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Adolescent internalizing symptoms: The importance of multi-informant assessments in childhood Marie C. Navarro , Massimiliano Orri , Daniel Nagin , Richard E. Tremblay , Sˆınziana I. Oncioiu , Marilyn N. Ahun , ´ ´ , Maria Melchior , Judith van der Waerden , Cedric Galera ˆ e´ Sylvana M. Cot PII: DOI: Reference:
S0165-0327(19)32340-7 https://doi.org/10.1016/j.jad.2020.01.106 JAD 11555
To appear in:
Journal of Affective Disorders
Received date: Revised date: Accepted date:
30 August 2019 29 November 2019 20 January 2020
Please cite this article as: Marie C. Navarro , Massimiliano Orri , Daniel Nagin , Richard E. Tremblay , Sˆınziana I. Oncioiu , Marilyn N. Ahun , Maria Melchior , ´ ´ , Sylvana M. Cot ˆ e´ , Adolescent internalizing symptoms: Judith van der Waerden , Cedric Galera The importance of multi-informant assessments in childhood, Journal of Affective Disorders (2020), doi: https://doi.org/10.1016/j.jad.2020.01.106
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
Highlights 
Childhood internalizing symptoms can be associated with adolescent anxiety and depression.

Mothers and teachers have low to moderate levels of agreement on rating childhood internalizing symptoms.

Multi-informant assessment in childhood improves adolescent symptoms prediction.

Assessors‟ agreement is required to predict boys‟ social-phobic and girls‟ depression symptoms in adolescence.

Prediction of generalized anxiety symptoms in girls required at least a moderate level of childhood symptoms according to both informants.
Adolescent internalizing symptoms: The importance of multi-informant assessments in childhood Marie C. Navarro, MPH,1 Massimiliano Orri, PhD,1,2 Daniel Nagin, PhD,3 Richard E. Tremblay, PhD,4,5 Sînziana I. Oncioiu, MPH,1 Marilyn N. Ahun, BA,6 Maria Melchior, ScD,7 Judith van der Waerden, PhD,7 Cédric Galéra, MD, PhD,1,8 Sylvana M. Côté, PhD 1,6 Affiliations 1 Bordeaux Population Health Research Centre, INSERM U1219 and University of Bordeaux, Bordeaux, France 2 McGill Group for Suicide Studies, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, Canada 3 Carnegie Mellon University, Pittsburgh, Pennsylvania 4 School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland 5 Departments of Pediatrics and Psychology, University of Montréal, Montreal, Canada 6 Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada 7 Sorbonne Université, UPMC Université Paris 6, Inserm, Institut Pierre Louis d‟Épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France 8 Centre Hospitalier Charles Perrens, Bordeaux, France Corresponding author. Sylvana M. Côté, Research Center Ste Justine's Hospital, 3175 Chemin Côte SteCatherine, Montreal, Canada, H3T 1C5. Tel.: 1-514-345-2175. Email: [email protected]
ABSTRACT Background: Childhood internalizing symptoms can be associated with adolescent internalizing symptoms, but only a small proportion of symptomatic children are at long-term risk. Our objectives were to (1) distinguish between typical and atypical levels of internalizing symptoms using mother- and teacherassessments and (2) test the association between childhood internalizing symptoms and adolescent generalized anxiety, depression, and social phobia symptoms in boys and girls. Methods: Multi-trajectory models were used to estimate the evolution of mother- and teacher-reported internalizing symptoms across childhood (1.5 to 12 years) in a large population-based cohort (n=1431). Multiple linear regression models were implemented to estimate the association between childhood group membership of internalizing symptoms and self-reported specific internalizing symptoms at 15 years by sex. Results: Five groups of childhood internalizing symptoms were identified: Mother & teacher low (22.6%), Mother moderate/teacher low (37.9%), Mother moderate/teacher high (18.3%), Mother high/teacher low (11.8%) and Mother & teacher high (9.5%). Multiple linear regression models showed that compared to the low group, (1) boys in the high group reported higher social phobia symptoms (p=0.04), (2) girls in the high group reported higher depression (p=0.01) and generalized anxiety (p<0.01) symptoms, and (3) girls in the moderate/high group reported higher generalized anxiety symptoms (p=0.02) in adolescence.
