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It is Time to Play! Peer Implemented Pivotal Response Training with a Child with Autism during Recess , Leigh Anne Sams

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The Evaluation of a Commercially-Available Abduction Prevention Program , Kimberly V. Beck

Expert Video Modeling with Video Feedback to Enhance Gymnastics Skills , Eva Boyer

Behavior Contracting with Dependent Runaway Youth , Jessica Colon

Can Using One Trainer Solely to Deliver Prompts and Feedback During Role Plays Increase Correct Performance of Parenting Skills in a Behavioral Parent Training Program? , Michael M. Cripe

Evaluation of a Functional Treatment for Binge Eating Associated with Bulimia Nervosa , Tamela Cheri DeWeese-Giddings

Teaching Functional Skills to Individuals with Developmental Disabilities Using Video Prompting , Julie A. Horn

Evaluation of a Standardized Protocol for Parent Training in Positive Behavior Support Using a Multiple Baseline Design , Robin Lane

Publicly Posted Feedback with Goal Setting to Improve Tennis Performance , Gretchen Mathews

Improving Staff Performance by Enhancing Staff Training Procedures and Organizational Behavior Management Procedures , Dennis Martin McClelland Jr.

Supporting Teachers and Children During In-Class Transitions: The Power of Prevention , Sarah M. Mele

Effects of Supervisor’s Presence on Staff Response to Tactile Prompts and Self-Monitoring in a Group Home Setting , Judy M. Mowery

Social Skills Training with Typically Developing Adolescents: Measurement of Skill Acquisition , Jessica Anne Thompson

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Evaluating the effects of a reinforcement system for students participating in the Fast Forword language program , Catherine C. Wilcox

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The Acquisition of Functional Sign Language by Non-Hearing Impaired Infants , Kerri Haley-Garrett

Response Cards in the Elementary School Classroom: Effects on Student and Teacher Behavior , Shannon McKallip-Moss

The Effects of a Parent Training Course on Coercive Interactions Between Parents and Children , Lezlee Powell

The Effects of Role-Playing on the Development of Adaptive Skills in a Parent Training Program , Chantell A. Rodriguez-Del Valle

Archival evaluation of a proactive school wide discipline plan , Beth Rutz-Beynart

Effects of a multi-component interdependent group contingency game on the classroom behavior of typically developing elementary school children , Stacey D. Simonds

Establishing a Functional Analysis Protocol for Examining Behavioral Deficits using Social Withdrawal as an Exemplar , Melissa Penaranda Walters

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The Role of Choice Versus Preference: An Analysis of Why Choice Interventions Work , John D. Adelinis

The Effect of Direct Instruction Math Curriculum on Higher-Order Problem Solving , Pamela Christofori

The Effects of Response Cards on the Performance and Generalization of Parenting Skills , Bennie L. Colbert

A Comparison of Two Prompting Procedures on Tacting Behavior , Kelley N. Gardner

The Effects Of The Presence Of A Dog On The Social Interactions Of Children With Developmental Disabilities , Stephanie Walters

The Effects of Fluency Training on Performance, Maintenance, and Generalization of Parenting Skills , Gertie Williams

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Use of the Power Card Strategy as an Intervention with an Elementary School Student with Asperger Syndrome: Increasing On-Task Behavior in the General Education Setting , Jane M. Devenport

The Importance of Program-Delivered Differential Reinforcement in the Development of Classical Music Auditory Discrimination , Gudmundur Torfi Heimisson

The Impact of a Goal Setting Procedure on the Work Performance of Young Adults with Behavioral/Emotional/Learning Challenges , Robin Wagner Hogsholm

The Effects of Graphic Display and Training in Visual Inspection on Teachers' Detection of Behavior Change , Allana Duncan Luquette

Imitation and its Reciprocity in the Treatment of Autism , Roxana I. Nedelcu

Utility of Positive Peer Reporting to Improve Interactions Among Children in Foster Care , Jenny L. Van Horn

Behavioral Analysis of Interactions Between Teachers and Children with Selective Mutism , Jason D. Wallace

Theses/Dissertations from 2003 2003

Creating Positive Experiences: Increasing Parent Participation In A Low Income Elementary School , Krista Stinson Cayer

Evaluation Of A Presentation And Measurement Method For Assessing Activity Preference , Tara L. Lieblein

Using The ABLLS with English Language Learners: Implications for Students and Teachers , Lorie G. Schultz

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• Research article
• Open access
• Published: 19 May 2020

A qualitative research of adolescents with behavioral problems about their experience in a dialectical behavior therapy skills training group

• Eva Sesma Pardo   ORCID: orcid.org/0000-0003-2150-1616 1 ,
• Aránzazu Fernández Rivas 1 , 2 ,
• Pablo Orgaz Barnier 1 ,
• Marina Beá Mirabent 1 ,
• Iñaki Kerexeta Lizeaga 1 ,
• Aída Díaz Cosgaya 1 ,
• Ana Catalán Alcántara 1 , 2 ,
• Esther Vivanco González 1 ,
• Blaise Aguirre 3 , 4 &
• Miguel Angel González Torres 1 , 2  

BMC Psychiatry volume  20 , Article number:  245 ( 2020 ) Cite this article

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Several quantitative studies support the effectiveness of the Dialectical Behavior Therapy (DBT) psychosocial skills training group component for adolescents with impulse-control disorder and/or emotional dysregulation. However, qualitative research to assess this psychotherapeutic tool in the adolescent population is sparse. This study aims to examine the subjective experience of adolescents with behavioral issues who have completed DBT skills training group, as well as using this experience to extract hypotheses regarding its usefulness which can then be verified at a later time by means of quantitative instruments.

We developed a qualitative study by using focus groups with adolescents ( N  = 20) whose diagnosis includes symptoms such as behavior disorder, impulse-control disorder and/or emotional dysregulation, and good informants, who have completed DBT skills training. Three focus groups were created.

The subjective experience of adolescents who have completed a DBT skills training group is collected in four main categories: experience of illness, motivation for therapy, experience of therapy and results of the therapy.

Conclusions

Adolescents with behavioral problems assess their participation in the DBT skills training group positively, even recommending its usefulness to healthy population. Beyond learning skills, they emphasize the intrapsychic changes (as improvement in reflective activity) that they objectify after the group experience.

Peer Review reports

Adolescence can be seen as a period of coping with a variety of challenges, necessary for normal development [ 1 ]. During adolescence, emotional dysregulation leading to impulsivity and the emergence of behavioral problems is common [ 2 ]. Emotional dysregulation consists of poor control over his or her own affective expression in different situations. It is characterized by little flexibility and spontaneity, lack of control and disruptive behaviors. Following Linehan’s biosocial model, we conceptualize emotion dysregulation in borderline personality disorder (BPD) as consisting of four components: emotion sensitivity, heightened and labile negative affect, a deficit of appropriate regulation strategies, and a surplus of maladaptive regulation strategies. Emotional dysregulation is a dimensional entity, not exclusively related to any specific disorder and may be present both in externalizing and internalizing disorders [ 3 , 4 , 5 ].

Dialectical behavior therapy (DBT) was developed specifically to address Borderline Personality Disorder (BPD). It includes four components: individual therapy, psychosocial skills training, telephone coaching for patients, and a supervision team for the therapists [ 6 , 7 ]. DBT is conceptualized as a transdiagnostic treatment [ 8 ], the aim of which is to help the patient initiate functional behavior, even when they are experiencing very intense emotions [ 9 ]. Skills training appears to be the most effective component of DBT when emotional dysregulation predominates [ 10 ] and also for adolescent patients [ 11 , 12 , 13 ]. It includes five modules (mindfulness, distress tolerance - DT, emotion regulation - ER, interpersonal effectiveness -IE, and walking the middle path) taught throughout sixteen weeks in group format. Mindfulness and DT are the skills most valued by adolescents [ 14 , 15 ].

Several quantitative studies support the effectiveness of DBT for adolescent populations who present multiple problems [ 16 , 17 , 18 , 19 ] including BPD traits, suicidal and/or self-injurious ideation and behavior [ 20 , 21 , 22 , 23 , 24 , 25 ]. Furthermore, preliminary effectiveness of DBT for pre-adolescent children with mood disruptive dysregulation disorder has also been reported in a randomized controlled trial [ 26 ].

The subjective view of young adults treated with DBT regarding the process and outcome of the therapy has been explored using qualitative methodology. Factors such as therapeutic relationship, self-motivation to change, validation and the perception of genuine interest in the support offered by the leaders of the skills group, are described as fundamental components to the improvement experienced [ 27 , 28 , 29 ]. The most valued skills were mindfulness and DT [ 30 ].

Even though DBT for adolescents has provided consistent evidence of efficacy, there are often patients who drop out, others who show insufficient outcomes and some others who find difficulties in adapting to the requirements of participation in skills groups. We think the exploration of the subjective experience of participants with a qualitative methodology could provide potentially interesting insights regarding ways to deal with those problems. Besides that, we believe the qualitative exploration of subjective experience in a group context could not only add to the existing knowledge about emotional dysregulation and interpersonal difficulties shown by those patients but could also give us clues to a better understanding of the healing process itself.

We conducted a study employing qualitative methods with the following objectives: (i) To better understand the subjective experience of adolescents with behavioral problems who have participated in DBT skills training groups, (ii) To assess the perceived usefulness of those skills, and (iii) To ascertain the subjective benefit from participating in a group as a place of learning with peers and authority figures.

