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Marilyn J. Essex, PhD; Helena C. Kraemer, PhD; Jeffrey M. Armstrong, MS; W. Thomas Boyce, MD; H. Hill Goldsmith, PhD; Marjorie H. Klein, PhD; Hermi Woodward, BS; David J. Kupfer, MD

Arch Gen Psychiatry. 2006;63:1246-1256.

Context  Exploratory studies that generate testable models of how risk factors for childhood mental health problems work together over time are critical for developing effective prevention and treatment strategies.

Objective  To build models addressing the following 2 questions: (1) How early can we identify children at risk for mental health problems in third grade? (2) How do the risk factors work together over time?

Design and Participants  We assessed a Wisconsin community sample 8 times, beginning during pregnancy. Three hundred seventy-nine families completed multi-informant reports (mothers, teachers, and children) of children's mental health symptoms in third grade.

Main Outcome Measures  Symptom severity and directionality (externalizing vs internalizing).

Results  The hypothesis was generated that family socioeconomic status (SES) defined different pathways to symptom severity. In low/middle SES families, children were at risk if their mothers were distressed during the infancy period, which was then associated with more generalized maternal and child distress and dysregulation during the preschool period. In high SES families, the picture was more complex, beginning with parental histories of depression and family psychopathology, which then led to greater family stress in the infancy period and maternal and child distress and dysregulation during the preschool period. For all children, social and academic impairment during the school transition was an important mediator. Two pathways to later symptom directionality consisted of one beginning with child sex and the other with child temperament.

Conclusions  Most risk factors predicted symptom severity and not directionality. The risk factors for internalizing and externalizing problems may be much the same, and the same preventive interventions might be effective for both classes of problems. Furthermore, at-risk children from high SES families might be identifiable as early as infancy, whereas those from lower SES families may be identifiable only as preschoolers.

Author Affiliations: Departments of Psychiatry (Drs Essex and Klein and Mr Armstrong) and Psychology (Dr Goldsmith), University of Wisconsin–Madison; Department of Psychiatry and Behavioral Sciences, Stanford University (Dr Kraemer); School of Public Health, Institute of Human Development, University of California–Berkeley (Dr Boyce); and Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pa (Ms Woodward and Dr Kupfer).

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