Limitations: The main limitation is that mothers‟ and teachers‟ assessments mostly covered different developmental periods. Conclusions: A multi-informant assessment of childhood internalizing symptoms improves adolescent specific internalizing symptoms identification in a general population sample over reliance on a single informant. Keywords: Childhood internalizing symptoms; multiple informants; prediction; adolescent internalizing symptoms
INTRODUCTION Internalizing symptoms such as anxiety, depression, and social phobia, are the most common mental health problems in adolescence, with an estimated prevalence of 15% (Beesdo, Knappe, & Pine, 2009; Mojtabai, Olfson, & Han, 2016). They are associated with functioning impairments within relationships (e.g., friends and family) and adult mental health/adaptation problems (e.g., depression, substance abuse, suicidality) (Roza, Hofstra, van der Ende, & Verhulst, 2003; Silk, Davis, McMakin, Dahl, & Forbes, 2012). While the prevalence and development of internalizing symptoms during early/middle childhood are similar in boys and girls (Brendgen, Vitaro, Bukowski, Doyle, & Markiewicz, 2001; Colder, Mott, & Berman, 2002), sex differences have been reported in adolescence, with girls being at higher risk than boys (Angold, Costello, & Worthman, 1998; Wade, Cairney, & Pevalin, 2002). During childhood, anxiety and depression symptoms in general population samples are usually considered as a single category of internalizing problems (Sterba, Prinstein, & Cox, 2007). Internalizing problems are distinguished into generalized anxiety, depression, and social phobia in late childhood or adolescence (Hale, Raaijmakers, Muris, van Hoof, & Meeus, 2009; Ross, Gullone, & Chorpita, 2002). Clinically significant levels of internalizing symptoms can be detected during early childhood (Luby, Si, Belden, Tandon, & Spitznagel, 2009), indicating that some children may already need support prior to school entry. To inform prevention efforts, we need a good understanding of the normative versus atypical developmental patterns of internalizing symptoms from early childhood to adolescence. We also need to know the extent to which early childhood symptoms are related to adolescent internalizing problems with specific clinical features (e.g. generalized anxiety, social phobia). Assessing internalizing problems from
early childhood to adolescence in general population samples is challenging because the best informants on children‟s symptoms may vary across developmental periods. For instance, reliance on maternal reports is most common during early and middle childhood (Côté et al., 2009; Sterba et al., 2007); while reliance on self-reports is the norm in adolescence (Auger, 2004). Maternal mental health, especially depression, is one of the best predictor of maternal ratings of their child‟s internalizing symptoms (Côté et al., 2009) thus highlighting an important limitation of reliance solely on this type of ratings. Four studies have examined the association between childhood internalizing symptoms trajectories and adolescent internalizing symptoms and have relied on parent reports of child symptoms (Dekker et al., 2007; Sterba et al., 2007; Toumbourou John W., Williams Ian, Letcher Primrose, Sanson Ann, & Smart Diana, 2011; Zdebik et al., 2019). One study found that boys and girls following a higher trajectory of parent-reported internalizing symptoms from 3 to 15 years were more likely to experience depression symptoms in adolescence compared to children in lower trajectories (Toumbourou John W. et al., 2011). Similarly, another study using mother-reported internalizing symptoms from 2 to 11 years, found that boys and girls following high-symptom trajectories were more likely to experience pre-adolescent depression symptoms (Sterba et al., 2007). A third study using parent-reported internalizing symptoms from 4 to 18 years found that girls following high trajectories during early childhood and pre-adolescence, and boys in high trajectories during middle childhood, were more at-risk for later affective problems (Dekker et al., 2007). Finally, a study using mother-reported internalizing symptoms from 1.5 to 8 years found that boys and girls following low-symptom trajectories of anxiety and depression symptoms were less likely to experience internalizing symptoms in adolescence (Zdebik et al., 2019). As children enter school, teachers become available as informants and may represent a useful and complementary source of information on internalizing problems. Mothers and teachers have low-tomoderate levels of concordance on reports of internalizing symptoms, suggesting that they assess different aspects of internalizing symptoms (Achenbach, McConaughy, & Howell, 1987; van der Ende, Verhulst, & Tiemeier, 2012). For instance, mothers may be attuned to children‟s emotional difficulties in the family context, while teachers observe children in a group context. Mothers may be privy to details about children‟s emotional states, while teachers rather have a broad normative view of child development (Kerr, Lunkenheimer, & Olson, 2007; Saudino, Ronald, & Plomin, 2005). Mothers may better detect symptoms
related to everyday life (e.g., excessive preoccupations with casual activities), while teachers may better detect internalizing symptoms related to the social/school environment (e.g., anxiety during group activities, social withdrawal). Mothers with depression or anxiety may over-report internalizing problems (Côté et al., 2009; Fergusson, Lynskey, & Horwood, 1993) while teachers may be less prone to detect internalizing problems compared to externalizing problems (e.g., hyperactivity) (Lane, 2003). Importantly, given that maternal and teacher reports reflect child behaviors in different contexts, they each may contribute to the prediction of adolescent problems. Another important methodological feature when testing the association between childhood symptoms and adolescent psychopathology in population samples is the distinction between typical and atypical developmental patterns – where atypical refers to developmental patterns of symptoms presented by a minority of children. This is pertinent for two reasons. First, in population samples where clinical assessments are usually unavailable, relying on atypical levels – defined relative to a statistically normative group – is likely to provide a better identification of high-risk children than a continuous measure. Second, some symptoms (e.g., crying) are more frequent during certain developmental periods (e.g., toddlerhood) and may not be informative of future psychopathology. However, the same symptoms may become informative as they become infrequent for most children but persist over time for other children. Thus, a method allowing for the distinction between typical and atypical developmental patterns and using multiinformant reports may provide useful information about the risk of future internalizing symptoms. Using data from a large population-based study, our aims were to: (1) identify typical and atypical developmental trajectories of internalizing symptoms from 1.5 to 12 years using both maternal and teacher assessments; (2) model the association between risk factors, assessed when the child was 5 months, and membership on the identified trajectories; and (3) test the associations between these trajectories and adolescent self-reported generalized anxiety, depression, and social phobia symptoms.