Qualitative methodology is essential for health sciences when studying aspects unapproachable by other methodologies. These elements include values, attitudes, expectations, and the impact of suffering and sociocultural factors that influence health and illness. Within those methods of a qualitative nature, we chose focus groups due to the advantages they offer [ 31 ]. The key data generated by focus groups is the narratives of those participating [ 32 , 33 , 34 ]. The research team for our current study was composed of clinicians with experience in the field of psychotherapy and qualitative research [ 35 ].

Selection of the sample

Skills training groups for adolescents have been conducted by the Psychiatry Service of Basurto University Hospital (Bilbao), since January 2010. In parallel, their parents and families were offered similar groups. Adolescents who completed the skills training group (16 weekly sessions) and had shown during the process sufficient capacity to articulate opinions and disposition to share them, were considered as “good informants”. All those who met inclusion criteria (Table  1 ) were contacted by telephone and invited to participate. Their participation was voluntary and they received no incentive.

We contacted 30 patients of which 24 agreed to participate. After parents and adolescents signed informed consent, they were enrolled and allocated to different focus groups. Of the 24 enrolled, four candidates did not attend the focus group providing no reason or explanation. We performed three focus groups with 20 participants. In focus group number 1, 7 participants were cited and 6 attended. In focus group number 2, 7 participants were cited and 6 attended. In focus group 3, 10 participants were cited and 8 of them attended.

The sample consisted of 20 adolescents (mean age 15.40; SD 1.39). Sociodemographic and clinical data are shown in Table  2 . All assessments and diagnoses were performed by a senior Child and Adolescent psychiatrist using DSM-IV-TR [ 36 ] prior to inclusion in the skills training group.

Focus groups and data collection

The research team had previously met before starting the focus groups to prepare a script delineating the scope of inquiry. We agreed upon a set of questions covering topics that in our view merited initial exploration. Two weeks earlier, we piloted these questions with two individuals who had met inclusion criteria in order to establish the utility of the questions as well as to identify unconsidered topics. After determining that the question-set would provide insightful commentary, the questions were put forward to the entire focus group. After completing the first focus group, two researchers independently studied the videotapes and transcripts. Then, all the researchers agreed on adapting the initial questioning path integrating the new ideas expressed in the first group. This process was also repeated after the second group. After completing the third focus group, it was considered that information saturation (no new information added) had been achieved. Groups of ninety minutes duration were performed and were led by two researchers unknown to the participants. A trusting and empathic environment was actively promoted [ 35 ].

Data analysis

The data analysis process is shown in Fig.  1 . The transcript documents were the primary data source. Each of the researchers first performed an in-depth independent reading and then proceeded to the categorization stage. Research team met twice a week to share their findings and reviewed disagreements and discrepancies until a final consensus regarding categorization was reached.

Outline of data analysis process

Analysis of the transcriptions, as required by qualitative methodology (exploratory, inductive and ethnographic), was based on Grounded Theory [ 32 ] .The discourse is codified, broken down into units of meaning, and categorized by a procedure of progressive abstraction from a textual level to a conceptual level by applying the constant comparative method. For the qualitative analysis of the data, we used the MAXQDA software program (version 12) [ 37 ].

Ideas expressed by the participants were grouped into four categories: experience of illness, motivation for therapy, experience of therapy, and results of therapy (Table  2 ).

Experience of illness

• Emotional dysregulation

Adolescents reported the difficulties they had in regulating emotions as a core issue. The blocking of communication or the failure of a mechanism such as emotional restraint, may later lead to the appearance of mood disorders and behavioral dyscontrol.

“And what I did was try to keep it in, keep it in (the distress) and … it worked until I burst” (A; Male, 23).

Behavioral dyscontrol

They describe behavioral dyscontrol, with an aggressive undertone, as a way of regulating emotions.

“she (mother) didn’t do anything wrong, but for the most trivial reasons, like if she would disagree with me, I’d hit her to vent my anger” (A; female, 16).

Identity issues

Adolescents describe identity issues in relation to poor or devalued self-concept, and perceive the identity of sufferer as immutable.

“Well I was a person who … let’s say … lived for her illness … let’s say I thought I was my own illness and I don’t know, I didn’t want to change” (M; female, 19).

Global functional deterioration

They observe how their symptoms have a direct impact on their global functional behavior, describing it as a vital break with a pre-existing global functional deterioration.

“I quit going to class for a year, broke up with the boyfriend I had for a long time, stopped going out with my best friends … it was awful with my family … so yeah, there were repercussions” (A; female, 17).

Environmental feedback

The environment responds to the problems of adolescents in various ways. Sometimes it can act as an aid by offering support and external containment,

“The thing is, in my case, my parents have always been there for me, they’ve been the ones who’ve helped me in everything, I’ve never had any kind of problem with my parents … ” (Y; male, 17).

however, in other cases it can make problems worse, in invalidating environments or where the stigma attached to mental illness is manifestly present.

“They’ve even called me a mental bitch, crazy … all sorts of names” (E; female, 17).

Motivation for therapy

Time factor.

Adolescents state that motivation for therapy varies depending on the moment of the illness course.

“I think it (the therapy) came at just the right time and … maybe what I was referring to was that … this was the beginning of realizing something was wrong with me, I don’t know how to explain it, this helped me realize” (M; female, 19).

Group attendance

It is suggested that group attendance may represent an objective parameter to assess motivation for change and active involvement in therapy.

“I only missed once (one group session) and it was ‘cause I had my tonsils removed, I wanted to change and took it very seriously” (E; female, 17).

Resistance to change

Resistance to change and consequently to receive help at some point during the course of their illness is another characteristic shared by adolescents.

“and well, I didn’t think I wanted to change, nor I felt comfortable or with the strength to change, I didn’t want no help, it’s happened to all of us at some point” (T; female, 21).

Self-motivation for treatment

The importance of self-motivation for change is stressed as an essential factor for the effectiveness of therapy. Without it, the therapy does not work.

“You know, if a person doesn’t want to change, they’ll never change, like, even if someone goes to lots of groups, lots of therapies or even if they travel to 50 different countries to do different therapies, that doesn’t matter, if someone isn’t willing to change, they won’t change” (L; female, 17).

Experience of therapy

Group frame.

Those participating in this study mention certain positive aspects within the group space such as being psychopathologically heterogeneous groups,

“No one else (in the therapy) had my same problem and I think this was good, cause if I’d found people who were as angry as I was at the world … it wouldn’t have done me no good” (A; male, 22).

and the participatory approach as a differentiating characteristic from other therapies.

“(the therapist) for example he made us go up to the blackboard, to explain it, participate … it was like … he made us study the theory, to put it some way, and then would ask us to come up and explain it … , it was different from other groups” (N; female, 18).

The adolescents see some aspects of the group space as therapeutic in themselves. For example, they define the group space as a validating space where there is no room for stigma

“Precisely when I was at my worst I thought I wanted to have someone to talk to who would understand me, so I could share it, that was enough to calm me down” (L; female, 17).

and where interpersonal relationships are encouraged, forming group cohesion.

“And there was a boy (in the group) who was a metalhead, he was great, we would laugh so much … and that would also help me to get better, that good relationship … ” (T; female, 21).

“Well … I don’t know, both of us helped each other to get better and get out of the hell we were in and all” (I; male, 20).

Those participating in this study point out the importance of the images and graphics to help understand the skills,

“I remember the circles, which was rational (mind), irrational or something like that” (A; female, 17).

“I think that one about the emotional, rational (mind) … wise mind, I think that’s what stuck with me the most ‘cause it was an image … you know, it was plain simple” (A; female, 16).

which, in turn, coincides with the importance given to mindfulness, as mindfulness and DT are the most valued skills.

“But that thing about the wise mind and the emotional mind did stick with me” (L; female, 17).

“I will remember this lesson all my life, I use it a lot, it was an exercise which said suffering equals pain plus lack of acceptance, and when you accept that pain, it’s no longer suffering and only the pain remains, this has helped me greatly” (A; female, 18).

However, they do not associate the usefulness of homework with the generalization of the skills learned in the group as the therapists instructed them.

“Yeah, I always (did the homework), ‘cause I felt it was an obligation, I’m not sure if it helped me a lot but I did do it” (L; female, 17).

It is suggested that skills implementation should be done unconsciously, in situations without a high emotional load, where acting with a wise mind is easier.

“Yeah, that’s it, since the beginning what he (the therapist) taught us was what to do in situations like that, so I would always try to put it to the test, I even got the point where I could do it without thinking” (S; female, 15).

“If the anger, let’s say, wasn’t of a very high level, I could do it (apply the skills) without realizing it” (O; female, 15).

Nevertheless, if the situation poses a high emotional load then the implementation of the skills has to be done consciously, with total awareness, since acting with a wise mind is more difficult.

“Well, I remember one time I was in Mathematics class with the teacher I loved so much (sarcasm). I didn’t' want to argue with him in class again so I started to shriek “come on wise mind, wise mind” everyone was freaking out while I kept on “wise mind, wise mind” so I wouldn’t swear at him, ‘cause otherwise I would disrespect him like I always did” (N; female, 15).

Relationship with peers

Adolescents observe that the relationship with peers in the skills groups serves as a measuring tool to assess their own severity.

“Compared to the other girls I was with (in the group), my problems didn’t seem that bad” (S; female, 15).

and point out that the phenomenon of universalization is a relief factor at the beginning of therapy.

“I realized there were more people (in the group) other than me who were ill, and, let’s say that doesn’t make you feel so lonely … ” (M; female, 19).

