clinical outcomes associated with this co-occurring phenotype. We examined inherited and environmental risk factors for co-occurring symptoms in a sample of children adopted at birth and their birth mothers and adoptive mothers (N = 293). Inherited risk factors (i.e., birth mothers' processing speed and internalizing symptoms) and environmental risk factors (i.e., adoptive mothers' processing speed, internalizing symptoms, and uninvolved parenting) were examined as predictors for the development of internalizing-only, externalizing-only, or co-occurring symptoms using structural equation modeling. Results suggested a unique pattern of predictive factors for the co-occurring phenotype, with risk conferred by adoptive mothers' uninvolved parenting, birth mothers' slower processing speed, and the birth mothers' slower processing speed in tandem with adoptive mothers' higher internalizing symptoms. Additional analyses indicated that when co-occurring-symptom children were incorporated into internalizing and externalizing symptom groups, differential risk factors for externalizing and internalizing symptoms emerged. The findings suggest that spurious results may be found when children with co-occurring symptoms are not examined as a unique phenotypic group.

Childhood- versus adolescent-onset antisocial youth with conduct disorder: psychiatric illness, neuropsychological and psychosocial function

Objective

The present study investigates whether youths with childhood-onset antisocial behavior have higher rates of psychiatric illness, neuropsychological and psychosocial dysfunction than youths who engage in antisocial behavior for the first time in adolescence. Prior studies have generally focused on single domains of function in heterogeneous samples. The present study also examined the extent to which adolescent-onset antisocial behavior can be considered normative, an assumption of Moffitt’s dual taxonomy model.

Method

Forty-three subjects (34 males, 9 females, mean age = 15.31, age range 12–21) with a diagnosis of conduct disorder (CD) were recruited through Headspace Services and the Juvenile Justice Community Centre. We compared childhood-onset antisocial youths (n = 23) with adolescent-onset antisocial youths (n = 20) with a conduct disorder, across a battery of psychiatric, neuropsychological and psychosocial measures. Neuropsychological function of both groups was also compared with normative scores from control samples.

Results

The childhood-onset group displayed deficits in verbal learning and memory, higher rates of psychosis, childhood maltreatment and more serious violent behavior, all effects associated with a large effect size. Both groups had impaired executive function, falling within the extremely low range (severely impaired).

Conclusions

Childhood-onset CD displayed greater cognitive impairment, more psychiatric symptoms and committed more serious violent offences. The finding of severe executive impairment in both childhood- and adolescent-onset groupings challenges the assumption that adolescent-onset antisocial behavior is a normative process.

Anxiety in youth in Flemish care: a multi-informant study

Purpose

– The purpose of this paper is to investigate the prevalence of anxiety in youngsters with emotional and behavioral disorders, and its relation to other problems, using different informants.

Design/methodology/approach

– Data were collected in a Flemish treatment center. Educators completed a Child Behavior Checklist (CBCL) for each child, teachers completed a Teacher Report Form (TRF), and youth themselves completed a Youth Self Report (YSR) and a Screen for Child Anxiety Related Emotional Disorders (SCARED).

Findings

– Analyses indicated an explicit presence of anxiety. A clear relation was found between anxiety symptoms and internalizing problem behavior on the YSR, whereas only a slight relationship was found with the CBCL, and practically no relationship was found with the TRF. Only few correlations between anxiety and externalizing problems were found. Finally, youth themselves indicated strong correlations between anxiety and thought problems, whereas educators indicated strong correlations between youths’ anxiety and social problems.

Originality/value

– Several studies describe professionals’ difficulties to get a comprehensive perceptions of youths’ problems. This paper provides detailed insights in the nature of the informant discrepancies.