METHOD Participants Data came from the Québec Longitudinal Study of Child Development (QLSCD), a longitudinal populationbased cohort. Participants were selected from the Québec Birth Registry and the initial representative sample comprised 2,120 singletons born in Québec, Canada in 1997/1998. From 5 months to 8 years, annual home interviews with the mother about family/parental characteristics and parental and child behaviors were conducted. From 6 to 12 years, teachers assessed children‟s behavior. This study is based on 1431 children with at least 4 mother-reported and 2 teacher-reported assessments of internalizing symptoms. Table 1 presents the characteristics of included and excluded participants. Compared to the analysis sample, excluded participants were more likely to be boys, to have mothers with low levels of education, and to come from a non-intact or low socioeconomic status (SES) family at 5 months. To balance these differences, we used inverse probability weighting in which weights were calculated using variables independently associated with the probability of being missing at follow-up (i.e., sex, SES, family structure) (Seaman & White, 2013). The protocol of the QLSCD was approved by the Québec Institute of Statistics and the StJustine Hospital Research Center ethics committees. Written informed consent was obtained from all participants. Measures Internalizing symptoms in childhood. At 1.5, 2.5, 3.5, 4.5, 5, 6 and 8 years, mothers assessed their child‟s behavior using the Behavior Questionnaire (Murray, Eisner, & Ribeaud, 2019). The Behavior Questionnaire was created for the Canadian National Longitudinal Study of Children and Youth (Government of Canada, 2009) and incorporates items from the Child Behavior Checklist (Achenbach, Edelbrock, & Howell, 1987), the Ontario Child Health Study Scales (Offord, Boyle, & Racine, 1989), and the Preschool Behavior Questionnaire (Behar & Stringfield, 1974). Internalizing symptoms were assessed using 8 items (alpha=0.48-0.76) describing whether the child never (0), sometimes (1), or often (2) exhibited the following symptoms in the past 12 months: „too fearful/anxious‟; „worried‟; „nervous, high-strung, tense‟; „unhappy or sad‟; „not as happy as other children‟; „has trouble enjoying himself‟; „cries a lot‟; „has no energy, feels tired‟. At 6, 7, 8, 10 and 12 years, teachers completed the Behavior Questionnaire assessing children‟s internalizing symptoms using the same items as the mothers, plus one additional item: „incapable
of making decisions‟ (alpha=0.83-0.87). We created a score for each informant and each time point by averaging the items (range: 0-10). Adolescent internalizing symptoms. Symptoms of generalized anxiety (9 items, e.g. “too fearful or nervous”, “worried about my school work”; alpha=0.86), depression (8 items, e.g., “sad and unhappy”, “lost interest in things I usually like”; alpha=0.90) and social phobia (8 items, e.g., “blushed/trembled when faced with social situations that I fear”, “feared/tried to avoid situations that involved speaking in class”; alpha= 0.90) were assessed using the Mental Health and Social Inadaptation Assessment for Adolescents (MIA; Côté et al., 2017). The MIA is a self-reported instrument which assesses the symptoms described in the DSM-5 using a dimensional approach to assess the frequency of mental health and psychosocial adaptation problems. Items were answered on a 3-point scale (0=never, 1=sometimes, 2=often) and averaged to compute final scores (range 0-10). The MIA was validated in this same sample (Côté et al., 2017; Geoffroy et al., 2018; Vergunst et al., 2019), showing good psychometric properties including factor structure, reliability, and convergent and discriminant validity (detailed information is published elsewhere; Côté et al., 2017). Maternal/family characteristics. The following socio-demographic characteristics were reported by mothers when the child was 5 months old: child sex, family structure, maternal education, smoking during pregnancy (yes/no), family SES (aggregate of five items including parental education, parental occupation, and annual household income (range-3=low to 3=high, 0-centered), maternal depressive symptoms (assessed with 12 binary items from the Center for Epidemiological Study Depression Scale short version; range 010), and maternal age at child‟s birth used as a continuous variable. The Parental Cognitions and Conduct toward the Infant Scale (Boivin et al., 2005) was used to assess 5 dimensions of maternal parenting when the child was 5 months old: perceived self-efficacy (6 items) and perceived impact (6 items), reflecting the mother‟s beliefs about her role as a parent; maternal warmth (5 items), reflecting affection and awareness of her child‟s qualities; and hostile-reactive behaviors (7 items) and overprotection (5 items), which reflect the hostile/coercive responses to difficult behaviors in the infant and the excessive concern for the safety and protection of the child, respectively. Items were scored on a 10-point scale from 0 to 10 and a mean score was calculated for each dimension (alpha>0.70). Analyses