Relationship with therapists

Regarding the relationship with therapists, emphasis is placed on the need for their presence in order to regulate communication among the peers in the groups,

“I left the (WhatsApp) group chat … in any group of people with problems there has to be a therapist in between. Always” (L; female, 17).

and they value the therapist’s genuine interest to help as a crucial quality that contributes to their improvement.

“they (the therapists) would motivate you a lot, I remember I didn’t do the homework the first time I came here ‘cause I wasn’t motivated at all. Then the second time when I did it, he (the therapist) congratulated me, when I got the stuff done, when I did it well” (N; female, 18).

“they worried about what things served us the most to get better in the future, I don’t know, that was it in general, they were really implicated … ” (A; female, 17).

Results of the therapy

Positive assessment.

Adolescents assessed the skills training group (DBT) positively and recommended its potential usefulness in a healthy population.

“Well, I thought it was all very interesting and that’s something which is supposed to be basic but I think it should be way more in people’s minds, not only in our case; people who have problems, but in everyone else’s” (A; female, 17).

They have a realistic view of the results, being aware of the reversibility of the change, the results become noticeable over time and, likewise, last for a while.

“and eventually, as time went by (in the therapy) I did end up feeling an improvement” (O; female 15).

“yeah, but … even though, I think, to me, considering what I’m seeing lately, the group has served me just for some time ‘cause now I’m beginning to feel bad again” (I; male, 20).

The results are not idealized. Participants describe partial improvement and point out how difficulties in generalizing skills in certain situations still persist, especially those with a high emotional load.

“yeah, mine (the illness) stopped some time ago but I’m still having some bad periods … ” (M; female, 19).

The adolescents state that for the skills to work, motivation for change is essential, where life goals and self-reinforcement come into play.

“So I think all of us have experienced that what really makes us change is that we want to change, cause no one can do nothing for us, we have to take that kind of initiative like, alright, I’m gonna get better … ” (A; female, 16).

Acquiring abilities

The participants state that they acquire behavioral ability in the DBT skills training group to more adaptively cope with crisis situations and use tools to understand their own suffering. This on turn leads them to become aware of the difficulties they present and provide them with an understanding about their illness,

“I think (the therapy) came at the perfect time and … what I meant was that … this was the beginning of realizing something was wrong with me, I don’t know how to explain it … this helped to … stop seeing everything in black and white and lose control” (M; female, 19).

“to also make me realize that one can’t make a big deal out of everything (when asked, How did the therapy help you?)” (A; female, 16).

Intrapsychic changes

In parallel, intrapsychic changes occur, such as improvements in reflective activity. Projection is replaced by reflection, which allows patients to theorize about their illness from the observing self and to give meaning to their previous experience of suffering.

“every time I felt I wasn’t welcomed cause I had done something bad … to stop feeling upset, sometimes I would take two or three pills so I could swallow them … so I could feel as if I was swallowing my pain or something, to find something which would hurt me physically and not psychologically” (N; female, 15).

“cause you end up harming yourself … to forget the psychological pain through physical pain” (M; female, 19).

Adolescents in the skills training groups become aware of their problems and start to reflect upon causative mechanisms. They report difficulties in regulating their emotions as a core issue [ 3 , 5 , 6 ]. Following the group experience and the improvement in reflective function, they realize self-injury behaviors have an anxiolytic purpose [ 4 ].

The function our adolescents give to behavior coincides with the existing published studies. They use behavior to externalize internal difficulties [ 30 ]. This is a fact that supports the consideration of emotional dysregulation as a “transdiagnostic process” present in both internalizing and externalizing disorders [ 6 ].

Regarding their general experience of the skills training groups, participants mention several positive aspects:

They point out two qualities that are therapeutic in themselves: a validating environment and group cohesion. The group is referred to be validating when it is interested in and understanding of the individual’s experience and encourages them to express and communicate their emotions. Group cohesion provides relief, from the beginning of therapy, thanks to the universalization phenomenon and differentiation from peers [ 38 ]. However, we cannot consider these qualities as unique to DBT, because they can happen in other group approaches.

Adolescents also state a direct relationship between therapy effectiveness, self-motivation for change, and an active involvement in treatment [ 31 , 34 ]. Participants highlight how the benefits perceived are only obtained when the person is motivated for therapy, connecting this issue with the importance that DBT gives to the motivational work.

The participants express their preference towards the acceptance skills, mindfulness and DT, a finding consistent with existing literature [ 6 , 17 , 18 , 19 ]. They report that during therapy, mindfulness enables them to realize what is happening to them. ER skills allow them to rethink situations of the past and help to manage difficulties in the present. IE skills help them to have a representation of themselves and the other and be more effective in interpersonal relationships. These skills with the basic ingredients of DBT, validation and dialectics, favor intrapsychic changes such as an improvement in reflective activity.

Participants also express several critical views about the experience:

They do not seem to understand the relevance of homework assignments and how they promote the generalization of skills. It is true that we have not encountered rejection from the adolescents in the study towards completing the homework. This could be a topic to be more thoroughly addressed in groups of adolescents, making them truly aware of the importance of this aspect of the treatment to extend the effect of training across all areas of their lives.

Another relevant criticism concerns their view that improvement may not be complete or permanent, or that it does not come immediately, and relapses are possible. They see skills memorization and application with complete awareness as something difficult during an episode of high emotional dysregulation. Following these thoughts, some degree of maintenance or continuity of the treatment can be considered as a clear need. This could take the form of an extended period of individual DBT sessions, the so called “booster sessions” or graduate groups (involving participants who have already completed a skills training group) [ 12 ]. We opt for using a combination of individual sessions plus graduate groups as an ideal maintenance strategy. In any case the goals are relapse prevention, generalization of skills and promotion of behaviors that induce a positive quality of life.

Participants also mention other interesting proposals.

Taking their narratives into account, skills training is perceived as useful for emotional dysregulation issues. They regard its potential helpfulness also in healthy individuals, a finding shown in a qualitative study on adult population [ 27 ]. Including skills training in the socio-emotional learning curriculum for adolescents would equip them with tools to cope with different life situations, increasing their strength and consequently their resilience [ 38 ]. Likewise, this training may be of great help to encourage treatment adherence in those adolescents who not only suffer from a chronic medical illness [ 39 ] but also have a high resistance to assume and exercise responsibility for the treatment they require.

Therefore, our findings suggest that the flexibility and high structuring of skills training allow this component of DBT to become a vehicle through which we can reach out to adolescents and the multiple areas of their life.

In light of these findings, we see several avenues open to future studies.

Given the difficulties adolescents encounter to keep the gains obtained after the treatment, there is a clear need to evaluate maintenance interventions.

The important programs currently deployed to apply these interventions to healthy adolescents should be thoroughly extended and studied to examine their contributions to normal development and resilience [ 40 ].

Finally, as a logical step continuing from our study, subjective experience of parents and families of adolescent patients, participating in the parents skills training groups, should also be explored. In this instance, we believe a qualitative methodology is very well suited to carry on this study.

Limitations

Our study has two kinds of limitations. One is related to qualitative methodology itself and other specifically related to our study.

Qualitative studies all have an inherent problem of generalizability because the samples do not usually represent the population from where it comes. It is important to note that the goal here is to capture existing subjective experiences without assigning to them frequencies or intensities. These will be later studied through quantitative designs. The focus group format provides some important advantages but also implies limitations as the interaction among patients can favor inhibition of more passive individuals whose opinions fade to the background as a result of those who express more prominently their own opinions. Finally, we must not forget that discou-rse on any aspect of reality is conditioned by the semantic context in which an individual finds himself and in which he has grown up.

Some specific limitations of our study can also be pointed out. There is a lack of information about those subjects who declined to participate after having signed the informed consent. A possibility is that perhaps they had a negative view of the program and felt they would not be able to successfully voice their opinions and could even face rejection. Additionally, the researchers conducting the focus groups had never met the participants before the study, but the adolescents knew they belonged to the staff and this could have influenced the open sharing of their views.

Adolescents with behavioral problems who participated in this study identify the difficulties they have in adaptively managing the emotions that they feel to be a core issue. After completing skills training, they assess the psychotherapeutic tool positively and recommend its usefulness to a healthy population. They report that the motivation for change and the time factor are two aspects closely related to the effectiveness of the therapy. Furthermore, they also note that the most valued skills are mindfulness and DT. With regard to the results of the therapy, in addition to acquiring skills to adaptively manage suffering, they describe intrapsychic changes, such as an improvement in their reflective ability. This allows them to theorize about the difficulties they faced in their past and to better understand themselves in the present.

Availability of data and materials

Transcriptions are kept by the authors. Interested researchers can access them contacting the corresponding author and after complete anonimisation of participants is secured.

Abbreviations

Dialectical Behavior Therapy

Borderline Personality Disorder

Distress Tolerance

Emotion Regulation

Interpersonal Effectiveness

Diagnostic and Statistical Manual of Mental Disorders – IV - revised text

Spanish Association of Child and Adolescent Psychiatry

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Acknowledgements

The authors wish to thanks all of the participants of the study.