Identifying patterns of anxiety and depression in children with chromosome 22q11.2 deletion syndrome: comorbidity predicts behavioral difficulties and impaired functional communications

BACKGROUND

Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a complex genetic disorder with a variable clinical presentation that can include cardiac, neural, immunological, and psychological issues. Previous studies have measured elevated anxiety and depression in children with 22q11.2DS. Comorbity of anxiety and depression is well established in the pediatric literature but the nature of comorbidity patterns has not been empirically established in children with 22q11.2DS. Comorbidity of anxiety and depression has important implications for treatment and prognosis, and may be a marker of risk in this population of children at high-risk for developing schizophrenia.

METHOD

Participants were 131 boys and girls ages 8-14 with (n=76) and without (n=55) 22q11.2DS and their mothers. Children and mothers independently completed self- and parent-report measures of anxiety and depression. Mothers also completed measures of behavioral functioning including the Behavioral Assessment for Children, 2nd ed. (BASC-2). Cluster analyses were conducted to test if theoretically based groupings of anxiety and depression could be identified. We hypothesized four psychological profiles based on child- and mother-reports: low/no anxiety and low/no depression, higher depression and low/no anxiety, higher anxiety and no/low depression, and a comorbid profile of higher anxiety and higher depression. BASC-2 subscale scores were then compared across subgroups of children to determine if a comorbid profile would predict greater behavioral difficulties.

RESULTS

In the full sample of children both with and without 22q11.2DS, cluster analyses of self and maternal reported anxiety and depression revealed the expected subgroups: (1) a group of children with higher anxiety/lower depression (anxious); (2) a group with primary depression (lower anxiety/higher depression (depressed)); (3) a comorbid group with higher anxiety/higher depression (comorbid); and, (4) a lowest anxiety/lowest depression group (NP). Mothers' reports produced highly similar groupings. Furthermore, the 22q11.2DS youth were more likely to be in anxiety, depressed or comorbid clusters than the typically developing (TD) youth. Children with 22q11.2DS comorbid for anxiety and depression exhibited the worst functional outcomes (e.g., poor poorer functional communication, and reduced daily life activities).

CONCLUSIONS

Anxiety, comorbid with depression may be of particular concern in children with 22q11.2DS who arguably carry a greater burden on their stress coping resources than children without a complex genetic disorder. Furthermore, the manifestation of negative mood, anxiety and difficult behavior is likely to reverberate between the child and her or his environment. This can lead to negative interactions with family, peers, and teachers, which in turn further taxes coping resources. Comorbidity of anxiety and depression within a vulnerable population highlights the need for the development of tailored interventions.

Effectiveness of an individual school-based intervention for children with aggressive behaviour: a randomized controlled trial

BACKGROUND

For elementary school-children with aggressive behaviour problems, there is a strong need for effective preventive interventions to interrupt the developmental trajectory towards more serious behaviour problems.

AIM

The aim of this RCT-study was to evaluate a school-based individual tailor-made intervention (Stay Cool Kids), designed to reduce aggressive behaviour in selected children by enhancing cognitive behavioural skills.

METHOD

The sample consisted of 48 schools, with 264 fourth-grade children selected by their teachers because of elevated levels of externalizing behaviour (TRF T-score>60), randomly assigned to the intervention or no-intervention control condition.

RESULTS

The intervention was found to be effective in reducing reactive and proactive aggressive behaviour as reported by children, mothers, fathers or teachers, with effect sizes ranging from .11 to .32. Clinically relevant changes in teacher-rated externalizing behaviour were found: the intervention reduced behaviour problems to (sub) clinical or normative levels for significantly more children than the control condition. Some aspects of problems in social cognitive functioning were reduced and children showed more positive self-perception. Ethnic background and gender moderated intervention effects on child and teacher reported aggression and child response generation.

CONCLUSIONS

The results of this study demonstrate the effectiveness on outcome behaviour and child cognitions of an individual tailor-made intervention across informants under real-world conditions.

Improving outcomes for at-risk youth: findings from the Prodigy Cultural Arts Program

Through this study the authors evaluate the Prodigy Cultural Arts Program, an early prevention program for adjudicated youth. A quasi experimental pre- and posttest was conducted. A significant reduction in mental health symptoms (particularly for females) and behavioral dysregulation (particularly for males), and increases in academic performance and family functioning were found. There was also a relationship between decreased mental health symptomology and perceived academic performance. The Prodigy Cultural Arts Program appears to be successful in intervening with youth who present challenges to the juvenile justice system due to the complexity of their mental health symptoms, behavioral regulation difficulties, and/or gender.