Identifying developmental groups of childhood internalizing symptoms. Preliminary analyses were conducted to examine sex differences in the intensity and developmental patterns of symptoms. We then used group-based multi-trajectory modeling (a generalization of group-based trajectory modeling based on semi-parametric mixture models and maximum-likelihood) (Nagin, Jones, Lima Passos, & Tremblay, 2016) to jointly model the repeated assessments of internalizing symptoms by mothers and teachers. This approach identified groups of children with typical and atypically high levels of symptoms over the follow-up period using information from both mothers and teachers in the same model. Models having 3 to 7 latent groups were estimated and compared. The best model was determined using the Bayesian Information Criterion (NAGIN, 2005). Analyses were conducted using the traj procedure (STATA 14) (Jones & Nagin, 2013). Identifying baseline differences between children in the identified groups We identified baseline (age 5 months) socio-demographic, family, and maternal characteristics distinguishing children in the different groups using univariate multinomial logistic regressions (p<0.20). We then used a multivariable model keeping variables at p<0.05. Variables associated with the groups at p<0.05 were used as adjustment variables in subsequent multivariate models to estimate associations between childhood groups and adolescent internalizing symptoms over and above baseline differences between children in the different groups. Estimating associations between childhood internalizing symptoms groups and adolescent internalizing symptoms. Linear regressions were used to estimate the association between childhood internalizing symptoms group membership and adolescent internalizing symptoms. Group membership was indexed in the models using the posterior probabilities of class membership to better account for uncertainty in model classification. Models were estimated separately for boys and girls and adjusted for baseline variables as previously described. Cohen‟s d was used as a measure of effect size (Cohen, 1992). Missing data for covariates were handled using multiple imputation by chained equations (n=50 imputed datasets).
RESULTS Identifying developmental groups of childhood internalizing symptoms. Preliminary analyses did not reveal sex differences in the intensity and developmental patterns of internalizing symptoms. We therefore estimated trajectories for both sexes combined. The best model identified five groups (Figure 1). For all groups, maternal assessments showed a pattern of increasing level of symptoms from 1.5 to 8 years, while teacher assessments showed a more stable pattern of symptoms from 6 to 12 years. However, regardless of the pattern, children maintained the same rank in the symptom‟s distribution within each informant. In other words, rank stability – as shown by the fact that trajectories do not cross within each informant – was maintained for all trajectory groups. The identified groups were: 1) Mother & teacher low (22.6%) showing low and slowly increasing symptoms during early childhood according to mothers, and low/stable symptoms during middle childhood according to teachers; 2) Mother moderate/teacher low (37.9%) showing increasing symptoms reaching moderate levels at age 6 according to mothers, and low/stable symptoms according to teachers; 3) Mother moderate/teacher high (18.3%) showing increasing symptoms during early childhood according to mothers and high symptoms during middle childhood according to teachers; 4) Mother high/teacher low (11.8%) characterized by a steep increase in symptoms during early childhood according to mothers, reaching the highest level among all groups at age 6, but low/stable symptoms according to teachers; and 5) Mother & teacher high (9.5%) showing increasing and high symptoms during early childhood according to mothers, as the previous group, but also the highest level of chronic symptoms during middle childhood according to teachers. The results indicate that children classified in a high-ranking trajectory of symptoms by the mother were not always classified in a similarly high-ranking trajectory of symptoms by the teacher. For example, among the children classified in the highest-ranking trajectory of symptoms according to mothers (i.e., those in the Mother & teacher high and Mother high/teacher low trajectories), only a proportion of children were also classified in the highest-ranking trajectory according to the teacher (i.e., those in the Mother & teacher high trajectory). We therefore defined “concordance” between informants as classification in a group with the same rank order based on mother and teacher ratings. For instance, there is concordance for the 9.5% of children assigned to the Mother & teacher high group, because they are ranked at the highest-ranking
trajectory according to both mother-reported symptoms between 1.5 and 8 years and teacher-reported symptoms between 6 and 12 years. Identifying baseline differences between children in the identified groups Compared to children in the Mother & teacher low group, children in other groups were more likely to have young mothers and mothers reporting high depressive symptoms (Table 2). Children in the Mother & teacher high group were more likely to have low SES and overprotective mothers compared to those in the Mother & teacher low group. Estimating associations between childhood internalizing symptoms groups and adolescent internalizing symptoms. Multiple linear regressions adjusting for maternal age at child‟s birth, SES, maternal depressive symptoms and parenting (Table 3) showed that boys in the Mother & teacher high group reported more social phobia symptoms in adolescence compared with those in the Mother & teacher low group. In contrast, boys in the Mother moderate/teacher low, Mother moderate/teacher high and Mother high/teacher low groups did not differ from boys in the Mother & teacher low group on adolescent outcomes. Girls in the Mother & teacher high group reported more depression and generalized anxiety symptoms in adolescence compared to girls in the Mother & teacher low group (Table 3). Additionally, we found that girls in the Mother moderate/teacher high group reported more generalized anxiety symptoms in adolescence compared to girls in the Mother & teacher low group. Girls in the Mother moderate/teacher low and Mother high/teacher low groups did not differ from girls in the Mother & teacher low group on adolescent outcomes. All associations corresponded to medium-high effect sizes (d>0.29).