This study was partially funded by the Spanish Association of Child and Adolescent Psychiatry (AEPNYA) by awarding the research team the 2015 AEPNYA research prize. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Eva Sesma Pardo, Aránzazu Fernández Rivas, Pablo Orgaz Barnier, Marina Beá Mirabent, Iñaki Kerexeta Lizeaga, Aída Díaz Cosgaya, Ana Catalán Alcántara, Esther Vivanco González & Miguel Angel González Torres

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ESP: design, analysis, manuscript, final approval, corresponding author. AFR: design, analysis, manuscript, final approval. POB: focus group leader, final approval. MBM: focus group leader, final approval. IKL: recruitment, analysis, final approval. ADC: recruitment, analysis, final approval. ACA: recruitment, design, final approval. EVG: recruitment, analysis, final approval. BA: design, manuscript, final approval. MAGT: design, analysis, manuscript, final approval. All authors have read and approved the manuscript.

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Pardo, E.S., Rivas, A.F., Barnier, P.O. et al. A qualitative research of adolescents with behavioral problems about their experience in a dialectical behavior therapy skills training group. BMC Psychiatry 20 , 245 (2020). https://doi.org/10.1186/s12888-020-02649-2

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Behavioral problems of school children: impact of social vulnerability, chronic adversity, and maternal depression

• Ana Karina Braguim Martineli   ORCID: orcid.org/0000-0003-2549-5583 1 ,
• Fernanda Aguiar Pizeta 1 &
• Sonia Regina Loureiro 1  

Psicologia: Reflexão e Crítica volume  31 , Article number:  11 ( 2018 ) Cite this article

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This study’s objective was to identify the predictive effect of indicators concerning social vulnerability, chronic adversity, and maternal depression on behavioral problems among school-aged children, according to the perceptions of mothers and teachers, considering the presence or absence of difficulties in the contexts of family and school. A total of 85 pairs of mothers and school children were distributed into three groups according to the behavioral problems identified. A General Questionnaire, the PHQ-9, the Chronic Adversity Scale, and the (Strengths and Difficulties Questionnaire) SDQ were applied to the mothers; the Raven’s Colored Progressive Matrices were applied to the children; and the SDQ was applied to the teachers. Data were analyzed with descriptive, predictive, and comparative statistical procedures ( p  ≤ 0.05). The results reveal the presence of cumulative risks for children with behavioral problems; mothers more frequently identified behavioral problems than teachers; and maternal depression was a predictor for behavioral problems. Such findings are relevant for devising mental health programs.

The behavior of school-aged children is an important indicator of adaptation in this stage of development; however, not all children are successful and may present externalizing or internalizing behavioral problems, expressed within the family and/or school contexts (Achenbach, Ivanova, Rescorla, Turner, & Althoff, 2016 ; Linhares & Martins, 2015 ; Marturano, 2013 ).

Families present structural and internal dynamics that may contribute to either risk or protective outcomes in terms of child development (Macana & Comim, 2015 ; Walsh, 2016 ) so that adaptive difficulties associated with behavioral problems are frequent among children (Pizato, Marturano, & Fontaine, 2014 ). Considering the relevance of the influence exerted by the family context on school children, various studies have addressed the association of cumulative adversity present in the family context and the outcomes of behavioral problems among children (Duncombe, Havighurst, Holland, & Frankling, 2012 ; Leis, Heron, Stuart, & Mendelson, 2014 ; Pizeta, Silva, Cartafina, & Loureiro, 2013 ).

When analyzing the potential risk factors for the development of psychopathologies in 252 children and adolescents who are victims of domestic violence, Hildebrand, Celeri, Morcillo, and Zanolli ( 2015 ) verified that 92.8% of the participants were exposed to at least one risk factor. The authors also noticed that the association of two or more risk factors were present in 53.2% of the sample, namely family conflicts, mental health problems within the family, gender violence between parents, family involvement with drug trafficking and criminal behavior, and the abusive consumption of alcohol by parents or legal guardians, among others.

Therefore, among the events listed as conditions that predispose children to behavioral problems, we highlight indicators of chronic adversity and mental health conditions affecting the parents, especially maternal depression, as risk conditions acknowledged to have a negative impact on children. Additionally, the presence of variables related to social vulnerability is also identified based on conditions or events of life that may interfere in the course of developmental outcomes for children, contributing to the maladaptation of children in typical developmental tasks when experiencing risk conditions.

Considering social vulnerability in the population in general, low socioeconomic status and unemployment among mothers were identified as predictors of behavioral problems among children in situations of poverty, according to a study conducted by Bele, Bodhare, Valsangkar, and Saraf ( 2013 ) of children in India. In the Brazilian context, Correia, Saur, and Loureiro ( 2014 ) conducted a cohort study and identified an association of behavioral problems with low socioeconomic status for boys and low maternal education and larger families for girls. In the same direction, Pizato et al. ( 2014 ) verified association between improved socioeconomic conditions with fewer behavioral problems and more social skills in school-aged children; Saur and Loureiro ( 2015 ) identified associations between behavioral problems among 10-year-old children with low maternal educational level and low socioeconomic status and families with more than four members. It is also considered that the family socioeconomic condition can influence the cognitive performance of children, being this condition strongly related to other environmental aspects such as maternal depression (Piccolo et al., 2012 ).

In regard to the parents’ mental health, maternal depression, especially given its high prevalence and recurrence (World Health Organization [WHO], 2017a , 2017b ), stands out as a form of adversity in different periods of child development, impacting the behavior of school-aged children (Bagner, Pettit, Lewinsohn, & Seeley, 2010 ; Callender, Olson, Choe, & Sameroff, 2012 ; Edwards & Hans, 2015 ; Loosli, Pizeta, & Loureiro, 2016 ). Such a psychopathology, however, is associated with other adverse contextual conditions, favoring cumulative risk in the family context (Kessler, 2012 ). Note that the condition of cumulative risk has been acknowledged in the literature as having a greater impact for outcomes among children compared to the presence of a single risk (Evans, Li, & Whipple, 2013 ). Thus, this justifies the relevance of studying potential associations between maternal depression and behavioral problems, including other variables in the family environment, as proposed in this paper.

Indicators of social vulnerability and clinical characteristics of maternal depression have been identified as relevant factors to understanding risk conditions for child development. Barker, Copeland, Maughan, Jaffee, and Uher ( 2012 ) monitored children from their first year of life up to the age of 7 and verified that, in comparison to children of mothers without depression, children of mothers with depression were more frequently exposed to 10 out of the 11 risk factors assessed in the study, among which, low socioeconomic status, single parent, physical abuse, low maternal education, and drug and alcohol consumption. The frequency of exposure was at a significant level. Indicators concerning the severity of depression and anxiety were examined by Leis et al. ( 2014 ), in a sample of 2891 mother-child pairs, taking into account the perspectives of mothers and teachers. The authors found an association between severe depressive symptoms during pregnancy and more frequent behavioral problems at the age of 10 and 11 years old, according to the reports of teachers. Conners-Burrow et al. ( 2016 ), who took into account the assessment of mothers, determined that early contact with maternal mild depressive symptoms increased the risk of children presenting internalizing and externalizing behavioral problems during school-age years.

Still considering chronic risk and adversity and their influence on child behavior, we highlight the study by Wang, Christ, Mills-Koonce, Garrett-Peters, and Cox ( 2013 ), who found associations between externalizing problems among 4- to 12-year-old children and the use of more rigid control and low maternal educational levels. The study by Bouvette-Turcot et al. ( 2017 ) reports that exposure to more adversity and low family income during childhood was associated with the development of depressive symptoms in adulthood.

When addressing behavioral problems, one issue that arises refers to the source of assessments, considering that children and adolescents may present problems in a specific context but not in another, for instance, family versus school, indicating a need to obtain assessments from multiple informants, especially from parents or legal guardians and teachers (Martoni, Trevisan, Dias, & Seabra, 2016 ; Miller, Martinez, Shumka, & Baker, 2014 ). In this direction, some studies draw attention to the low to moderate level of agreement obtained between informants and to the relevance of such information to implementing clinical practices intended to address specific contexts in which children present problems (De Los Reyes et al., 2015 ; Martel, Markon, & Smith, 2017 ). Despite disagreement among the various informants, different observers provide different perspectives of the same problem (Miller et al., 2014 ). Each observer, though, can provide potentially valuable data in regard to the same patient (De Los Reyes, Thomas, Goodman, & Kundey, 2013 ; Clark, Durbin, Hicks, Iacono, & McGue, 2017 ), taking into consideration different contexts.

With school-aged children in mind, mothers and teachers have a privileged opportunity to observe the behavior of children, since the family and school are the primary contexts of development where competence in specific tasks inherent to this period is acquired (Achenbach et al., 2008 ), as previously mentioned. Some studies addressing the behavior of children according to the assessments of parents and teachers highlight the discrepancy between such assessments. Johnson, Hollis, Marlow, Simms, and Wolke ( 2014 ) used the Strengths and Difficulties Questionnaire (SDQ) to assess 219 children aged 11 years old who were born prematurely. The authors verified that the parents considered their children to present more emotional, attention, and relationship problems compared to the assessments provided by teachers. The informants agreed only in regard to the assessment of problems related to hyperactivity, which indicates the importance of using combined assessments. Kovess et al. ( 2015 ) conducted a study with 9084 children between 6 and 9 years of age, from seven countries (Italy, the Netherlands, Germany, Romania, Bulgaria, Lithuania, and Turkey), in which both teachers and parents were informants. The objective was to identify risks to the mental health of students. They verified that the teachers found the children to present more externalizing problems and fewer internalizing problems when compared to the parents’ assessments.