Treating comorbid anxiety and aggression in children

OBJECTIVE

The aim of the study was to evaluate the effectiveness of an intervention that targeted both anxious and aggressive behaviors in children with anxiety disorders and comorbid aggression by parent report.

METHOD

The effects of a cognitive-behavioral therapy intervention targeting comorbid anxiety and aggression problems were compared with a standard cognitive-behavioral therapy intervention targeting anxiety only. The study was conducted over a period of 2 years, and 69 families were included, with participating children ranging in age from 8 to 14 years. Intervention effects were evaluated at posttreatment and 3 months following treatment.

RESULTS

An intent-to-treat analysis identified few significant differences between conditions in level of improvement following treatment and at follow-up, with the exception of parent-reported stress, anxiety, and depression, which improved in the anxiety treatment condition. Both treatment programs led to significant reductions in parent-reported child externalizing and internalizing problems and child-reported internalizing problems and to improved parenting practices.

CONCLUSIONS

Comorbidity did not appear to significantly affect treatment outcome for anxiety disorders, and combining existing treatments to address comorbid problems did not enhance treatment effectiveness. Further trials are required to assess the effectiveness of an expanded combined treatment program that allows adequate time to address both internalizing and externalizing problems.

Depressive Symptoms Among Delinquent Youth: Testing Models of Association with Stress and Support

The high prevalence of depression among incarcerated youth indicates a need to better understand factors that contribute to depression within this vulnerable subgroup. Previous research in general community samples has suggested that high levels of stress and low levels of parental support are associated with depression in young people, but it is unclear whether or how they might be associated with depression among incarcerated youth who are already vulnerable. Using a sample of 228 adolescents (aged 13-18 years) who were detained in the juvenile justice system, stress and support were modeled as independent main effects and as interactive risk factors in relation to depressive symptoms. More stressful life events and less caregiver support were each independently associated with depressive symptoms, but no evidence was found for the buffering hypothesis in this sample. Stressful life events were more strongly associated with depressive symptoms among boys compared to girls.

Transforming mental health care for children and their families

In April 2002, the President's New Freedom Commission on Mental Health was created by executive order to study the mental health care delivery system in our nation and to make recommendations for improvements so that individuals with serious mental disorders can live, work, learn, and fully participate in their homes and communities. In its report, "Achieving the Promise: Transforming Mental Health Care in America," the commission provided strategies to address critical infrastructure, practice, and research issues. This article focuses on the work of the commission's Subcommittee on Children and Families, describing its vision for mental health service delivery for children and providing suggestions for strengthening community-based care for youths with or at risk of behavioral health disorders. Training, research, practice, and policy implications for psychologists are discussed.

Pure Versus Co-occurring Externalizing and Internalizing Symptoms in Children: The Potential Role of Socio-Developmental Milestones

Co-occurring internalizing and externalizing disorders are moderately prevalent in children, adolescents, and adults (Anderson, Williams, McGee, & Silva, 1987; McConaughy & Skiba, 1994), but much remains to be understood regarding why some children show "pure" versus co-occurring internalizing and externalizing symptoms. One possible influence that has previously not been considered is the failure to attain socio-developmental milestones, which paradoxically may prevent the development of co-occurring symptoms for some children. The present study proposes a model in which failure to attain relevant socio-developmental milestones might explain why some children may not develop heterotypic co-occurring symptoms. Specifically, it is proposed that specific clusters of internalizing symptoms (i.e., high social anxiety, withdrawal, and inhibition) and externalizing symptoms (i.e., high impulsivity, hyperactivity, and emotional reactivity) may be associated with the failure to attain socio-developmental milestones (i.e., poor peer relations for anxious children, lack of self-reflection and evaluation for impulsive/reactive children) that, in turn, may prevent subgroups of children from developing co-occurring, heterotypic symptoms.