DISCUSSION Using an innovative approach for combining mothers‟ and teachers‟ longitudinal assessments in a population-based sample, we identified five distinct developmental groups of internalizing symptoms from 1.5 to 12 years of age. We found that children assessed as having the highest-ranking level of symptoms according to both mothers and teachers were at increased risk of having high social phobia (for boys), generalized anxiety, and depression symptoms (for girls) compared with children assessed as having the lowest-ranking symptoms according to both mothers and teachers. We also found that girls assessed as having moderate internalizing symptoms by mothers and high symptoms by teachers in childhood reported more generalized anxiety symptoms in adolescence, compared to girls assessed as having low symptoms according to both informants. However, no increased risk for any outcome was found for children in the other groups. Across the identified groups, we found an increase in internalizing symptoms between 1.5 and 8 years, reflecting the normative development of internalizing symptoms in early/middle childhood (Bongers, Koot, van der Ende, & Verhulst, 2003; Côté et al., 2009). Importantly, trajectories of internalizing symptoms, within each informant, did not overlap or cross, suggesting rank stability of children‟s symptoms. That is, children who initially exhibited high levels remained high while those with initially average or low levels remained average or low, respectively. This means that children with atypically high levels of symptoms had the highest symptom level relative to other children from 1.5 to 12 years. We found that for a third of our sample, the intensity of mother and teacher-reported symptoms was similar, with children assessed as either having low (i.e., Mother & teacher low) or high (i.e., Mother & teacher high) levels of symptoms according to both informants. However, differences in mother and teacher reports were found for a large proportion of children, i.e., the two thirds of the sample classified in the Mother moderate/teacher low, Mother moderate/teacher high or Mother high /teacher low groups. Different factors may explain this lack of concordance. First, mothers and teachers assess symptoms according to the behaviors exhibited in different settings. For example, children may manifest more internalizing symptoms in the family context if the home environment is a source of anxiety, such as in families with maladaptive parenting or parental conflicts (Sander & McCarty, 2005; Stice, Ragan, & Randall, 2004). Conversely, children may manifest more internalizing symptoms at school if the academic context is a source of stress, such as in cases of peer
victimization or interpersonal difficulties (McLaughlin, Hatzenbuehler, & Hilt, 2009; van Oort, GreavesLord, Ormel, Verhulst, & Huizink, 2011). Second, differences between mother and teacher assessments may depend on the informants‟ characteristics. For example, studies showed that maternal characteristics such as depressive symptoms may influence mothers‟ report of child behavior (Fergusson et al., 1993; Stone, Speltz, Collett, & Werler, 2013). Third, although there is rank stability in mothers‟ and teachers‟ evaluations, they did not assess children at the same time points but across different developmental periods. Children entering school may experience new stressors which can increase the risk of internalizing symptoms across this period. It is therefore possible that some children manifested more internalizing symptoms only in the school context, creating divergence in mothers‟ and teachers‟ reports. Consistent with previous studies (Ahun et al., 2018; Kiernan & Huerta, 2008; Weeks et al., 2014), low socio-economic status, low maternal age at birth, maternal depressive symptoms and maternal overprotection were associated with membership in the Mother & teacher high group. Focusing on the Mother moderate/teacher high group, low maternal age at birth, maternal depression, maternal coercion and low maternal awareness of child qualities tended to be associated with increased risk of membership in this group. High socio-economic status was slightly associated. Exposure to maternal depressive symptoms is a robust risk factor for child and adolescent internalizing symptoms (Goodman et al., 2011; Sanger, Iles, Andrew, & Ramchandani, 2015). Evidence also suggests that parenting practices, including overprotection, are associated with an increased risk of anxiety and depression symptoms in children (Yap, Pilkington, Ryan, & Jorm, 2014). These findings underscore the importance of considering the family context. In this study, we found sex-specific associations between trajectories of internalizing symptoms and adolescent outcomes. That is, boys rated as having high symptoms by both mothers and teachers reported higher levels of social phobia symptoms in adolescence, while girls rated as having moderate or high symptoms by mothers and high symptoms by teachers reported higher levels of depression and generalized anxiety symptoms in adolescence. These findings are informative for screening and prevention of internalizing disorders (i.e., identification and focused application of preventive interventions) and clinical practice (i.e., psychologists/psychiatrists/pediatricians‟ decision-making). First, mother-teacher concordance in assessing symptoms intensity at the highest rank (although in 2 developmental period) may help identifying boys at risk of developing social phobia and girls at risk of