Even though assessments provided by multiple informants are considered relevant, the literature still lacks data. This study seeks to fill this gap and is intended to produce new data concerning the behavior of school children assessed by mothers and teachers, considering conditions in which children live with maternal depression and other adversities. Therefore, this study is intended to fill the gaps pointed out by De Los Reyes et al. ( 2015 ) concerning the need for further research using the assessments of multiple informants and addressing the specifics of contexts in which behavioral problems manifest, as a way to improve understanding regarding such problems, focusing on maternal depression. According to Goodman et al. ( 2011 ), there is a need for studies focusing on the multiple adversities presented in the family environment, taking into account the influence of maternal mental health when assessing the behavior of children, as indicated by Leis et al. ( 2014 ).

Therefore, the objective was to identify the behavioral profile of school children and associations between the evaluation of mothers and teachers, identifying the level of agreement among the informants. In addition, we aimed to evaluate the predictive effect of indicators concerning social vulnerability, chronic adversity, and maternal depression on behavioral problems presented by school children, according to the perspectives of mothers and teachers, considering the presence or absence of difficulties in both family and school contexts. The hypothesis guiding this study was that social vulnerability, chronic adversity, and maternal depression predict more frequent behavioral problems among school children in both developmental contexts, family and school, assessed by mothers and teachers, respectively.

A cross-sectional, correlational, predictive, comparative design was adopted using data obtained with different techniques from different sources, namely mothers, teachers, and children. The study was approved by the Institutional Review Board (no. 36415514.5.0000.5407) and complied with the ethical recommendations proposed by the Declaration of Helsinki.

Participants

A total of 85 mother-child pairs and 16 teachers from a public school located in the state of São Paulo, Brazil, took part in this study. The participants were assigned to three groups, according to the children’s indicators of behavioral problems assessed by their mothers and teachers, namely G1 = 18 children with behavioral problems according to their mothers and teachers, G2 = 39 children with behavioral problems according to their mothers or teachers, and G3 = 28 children without behavioral problems according to their mothers and teachers.

According to the inclusion criteria, mothers were aged between 25 and 45 years old, 34.5 years old on average (SD = 5.51), and all were literate. The children were aged between 7 and 10 years old, 8.8 years old on average (SD = 1.06) and were homogeneously distributed into three groups. In regard to the children’s sex, 39 were girls and 46 were boys, making a balanced distribution according to sex impossible: G1 presented significantly more boys than girls when compared to the G2 and G3 ( p  = 0.05; p  = 0.02, respectively). In order to assess the weight of this variable for the presence or absence of behavioral problems among children, as assessed by both their mothers and their teachers, an ordinal regression analysis was performed considering the sex of the children, which revealed a model that did not present the minimum criteria regarding slope homogeneity [chi-square (1) = 5.285; p  = 0.022; D (1) = 5.524; p  = 0.019], that is, it is not a model that fits data under analysis.

The inclusion criteria are that the children live with their biological mothers, rather than adoptive mothers, and have attended at least 1 year of primary school. Institutionalized children or those with apparent physical or mental disabilities were excluded. The assessment of children was initiated after consent was obtained from their mothers, and only one child per family was included in the study. In regard to the teachers, only those who had had at least 3 months of contact with the children and taught the children whose mothers explicitly consented to the assessment of their children at school were included. In accordance with the principles of good research practices, the participation of mothers and teachers was voluntary, without incentive payment mechanisms that stimulated the involvement with the research. A lecture was offered to the school on the behavior and learning of school children.

Instruments

Raven’s colored progressive matrices (raven).

The Raven is an instrument standardized by Angelini, Alves, Custódio, Duarte, and Duarte ( 1999 ), to assess the intellectual level of Brazilian children between 5 and 11 years old. It is a psychological test of non-verbal intelligence; the objective of which is to assess one’s analogical reasoning as a general factor, composed of three series: A, AB, and B, each with 12 problems. It presents good psychometric qualities, inferred by construct validity, internal consistency, with item-total correlation between 0.30 and 0.80 for most items, as well as precision, inter-item coefficient of correlation for the total sample equal to 0.92 (Angelini et al., 1999 ). Children presenting potential cognitive deficits, who presented percentiles lower than 25, were excluded from the study (Muniz, Gomes, & Pasian, 2016 ), balancing groups according to the percentiles obtained by the children.

Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is a module directly based on the diagnostic criteria for major depression disorder from the DSM-IV, proposed and validated by Spitzer, Kroenke, and Williams ( 1999 ) and by Kroenke, Spitzer, and Williams ( 2001 ). The questionnaire enables both screening for signs and symptoms of current major depression, as well as classifying levels of severity, from mild to moderate or severe; the greater the score, the more indicators of problems the individual presents. It is composed of nine items assessed by an ordinal scale that measures the frequency of signs and symptoms of depression in the last 2 weeks. According to the instrument’s technical instructions, the total score was used so that scores greater than or equal to 10 indicate the presence of depressive symptoms, while scores lower than 10 indicate an absence of such symptoms. The Brazilian version used in this study was translated by Pfizer (Copyright  © 2005 Pfizer Inc., New York, NY), the reliability of which was verified by Osório, Mendes, Crippa, and Loureiro ( 2009 ), presenting satisfactory psychometric indicators.

Strengths and Difficulties Questionnaire (SDQ)

The SDQ was developed by Goodman ( 1997 ) and is intended to assess the behavior of children and adolescents, aged between 4 and 16 years old, by screening their behavioral strengths and difficulties. There is a version for children and adolescents between 11 and 16 years of age, a version for parents, and another for teachers. The SDQ is composed of 25 items subdivided into five subscales: emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and pro-social behavior, with five items each. It provides raw scores and cutoff points for each of the subscales, as well as a total score for difficulty that is obtained by totaling the four behavioral problem scales. Scores are classified as normal, borderline, and abnormal. It was translated to Portuguese and adapted for Brazilian sociocultural characteristics by Fleitlich, Cortázar, and Goodman ( 2000 ), while psychometric data, concerning validity and reliability, were described by Woerner et al. ( 2004 ), presenting good indicators. In this study, based on individual scores and cutoff points established for the Brazilian population, we considered the outcome variable for children classified as normal or borderline, according to the SDQ, to be “without difficulties,” while those who were classified as abnormal to be “with difficulties.” These outcomes were grouped with the assessments performed by the mothers and teachers, according to the distribution in the groups.

Chronic Adversity Scale (CAS)

The CAS was proposed by Marturano ( 1999 ) and is intended to identify recurrent adverse events that may have taken place in a child’s life and happened repeated times or lasted 1 year or longer. It is composed of 18 items addressing issues concerning chronic adversity regarding the child’s or the parents’ health, parents’ temperament, and potential family or marital conflicts. The scale is completed by the mothers based on a list of adverse conditions that may have developed in the lives of children since birth, specifying the duration in years and the child’s period of life at the time. Each item is scored either 0 (absence of recurrence or chronic nature of the event in the child’s life) or 1 (the event was recurrent or has a chronic nature); the sum of all 18 items results in the total score, which is used to identify the existence of chronic events.

General Questionnaire

This questionnaire addresses sociodemographic data and specific information concerning the mothers’ age, marital status, and educational level; the families’ monthly income and socioeconomic status; and the age, sex, and education of the children included in the study. The items from the Brazil Economic Classification Criteria, developed by the Brazilian Association of Survey Companies ( 2015 ), were used to assess socioeconomic conditions. Such information was used to characterize the participants and groups, as well as to identify social vulnerability indicators, including low maternal and paternal education, single-parent families, low socioeconomic status, and low family income, as well as being recipients of governmental financial support.

Data collection procedures

Preferably, data were collected at school in a private room, or in the families’ homes when requested by the mothers, in which case we sought to preserve the respondents’ privacy and convenience. All interviews were held by the first researcher, who is a psychologist and properly trained in the application of instruments.

Initially, 427 families received an invitation letter, which was delivered to the children in their classrooms. The 260 families who responded to the invitation were contacted by phone with the objective to provide clarification about the study’s objectives and schedule an assessment. A total of 154 families accepted the invitation to cooperate with the study, but nine of these were excluded because the grandmothers were the primary caregivers of these families’ children. Of the 145 mothers scheduled for assessment, 43 did not attend the interviews, resulting in 102 families. Seventeen of these did not meet the inclusion criteria: adolescent mothers or mothers older than 45 years of age, children exclusively living with their fathers, and children with characteristics that were not homogeneous with those presented by the groups. Thus, a total of 85 mother-child pairs were included and assessed.

Of the 427 families initially invited to participate in this research, 316 refused to collaborate with the survey and 26 were excluded because they did not meet the inclusion criteria.

The instruments were individually and in-person applied to mothers in a single section according to the following order: General Questionnaire, PHQ-9, CAS, and SDQ, with an average duration of 60 min. The researcher read the instruments and checked the responses while the mothers had a copy of the instruments to accompany the reading. This procedure was adopted to deal with potential difficulties or fatigue that the reading could produce in the mothers, given their level of education or potential depressive symptoms, though the mothers presented a minimum level of literacy that enabled them to understand the questions posed by the instruments.

The children were assessed at school in individual sessions that lasted an average of 15 min. After briefly establishing rapport, the Raven’s Colored Progressive Matrices was applied. The three groups were compared according to the percentiles children obtained in order to balance the groups in regard to this variable. Note that there were no significant statistical differences between them in regard to the children’s cognitive performances (G1: \( \overline{x} \)  = 75.1; σ  = 19.12; G2: \( \overline{x} \)  = 76.0; σ  = 13.44; G3: \( \overline{x} \)  = 66.9; σ  = 14.97).