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.

Risk factors for community violence exposure in adolescence

Community violence is recognized a significant public health problem. However, only a paucity of research has examined risk factors for community violence exposure across domains relevant to adolescents or using longitudinal data. This study examined youth aggressive behavior in relation to community violence exposure among a community epidemiologically defined sample of 582 (45% female) urban adolescents. Internalizing behaviors, deviant peer affiliation, and parental monitoring were examined as moderators of the association between aggressive behavior and exposure to community violence. For males with aggressive behavior problems and deviant peer affiliation or low parental monitoring, co-occurring anxiety symptoms protected against subsequent witnessing community violence. In contrast, males with aggressive behavior problems and co-occurring depressive symptoms were at increased risk for witnessing community violence. Implications of the findings for preventive interventions and future research are discussed.

Codevelopment of externalizing and internalizing problems in early childhood

Using cross-domain latent growth modeling, we examined trajectories of externalizing and internalizing problems in disadvantaged boys followed from ages 2 to 6 years (N = 303). On average, externalizing problems gradually decreased and internalizing problems gradually increased. However, we found significant variability in individual-level trajectories. Higher levels of externalizing problems were associated with higher levels of internalizing problems; rates of change were also positively correlated across domains. In addition, high levels of externalizing problems predicted rapid increases in internalizing problems. In follow-up analyses involving child and parenting factors, the combination of high negative emotionality, low fearfulness, and high negative maternal control preceded high, nondecreasing externalizing trajectories. The combination of high negative emotionality, high fearfulness, and high negative maternal control preceded high, increasing internalizing trajectories. Taken together, the results indicate both general and specific processes in the development of early externalizing and internalizing problems.

Rates and patterns of comorbidity of adolescent behavioral syndromes as reported by parents and teachers in a Taiwanese nonreferred sample

OBJECTIVE

To evaluate the rates and patterns of comorbidity between behavioral syndromes in adolescents as reported by parents and teachers. Whether the patterns of comorbidity were "epiphenomenal" was also assessed.

METHOD

Parents of 854 randomly selected students (response rate = 88%) in Taipei in 1996 completed the Child Behavior Checklist; among them, 240 also were randomly selected to have the Teacher's Report Form completed by their teachers. In addition to bidirectional comorbidity rates, odds ratios with and without other comorbid pairs controlled for were estimated via multiple logistic regressions.

RESULTS

High comorbidity rates between behavioral syndromes were found in adolescents as reported both by parents and teachers except for that of Somatic Complaints with other syndromes. When other comorbidity pairs were controlled for, the comorbidity rates between Anxious/Depressed with externalizing syndromes turned out to be epiphenomenal, whereas those between externalizing syndromes remained high for both informants' reports. Attention Problems also remained significantly comorbid with other syndromes in the multiple logistic regressions except for that of Aggressive Behavior in the Teacher's Report Form sample.

CONCLUSION

High comorbidity rates between adolescent behavioral syndromes exist in both parents' and teachers' reports, and it is important to control for the epiphenomenal condition when assessing such comorbidity rates.

Causal links between stressful events, coping style, and adolescent symptomatology

In a longitudinal study, the causal links between different types of stressors, coping styles and adolescent symptomatology were investigated. A total of 94 adolescents and their mothers participated in three annual assessments of critical life events, daily stressors and coping styles. The longitudinal associations between life events, everyday stressors, a dysfunctional coping style and symptomatology were analyzed via a path-analytic model. Critical life events and daily stressors were found to be strongly related over time; however, the type of stressor was not consistently linked with adolescent symptomatology. In contrast, withdrawal, a form of avoidant coping, emerged as a significant predictor of adolescent symptomatology across all times. Further, emotional and behavioral problems led to a time-lagged increase in withdrawal, creating a vicious circle. The results are discussed with reference to the coping-skill deficit model.

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.