depression symptoms in adolescence. However, we found that to identify girls likely to show generalized anxiety symptoms in adolescence, less stringent level of concordance was required. It should be noted that teachers may be more prone to identify girls likely to report generalized anxiety symptoms at 15 years because their assessments are closer in time to the outcome. Overall, our results are consistent with previous studies using parent-reported childhood internalizing symptoms trajectories, which identified children following a high trajectory as those at risk for internalizing problems (Dekker et al., 2007; Sterba et al., 2007; Toumbourou John W. et al., 2011; Zdebik et al., 2019). However, our findings also suggest that only a subgroup of children identified as exhibiting elevated levels of internalizing symptoms according to a single informant are indeed at risk of high levels of internalizing symptoms. This possibility should be investigated in future studies, as the lack of longitudinal studies examining the association between multi-informant reports of internalizing symptoms across childhood and specific internalizing symptoms in adolescence prevent definitive comparisons between ours and previous findings. Second, our findings indicate that children classified in a high-ranking trajectory according to a single informant (i.e. absence of concordance between mother and teacher rankings) were not at higher risk of adolescent internalizing symptoms compared to children manifesting low symptoms in both contexts. If ratings are accurate reflections of the child‟s internalizing symptoms, this result suggests that wellbeing in at least one context (i.e., experiencing either the home or the school environment as non-stressful) may be an important factor of resilience. Previous studies show that for children exposed to adverse family conditions (e.g., depressed mothers, low SES), an out-of-home educational context may limit the exposure to adverse family environments and associated consequences (Côté et al., 2007; Herba et al., 2013). Interventions can therefore be targeted to maximize protective factors of either the home or the school environment to prevent adolescent psychopathology in children experiencing internalizing symptoms in a single context. Strengths and Limitations Relying on longitudinal data with assessments spanning from birth to adolescence, we applied an innovative person-centered approach to identify groups of children with atypically high levels of internalizing symptoms according to two informants and examined their association with internalizing symptoms in adolescence. Using joint assessments of key informants in the environments where children spend most of their time –home and school – contributed to a better understanding of the development of
internalizing symptoms compared to previous studies based on a single informant. Despite these strengths, the following limitations have to be considered in the interpretation of our findings. First, as mothers‟ and teachers‟ assessments overlapped only between 6 and 8 years of age, most of their assessments relate to different developmental periods (early childhood for mothers, middle childhood for teachers). Difference in developmental period rather than differences in the perspectives of informants may explain some of the discrepancies in ratings. However, given the rank stability of symptoms within each informant (i.e. the fact that trajectories did not overlap with each other within mother or teacher assessments) over time, it is plausible that the same pattern of trajectories would have been observed if teachers had assessed children before age 6 or mothers after age 8. Future studies using perfectly overlapping assessments are needed to replicate our findings. Second, as this is a population-based study focusing on development from birth to adolescence, we have information on symptoms severity in adolescence, but not on psychiatric diagnoses. Third, due to attrition, analyses were performed on 67% of the initial representative sample. However, attrition was accounted for by using inverse probability weights, and the same pattern of results was obtained with and without weights. Fourth, we did not account for paternal characteristics and mental health due to the large amount of missing data on paternal data. Nevertheless, these factors may be important variables to take into account in future studies. Fifth, our outcomes were assessed at a single time-point using only self-reported data. Finally, although teenagers are known to be the most reliable informants of their own internalizing symptomatology (Boardman, 2006; Breidablik, Meland, & Lydersen, 2009), these findings should be replicated using a multi-informant perspective. Finally, although we referred to adolescence as the time point in which our outcome was measured (i.e., 15 years of age), adolescence is a broader period likely to start before age 15 (Sawyer, Azzopardi, Wickremarathne, & Patton, 2018). Conclusion These findings stress the importance of accounting for multiple informants, like mothers and teachers, to reliably identify children at risk for later internalizing problems, especially depression and social phobia symptoms in a general population sample over-reliance on a single informant. Over-reliance on motherreports and omission of teacher-reports in assessment of child internalizing symptoms may limit prognostic value of these assessments.