The 16 teachers collectively completed the SDQ, focusing on the behavior of 85 children who had been previously assessed by their mothers, at the regular time scheduled for a meeting concerning collective teaching work. Each teacher was supposed to assess up to five students per meeting, with an average duration of 50 min and approximately 10 min per child. The teachers filled in the questionnaire, and the researcher remained in the room during the assessment to clarify potential doubts.

Data treatment and analysis

The PHQ-9, Raven, SDQ, and CAS were coded according to the purpose of each instrument. The assessments concerning the behaviors of children performed by the mothers and teachers using the SDQ were used as distinct sources in paired samples, in order to assign the participants to one of the three groups.

Coded data were typed in an Excel® spreadsheet and checked by independent reviewers. The statistical analyses were performed using IBM SPSS Statistics (v. 23; IBM SPSS, Chicago, IL), and a significance level of 0.05 was adopted.

The reliability of the PHQ-9 was verified for this sample using Cronbach’s alpha, which presented good psychometric quality ( α  = 0.87). The reliability of the SDQ ( n  = 85) for the totality of items regarding difficulties was based on the mothers’ ( α  = 0.77) and teachers’ answers ( α  = 0.89), as well as items of the pro-social behavior scale answered by mothers ( α  = 0.71) and teachers.

Normality tests (Kolmogorov-Smirnov, with Lilliefors significance correlation, and Shapiro-Wilk) were performed to guide decision-making regarding the statistical tests used for each set of variables.

The behavioral profile of children, obtained through the assessments of mothers and teachers and represented by the raw scores obtained on the scales addressing problems and pro-social resources and the total scale of difficulties in the SDQ, was analyzed using descriptive and comparative statistics by means of the Wilcoxon test. Indicators of the presence and absence of behavioral problems among children, assessed by the mothers and teachers using the SDQ, were compared using the McNemar test. Inter-observer agreement was also verified using the Kappa coefficient, while the criterion proposed by Landis and Koch ( 1977 ) was adopted.

The sociodemographic data and profiles of social vulnerability and chronic adversity were analyzed using descriptive statistics, while the groups were compared using chi-square and Kruskal-Wallis tests. After the univariate analysis, the predictive effect of cumulative adverse conditions on school children’s behavioral problems was assessed using ordinal regression analysis (Maroco, 2014 ), adopting criteria proposed by Field ( 2013 ) for the inclusion of predictive variables.

The weight of contextual adverse cumulative variables for the children’s behavioral problems was tested using ordinal regression analysis based on the significant variables identified in the comparison between groups. The predictive variables were included in the model (family income, mother’s education, and maternal depression were included as factors, and the score of chronic adversity was included as a covariant), independently tested, and combined with the sex of children, because the distribution of children in the groups according to sex was not homogeneous. Additionally, the contextual variables of cumulative risk were jointly tested in a multivariate model.

The analysis of the social vulnerability indicators (income and maternal education) and maternal depression, in one analysis disregarding the sex of children and then one considering the sex of children, showed that the models did not fit the data. The analysis of the models that included chronic adversity, as a single variable or associated with the sex of children, revealed statistically significant models, with very small effect sizes, in which independent variables did not predict the behavioral outcome among children, thus did not present relevant results. Afterwards, the multivariate model including maternal depression, social vulnerability indicators, and chronic adversity was tested and presented goodness of fit and is the model presented here.

Based on the objectives proposed, the results are presented taking into account the analyses concerning the children’s behavioral profiles according to the assessments of mothers and teachers as distinct sources, comparisons between G1, G2, and G3 regarding profile of social vulnerability, maternal depression, and chronic adversity, as well as the predictive effect of significant variables on the children’s behavioral problems assessed by mothers and professors, as combined sources of information.

The children’s behavioral profiles

Table  1 presents the behavioral profiles of the children assessed, according to the SDQ, by mothers and teachers as two different sources, adopting the presence or absence of behavioral problems verified by the SDQ and total difficulties as the outcome of the development of school children.

Significant statistical differences were found when comparing mothers and teachers in regard to the four specific scales of difficulties and total difficulties. Note that the mothers considered their children to present more emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and total difficulties than the teachers. In regard to pro-social behavior, no statistically significant differences were found in regard to the comparisons between mothers and teachers.

In regard to the level of agreement obtained between assessments (mothers and teachers), note that reasonable agreement levels were found for conduct problems (kappa = 0.29 p  = 0.003) and total behavioral problems (kappa = 0.21; p  = 0.007), in addition to minimum indexes for hyperactivity (kappa = 0.19; p  = 0.035).

Similarly, the same differences were found for continuous scores. The means of the mothers were greater than those presented by the teachers for the total difficulties score (mothers: \( \overline{x} \)  = 17.5; σ  = 6.98; teachers: \( \overline{x} \)  = 9.33; σ  = 7.28; p  <  0.001) and for the four scales concerning symptoms: emotional symptoms (mothers: \( \overline{x} \)  = 3.19; σ  = 2.52; teachers: \( \overline{x} \)  = 2.26; σ  = 1.89; p  <  0.001), conduct problems (mothers: \( \overline{x} \)  = 3.32; σ  = 2.56; teachers: \( \overline{x} \)  = 1.59; σ  = 2.23; p  < 0.001), hyperactivity (mothers: \( \overline{x} \)  = 6.79; σ  = 2.76; teachers: \( \overline{x} \)  = 4.04; σ  = 3.23; p  < 0.001), and peer relationships (mothers: \( \overline{x} \)  = 2.20; σ  = 2.20; teachers: \( \overline{x} \)  = 1.42; σ  = 1.90; p  < 0.001).

The profiles of families in terms of vulnerability and risk variables

Table  2 presents comparisons concerning social vulnerability, maternal depression, and chronic adversities presented in the family context of children according to their distribution in the three groups.

Statistically significant differences were found between G1, G2, and G3 in regard to maternal education, family income, maternal depression, and chronic adversity. The comparison concerning maternal education revealed significant differences between G1 and G3 ( χ 2  = 5.660, p  = 0.017) and between G2 and G3 ( χ 2  = 12.075, p  < 0.001). Significant differences were also found in terms of family income between G1 and G2 ( χ 2  = 4.349, p  < 0.037) and between G1 and G3 ( χ 2  = 5.841, p  = 0.016). No differences were found between groups in terms of paternal education, marital status, socioeconomic status, or receiving governmental financial aid. Considering the variable maternal depression, however, statistically significant differences were found between G1 and G2 ( χ 2  = 13.876, p  < 0.000) and between G1 and G3 ( χ 2  = 22.489, p  < 0.001). G1 was the group in which mothers more frequently presented current symptoms of depression in comparison to the other two groups, while no differences were found between G2 and G3.

Comparisons concerning chronic adversities revealed significant differences between G2 and G3 ( F  = 363.000, p  = 0.016), but no differences were found between G1 and G2 or between G1 and G3.

The predictive effect of adverse cumulative variables on child behavior

Table  3 presents the weight of adverse cumulative contextual variables on child behavior, including data concerning coefficients and significance of the adjusted ordinal model.

Data suggest that the adjusted model is significantly better than the null model [ G 2 (4) = 24,792, p  < 0.001). Additionally, the multivariate model was statistically significant [chi-square (58) = 50,367, p  = 0.752; D (58) = 57,402, p  = 0.497] and showed moderate effect size (R 2 MF = 0.253; R 2 N = 0.288; R 2 CS = 0.139). According to the model, children are more likely to present behavioral problems when their mothers present indicators of depression, according to the assessments of both mothers and teachers ( b  = 1.955, p  = 0.001).

This study was intended to verify associations between indicators of social vulnerability, chronic adversity, and maternal depression, and the weight of such associations, with behavioral problems among school children, as assessed by their mothers and teachers. In this study, mothers and teachers were considered distinct sources of information, and the information they provided on the children’s behaviors was combined considering the presence or absence of difficulties manifested in the two developmental contexts of family and school. The hypothesis guiding this study that social vulnerabilities, chronic adversity, and maternal depression impact behavioral problems among school children was partially confirmed, as data analysis revealed peculiarities regarding such variables, which deserve to be highlighted.

The assessments of the children’s behavior from the perspectives of mothers and teachers in general showed that mothers identified more behavioral problems in children than did the teachers. This finding is in agreement with those reported in the studies conducted by De Los Reyes et al. ( 2015 ) and Martel et al. ( 2017 ), which indicate low to moderate agreement among informants. In this same direction, Clark et al. ( 2017 ) consider that agreement between assessments of parents, teachers, and children is rarely high, however, emphasizing that varied information enriches the understanding of the associations between academic conditions, personality, psychosocial functioning, behavioral aspects, mental health, and social adjustment of school children. According to the mothers’ assessments, a larger number of children experienced difficulties concerning emotional symptoms, while the teachers identified a larger number of children with externalizing problems expressed through conduct problems and hyperactivity. Such results are similar to those reported by Kovess et al. ( 2015 ), who note that externalizing problems are more visible to teachers than internalizing problems.

Analysis of this discrepancy between assessments should take into account that the interaction of mothers and teachers with children occurs in contexts that exhibit different demands, in addition to the fact that observers are guided by different criteria. In the family context, mothers have a more detailed picture of their children’s behavior due to the large range of daily situations, which are not always structured (Leis et al., 2014 ). In the case of the mothers, the parameter is one specific child. In the classroom, in contrast, teachers have more structured situations to assess children and the teachers’ references include comparing the behavior of a set of children with similar demographic parameters. In this sense, when the assessments of mothers and teachers were combined, we accessed a larger set of information concerning the behavior of children, focusing on aspects of contextual comparisons and individual and collective parameters, as proposed by Miller et al. ( 2014 ) and De Los Reyes et al. ( 2015 ).

The literature has recognized the relevance of assessments performed by teachers; however, few studies address behavioral difficulties of children using multiple informants and combined data as a strategy to identify the presence of problems in more than one context of life. The predominance of the mother as the only informant may compromise the results of assessments, especially when a mother presents a psychopathological disorder (Leis et al., 2014 ), such as depression. Such a disorder may influence the individual’s perception of child behavior, and avoiding this influence justifies the use of distinct and combined sources of information. Therefore, we note that one of the contributions of this study, in addition to including multiple informants, is the combined analysis of children’s behavioral outcomes, which enabled verifying problems in two contexts, family and school, to estimate how many children face these sorts of difficulties, information that is relevant for practices in the mental health field.

Another aspect to be analyzed involves social vulnerability, which was assessed considering different social and economic factors, among which are low maternal educational level and income. These are relevant social determinants associated with the presence of behavioral problems among children, according to the assessments by mothers and/or children, indicating aspects to be considered when planning preventive practices. Note that these findings are consistent with those reported by Correia et al. ( 2014 ), who identified association between child behavioral problems and low socioeconomic status and low maternal educational level, indicating a potential profile of cumulative vulnerability favoring behavioral problems among children. Families with low socioeconomic status generally have high rates of divorce, unemployment, and a larger number of members, while parents with a high socioeconomic level have a higher educational level and invest more in their children’s education (Carneiro, Meghir, & Parey, 2013 ; Piccolo et al., 2012 ).

The associations between mental health conditions and vulnerability indicators have been widely recognized by the World Health Organization (WHO, 2017a , 2017b ), which highlights low schooling, lower income, worse material and economic conditions, and less social support, as possible determinants that negatively influence health mental health of adults and children, favoring the accumulation of vulnerability and risk conditions. This developmental scenario focuses on the relevance of the present study, which encompasses diverse and competing contextual variables that influence children’s developmental outcomes in the perception of different informants.

The presence of current depressive symptoms among the mothers was associated with behavioral problems among the children, as indicated by the mothers and/or teachers, characterizing problems in two contexts, family and school. Such an association was also verified by Leis et al. ( 2014 ) and Conners-Burrow et al. ( 2016 ), who noted an increase in behavioral problems among children who had early experience with maternal depression. In this sense, when we considered the behavior of children from the perspectives of mothers and teachers together, we verified that, regardless of the informant, children living with maternal depression more frequently experienced behavioral problems, including in the school context, characterizing the need for specific mental health practices directed to this group, which was identified as the most vulnerable.

The presence of chronic adversities was also verified to identify variables with a potential negative impact on school-aged children. This study reveals that children facing behavioral difficulties, according to the combined assessments of mothers and teachers, lived in family environments that presented more chronic adversities, indicating cumulative and recurrent adversity in these children’s contexts of life. These findings corroborate the study conducted by Hildebrand et al. ( 2015 ), who identified an association of two or more risk factors for more than half of the sample under study.

The identification of differences among groups, especially for children facing problems in the family and school contexts (G1) in regard to social vulnerability, current maternal depression, and chronic adversity, characterizes a group that requires greater attention, as it is exposed to multiple risks. This information highlights the relevance of investigating the presence of cumulative risk in the family context to understand developmental outcomes among children (Evans et al., 2013 ; Goodman et al., 2011 ).

In regard to the identification of the predictive effect of cumulative risk variables and vulnerability, as potential predictors of behavioral problems among children, only maternal depression appears as an explanatory variable for the presence of behavioral problems among children in the context of multiple adverse conditions. These findings are in agreement with Bagner et al. ( 2010 ), who stress that living with maternal depression increases a child’s likelihood of presenting externalizing and internalizing behavioral problems up to the age of 12 years old. Therefore, maternal depression was the only adverse condition with the power to predict the behavioral problem outcome, confirming the relevance of considering such a variable when addressing child behavior, especially considering the high prevalence of depression among women of childbearing age (World Health Organization [WHO], 2017a , 2017b ).

As the positive aspects of this study, we highlight the presence of multiple informants, the methodological care adopted in the systematic assessment of the participants, and the use of validated instruments, in addition to the inclusion of diverse variables to identify, in the same sample, vulnerability indicators that potentially impact the behavior of school children. It is highlighted as the main strength of the study the inclusion of children in the groups considering the presence or absence of behavioral problems in the two main development contexts for the school period, namely, family and school, thus highlighting relevant variables associated with vulnerability and to developmental resources in both contexts, which may favor preventive care and target groups with potential risks.

This study’s limitations include the sample size, lack of a homogeneous distribution between groups in regard to the sex of children, and the identification of depressive symptoms using a screening instrument, which limit the generalization of results. Further studies adopting longitudinal designs, considering the influence of contextual risks over the course of a child’s development, including other sources of information, in addition to the reports of mothers, are needed, as well as observational measures. The relevance of inclusion in new studies of parents’/stepfathers’ evaluations, as well as studies that address the characteristics of the various family configurations in which children are inserted as conditions that can influence the behavior of the school-aged children, is also highlighted. Another relevant point to be considered in new studies is the inclusion of variables that may function as protective factors, which in a cumulative way to vulnerability and risk conditions may favor a more complete and complex analysis of the mechanisms that favor or hinder children’s behavioral problems.

Conclusions

In this study, low maternal educational level, low family income, the presence of more chronic adversity, and living with current maternal depression are factors associated with the outcome of behavioral problems among children in both family and school contexts, showing the importance of including such factors in assessment protocols intended to address the mental health of school-aged children. Note, however, that among these indicators, current maternal depression emerged as the most relevant variable in comparison to the remaining adversities analyzed here. Therefore, this condition requires specific care when implementing mental health actions.

Finally, these results can contribute to and have implications for the planning of mental health programs, confirming the relevance of identifying maternal depressive symptoms and multiple adversities, including social vulnerability indicators as conditions or events that demand attention.

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To the development of this research, we counted on the financial support of the National Council for Scientific and Technological Development (CNPq/Brazil) under number 307394/2014-0.

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Martineli, A.K.B., Pizeta, F.A. & Loureiro, S.R. Behavioral problems of school children: impact of social vulnerability, chronic adversity, and maternal depression. Psicol. Refl. Crít. 31 , 11 (2018). https://doi.org/10.1186/s41155-018-0089-9

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Childhood neglect and its association with internalizing problems, co-occurrence of abuse and neglect, child neglect and its relation to emotional and behavioral problems: a cross-sectional study of primary school-aged children in tanzania.

Published online by Cambridge University Press:  26 March 2018

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Child maltreatment is known to engender negative emotional and behavioral consequences. Although neglect is the most frequent form of maltreatment, it has thus far only received little attention, especially when looking at low-resource countries. The current study investigated possible associations between neglect and internalizing and externalizing problems. As neglect and abuse often co-occur, the latter was controlled for. In total, 409 Tanzanian primary school students (52% boys, M = 10.5 years, range = 6–15) participated in the cross-sectional study. Structured clinical interviews were conducted assessing maltreatment, internalizing problems, and externalizing problems. Overall, 31% ( n = 128) of the children reported at least one type of physical neglect and 31% ( n = 127) of emotional neglect. Using structural equation modeling, we found a significant association between neglect and internalizing (β = 0.59, p < .01) and externalizing problems (β = 0.35, p < .05). However, these associations could only be detected in younger children (ages 6–9), whereas in older children (ages 10–15), mental health problems were significantly related to violence and abuse. Our findings suggest that the current age may influence the association between maltreatment type and the development of internalizing and/or externalizing problems.

Child maltreatment, including physical, emotional, and sexual abuse, as well as emotional and physical neglect is a global phenomenon (Dubowitz & Bennett, Reference Dubowitz and Bennett 2007 ; Stoltenborgh, Bakermans-Kranenburg, Alink, & van IJzendoorn, Reference Stoltenborgh, Bakermans-Kranenburg, Alink and van IJzendoorn 2015 ). It is defined as “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child” (Leeb, Paulozzi, Melanson, Simon, & Arias, Reference Leeb, Paulozzi, Melanson, Simon and Arias 2008 , p. 11) and can result in several severe emotional, social, and cognitive consequences across the life span (Gilbert et al., Reference Gilbert, Widom, Browne, Fergusson, Webb and Janson 2009 ; Norman et al., Reference Norman, Byambaa, De, Butchart, Scott and Vos 2012 ).