Funding Source: The Québec Longitudinal Study of Child Development was supported by the Québec Government‟s Ministry of Health, Ministry of Education and Ministry of Family Affairs; The Lucie and André Chagnon Foundation; the Robert-Sauvé Research Institute of Health and Security at Work; the Québec Statistics Institute; the Fonds de Recherche du Québec–Santé; the Fonds de Recherche du Québec– Societé et Culture; Canada‟s Social Sciences and Humanities Research Council; the CIHR, and the StJustine Research Centre. Role of the Funder/Sponsor: Québec Statistics Institute collected data. The sponsors had no role in the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Acknowledgements: This work was supported by the French National Research Agency (Project ANR-17CE36-0002-01) and by the framework of the PIA3 (Investment for the Future). Project reference: 17-EURE0019. SMC and MO supervised the study.
Contributors’ statement Ms. Navarro designed and carried out all analyses, contributed to the interpretation of the data, drafted the initial manuscript, reviewed and revised the manuscript Dr. Orri supervised the study, designed the analyses, contributed to the interpretation of the data, and reviewed and revised the manuscript. Drs. Nagin, Melchior, van der Waerden and Galéra and Ms. Oncioiu and Ahun contributed to the interpretation of the data and reviewed and revised the manuscript. Dr. Tremblay conceptualized, designed the study, designed the data collection instruments, contributed to the interpretation of the data, reviewed and revised the manuscript. Dr. Côté conceptualized and designed the study, contributed to the interpretation of the data, critically reviewed the analyses and the manuscript, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Conflict of Interest Conflict of Interest Disclosures: Dr. Orri reports receiving a postdoctoral research fellowship from the Canadian Institute of Health Research (CIHR) and a grant from the European Union‟s Horizon 2020 research and innovation program (#793396). Ms. Ahun reports receiving a Vanier Canada Graduate Scholarship from the Social Sciences and Humanities Research Council. No other disclosures were reported. Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
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Figure Legend
Figure 1. Multi-trajectory analysis of mother and teacher assessments of internalizing symptoms, N=1431, QLSCD cohort, Canada
All the fit criteria showed good model fit: the mean posterior probability in each group exceeded 0.7, the odds of correct classification was higher than 6 and the estimated group probabilities were close to the proportions of the sample assigned to the groups. The BIC was -26225.54
Table 1. Demographic characteristics of included and excluded participants at 5 months of age (N=2120) Included (n = 1431) Excluded (n = 689) p-value* Child sex, No. (%) <0.01 Boy 682 (47.7) 398 (57.8) Girl 749 (52.3) 291 (42.2) Maternal education, No. (%) <0.01 No high school diploma 234 (16.4) 151(21.9) High school diploma 367 (25.7) 188 (27.3) Post high school diploma 413 (28.9) 198 (28.7) University diploma 416 (29.1) 150 (21.8) Family status, No. (%) <0.01 Intact 1170 (82.0) 536 (77.8) Always single 91 (6.4) 80 (11.6) Widowed 165 (11.6) 70 (10.2) Smoke during pregnancy, No (%) 0.67 No 1068 (75.1) 509 (73.9) Yes 355 (24.9) 178 (25.8) Mother‟s age at birth, mean (SD) 29.39 (5.2) 29.10 (5.2) 0.35 Family socioeconomic status, mean (SD) 0.07 (0.9) -0.16 (1.0) <0.01 *p-values are based on a Chi-Square test of independence for categorical variables and on a Wilcoxon test for continuous variables. Data were compiled from the final master file of the Québec Longitudinal Study of Child Development (1998-2015), Québec Government, Québec Statistic Institute.
Table 2. Child and family characteristics associated with childhood internalizing symptoms group membership Mother moderate/teacher low group [95% CI] RRR Child sex Boy Girl Mother‟s age at birth Family socioeconomic status Maternal depressive symptoms Maternal efficacy Maternal impact Maternal coercion Maternal affection Maternal overprotection Maternal perception of child‟s qualities
Mother moderate/ teacher high group [95% CI] RRR
Mother high/teacher low group [95% CI] RRR
Mother & teacher high group [95% CI] RRR
p-value <0.01
1 0.73 0.91 0.85 1.41 0.84 0.97 1.00 1.64 1.02 0.95
[0.51 ; 1.03] [0.88 ; 0.95] [0.69 ; 1.06] [1.18 ; 1.66] [0.69 ; 1.03] [0.88 ; 1.08] [0.87 ; 1.15] [1.11 ; 2.45] [0.94 ; 1.10] [0.84 ; 1.07]
1 1.17 0.88 1.24 1.67 0.75 1.02 1.18 1.25 1.06 0.84
[0.79 ; 1.74] [0.84 ; 0.92] [0.97 ; 1.58] [1.40 ; 1.99] [0.61 ; 0.93] [0.91 ; 1.15] [1.02 ; 1.35] [0.90 ; 1.75] [0.97 ; 1.16] [0.74 ; 0.96]
1 1.32 0.93 1.19 1.40 0.89 1.04 1.13 1.13 1.01 0.92
[0.99 ; 1.76] [0.90 ; 0.96] [1.00 ; 1.41] [1.20 ; 1.62] [0.75 ; 1.05] [0.95 ; 1.14] [1.01 ; 1.26] [0.86 ; 1.47] [0.95 ; 1.08] [0.84 ; 1.02]
1 0.67 0.93 0.54 1.50 0.84 0.98 1.15 0.97 1.13 0.94
[0.42 ; 1.05] [0.89 ; 0.97] [0.40 ; 0.74] [1.24 ; 1.82] [0.66 ; 1.07] [0.87 ; 1.11] [0.97 ; 1.35] [0.68 ; 1.37] [1.02 ; 1.25] [0.81 ; 1.10]
<0.01 <0.01 <0.01 0.11 0.61 0.05 0.08 0.17 0.11
Relative risk ratios were estimated using a multiple multinomial logistic regression model, using as predictors the variables associated with group membership in univariate analyses. Abbreviations: RRR, relative risk ratio; CI, confidence interval
Table 3. Association between childhood groups of internalizing symptoms and adolescent internalizing symptoms in boys and girls Generalized Anxiety Not Adjusted Adjusted β (SE) p β (SE) d Boys (n=1080) Mother & teacher low (Reference) Mother moderate/teacher low Mother moderate/teacher high Mother high/teacher low Mother & teacher high Girls (n=1040) Mother & teacher low (Reference) Mother moderate/teacher low Mother moderate/teacher high Mother high/teacher low Mother & teacher high
Symptoms Depression p
Not Adjusted β (SE) p
Social Phobia
Adjusted β (SE) d
p
Not Adjusted β (SE) p
β (SE)
Adjusted d
p
-0.51 (0.27)
0.06
-0.53 (0.27)
-0.19
0.05
-0.15 (0.27)
0.59
-0.23 (0.28)
-0.08
0.41
-0.31 (0.26)
0.24
-0.31 (0.27)
-0.10
0.25
-0.03 (0.32)
0.92
-0.05 (0.32)
-0.03
0.87
0.41 (0.32)
0.21
0.33 (0.33)
0.11
0.32
0.25 (0.31)
0.41
0.26 (0.31)
0.10
0.42
0.37 (0.34)
0.27
0.31 (0.35)
0.04
0.37
0.38 (0.34)
0.27
0.23 (0.36)
0.03
0.52
0.42 (0.33)
0.20
0.43 (0.34)
0.13
0.21
0.23 (0.35)
0.50
0.30 (0.36)
0.17
0.41
0.28 (0.36)
0.44
0.25 (0.37)
0.12
0.50
0.61 (0.34)
0.07
0.71 (0.35)
0.33
0.04
0.52 (0.27)
0.05
0.50 (0.27)
0.17
0.06
0.42 (0.28)
0.14
0.47 (0.29)
0.14
0.11
-0.14 (0.29)
0.62
-0.13 (0.29)
-0.03
0.67
0.76 (0.35)
0.03
0.86 (0.36)
0.29
0.02
0.52 (0.37)
0.16
0.60 (0.38)
0.20
0.11
0.56 (0.38)
0.14
0.61 (0.39)
0.20
0.12
0.24 (0.34)
0.49
0.24 (0.35)
0.08
0.50
0.13 (0.36)
0.72
0.24 (0.38)
0.12
0.52
0.04 (0.37)
0.92
0.08 (0.39)
0.02
0.84
1.18 (0.40)
<0.01
1.26 (0.41)
0.44
<0.01
1.04 (0.42)
0.01
1.11 (0.44)
0.35
0.01
0.35 (0.43)
0.42
0.41 (0.45)
0.08
0.36
β, linear regression coefficient; SE, standard errors; d=Cohen‟s d (<0.20, low effect size; 0.20-0.50, medium effect size; ≥0.50 large effect size). The models are adjusted for maternal age at child‟s birth, maternal depression symptoms, maternal parenting practices and family socioeconomic status.