Compared to the definition of abuse, that of neglect is inconsistent and less clear in the research literature (Dubowitz et al., Reference Dubowitz, Newton, Litrownik, Lewis, Briggs, Thompson and Feerick 2005 ; Jud, Lips, & Landolt, Reference Jud, Lips and Landolt 2010 ). Complicating the search for a uniform definition may be the fact that neglect does not consist of clearly visible acts, such as actively harming someone. Instead, it contains acts of often invisible omission, which is the failure to act (Mennen, Kim, Sang, & Trickett, Reference Mennen, Kim, Sang and Trickett 2010 ). Neglect exists on a continuum (Dubowitz, Reference Dubowitz 2007 , Reference Dubowitz 2013 ), and defining a threshold where the failure to act becomes neglect has proven to be difficult (Dubowitz, Reference Dubowitz 2013 ; Dubowitz et al., Reference Dubowitz, Newton, Litrownik, Lewis, Briggs, Thompson and Feerick 2005 ; McSherry, Reference McSherry 2007 ). Moreover, neglect includes a wide variety of different forms, such as in regard to the child's emotional needs or the child's physical health (McSherry, Reference McSherry 2007 ). Neglect may occur for a variety of reasons, and parents or caregivers often do not intend to endanger the child (Dubowitz, Reference Dubowitz 2013 ). It is more likely that they do not have the necessary resources, do not recognize the potential danger, or suffer from psychological ailments themselves (Dubowitz & Bennett, Reference Dubowitz and Bennett 2007 ). This is of special importance with regard to low-resource countries, due to the high prevalence of difficult life circumstances (Mbagaya, Reference Mbagaya 2010 ). However, the lack of a uniform definition makes determination of prevalence rates difficult (McSherry, Reference McSherry 2007 ). In this paper, we define neglect as “the failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm or potential harm” (Leeb et al., Reference Leeb, Paulozzi, Melanson, Simon and Arias 2008 , p. 17). Furthermore, we follow the common differentiation of neglect into physical and emotional neglect. Physical neglect includes omissions like the failure to provide properly fitting clothes that are appropriate to the weather, not taking the child to the doctor when he or she is ill, or not feeding the child properly. Emotional neglect, in contrast, includes omissions like not interacting with the child or not responding to the child's emotional needs (Barnett, Manly, & Cicchetti, Reference Barnett, Manly, Cicchetti, Cicchetti and Toth 1993 ).

Child neglect is known as a type of maltreatment with a chronic nature as it usually occurs repeatedly over a period of time (Korbin & Krugman, Reference Korbin and Krugman 2014 ). It is the most common and the most frequently fatal form of child maltreatment (Korbin & Krugman, Reference Korbin and Krugman 2014 ; US Department of Health and Human Services, 2012 ). In addition, recent studies have found that, in contrast to other types of maltreatment, the prevalence rates of neglect are not declining (Korbin & Krugman, Reference Korbin and Krugman 2014 ). For example, Sedlak et al. ( Reference Sedlak, Mettenburg, Basena, Petta, McPherson, Greene and Li 2010 ) conducted a community survey in the United States and came up with a frequency of 31 incidences of neglect per 1,000 children. Another estimate stated that 78% of child maltreatment reported to the US child welfare system in 2009 was for neglect (US Department of Health and Human Services, 2010 ). However, in spite of these estimations, little attention has been paid to neglect. This is particularly true for middle- and low-income countries. For example, a meta-analysis on the global prevalence of neglect could only include three studies from Asia but none from South America nor from Africa (Stoltenborgh et al., Reference Stoltenborgh, Bakermans-Kranenburg, Alink and van IJzendoorn 2015 ; Stoltenborgh, Bakermans-Kranenburg, & van IJzendoorn, Reference Stoltenborgh, Bakermans-Kranenburg and van IJzendoorn 2013 ).

More than 30 years ago, Wolock and Horowitz ( Reference Wolock and Horowitz 1984 ) were the first to term this phenomenon “neglect of neglect.” Childhood neglect receives less consideration than other forms of maltreatment, with regard to research, public awareness, and money spent on prevention and treatment of neglected children (Korbin & Krugman, Reference Korbin and Krugman 2014 ; McSherry, Reference McSherry 2007 ), even though it often results in tremendous negative consequences (Dubowitz, Reference Dubowitz 2013 ). However, these consequences may appear only years later (Dubowitz, Reference Dubowitz 2007 ; Korbin & Krugman, Reference Korbin and Krugman 2014 ), which might have the effect of making neglect appear less detrimental at first sight. Besides that, neglect often occurs together with other types of maltreatment, such as different types of abuse (Finkelhor, Ormrod, & Turner, Reference Finkelhor, Ormrod and Turner 2007 ; Korbin & Krugman, Reference Korbin and Krugman 2014 ; Mennen et al., Reference Mennen, Kim, Sang and Trickett 2010 ). This co-occurrence makes it difficult to disentangle the consequences of neglect from consequences of other forms of maltreatment (Korbin & Krugman, Reference Korbin and Krugman 2014 ). However, Mills et al. ( Reference Mills, Alati, O'Callaghan, Najman, Williams, Bor and Strathearn 2011 ) and Hildyard and Wolfe ( Reference Hildyard and Wolfe 2002 ) found that neglect in early childhood can have unique influences on social, emotional, cognitive, and physical development all the way into adolescence and adulthood.

Several studies have found support for the association between childhood neglect and children's level of internalizing problems (Hildyard & Wolfe, Reference Hildyard and Wolfe 2002 ; Manly, Kim, Rogosch, & Cicchetti, Reference Manly, Kim, Rogosch and Cicchetti 2001 ; Spratt et al., Reference Spratt, Friedenberg, Swenson, LaRosa, De Bellis, Macias and Brady 2012 ). Comparing neglect with other types of maltreatment, Manly et al. ( Reference Manly, Kim, Rogosch and Cicchetti 2001 ) discovered that neglected children tend to internalize problems significantly more than physically abused children do. They also found neglected children to be more socially withdrawn compared to nonneglected children. In their review, Hildyard and Wolfe ( Reference Hildyard and Wolfe 2002 ) presented further support for this finding: neglected children experience relatively few positive social interactions. In addition, they reported an association between neglect and problems in emotion regulation. These emotional problems also appeared to be more severe than those of abused children (Hildyard & Wolfe, Reference Hildyard and Wolfe 2002 ). According to Widom, DuMont, and Czaja ( Reference Widom, DuMont and Czaja 2007 ), the risk of a diagnosis of depression is also increased in neglected children.

Neglect has also been associated with externalizing problems. For example, Kotch et al. ( Reference Kotch, Lewis, Hussey, English, Thompson, Litrownik and Dubowitz 2008 ) conducted a longitudinal study following children from birth until the age of 8. They discovered support for an association between early neglect and aggression later in life. Nevertheless, in another study, camp counselors rated neglected children as more aggressive compared to nonneglected children, but less aggressive than physically abused children (Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ). As neglect and abuse often co-occur, many studies fail to adequately disentangle the consequences of abuse and neglect. Widom and Maxfield ( Reference Widom and Maxfield 2001 ) found evidence for a significant association between maltreatment and violent criminal behavior when comparing arrest records of maltreated children with those of a control group. Furthermore, Widom et al. ( Reference Widom, DuMont and Czaja 2007 ) found an increased risk for later alcohol abuse in maltreated women compared to a nonmaltreated control group. However, in spite of these studies, it remains unclear whether the increased levels of externalizing problems are related to experiences of abuse, neglect, or both.

The same is also true for the consequences of abuse. Abuse has been consistently associated with externalizing problems (e.g., conduct disorder, hyperactivity, aggressive, and criminal behavior; Gershoff, Reference Gershoff 2002 ; Hecker, Hermenau, Isele, & Elbert, Reference Hecker, Hermenau, Isele and Elbert 2014 ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ; Sugaya et al., Reference Sugaya, Hasin, Olfson, Lin, Grant and Blanco 2012 ). Abuse has also be associated with internalizing problems (Hecker, Hermenau, Salmen, Teicher, & Elbert, Reference Hecker, Hermenau, Salmen, Teicher and Elbert 2016a ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ). However, most investigations of the consequences of child maltreatment focus only on exposure to violence, including abuse, and do not document whether they controlled for other types of maltreatment, such as neglect (Paolucci, Genuis, & Violato, Reference Paolucci, Genuis and Violato 2001 ). In addition, many studies did not differentiate between the different types of maltreatment at all (Danese & Tan, Reference Danese and Tan 2014 ). Thus, in many cases, findings cannot be attributed clearly to either abuse or neglect.

In this context, the application of the developmental traumatology model (de Bellis, Reference de Bellis 2001 ) may be helpful. This model posits that traumatic stress resulting from child maltreatment adversely affects biological stress systems and brain development (e.g., in the amygdala and the hypothalamus–pituitary–adrenal axis). These alterations increase the risk for mental health problems, such as posttraumatic stress disorder, internalizing and externalizing disorders, personality disorders, or substance abuse as well as compromised cognitive and psychosocial functioning (de Bellis, Reference de Bellis 2001 ). The development traumatology model predicts that abuse may result in a deregulation of the stress response axis. The deregulated stress response makes children overly alert and show increased hyperarousal. These children are prepared to react to danger (i.e., with fight or flight reactions) at any moment. As a consequence, they are more likely to show outburst of anger, to feel provoked, and to get into fights than other children. These effects combined with social learning theory (Bandura, Reference Bandura 1978 ; Hecker et al., Reference Hecker, Hermenau, Isele and Elbert 2014 ), which states that abused children learn from their abuser to solve conflict and demonstrate power with violent behavior, may predict that experiences of abuse will be particularly associated with externalizing problems of the affected children.

In contrast, learned helplessness (Abela, Reference Abela 2001 ; Abramson, Seligman, & Teasdale, Reference Abramson, Seligman and Teasdale 1978 ) would suggest that neglected children develop helplessness-related cognitions and as a consequence become vulnerable to developing internalizing problems, such as social withdrawal or depressive symptoms. This idea was supported by findings of a prospective longitudinal study with a large community sample of children. The study found that neglect was associated with more internalizing problems, and that neglected children reported higher levels of perceived external control (Bolger & Patterson, Reference Bolger and Patterson 2001 ). This was particularly true for children who have been neglected early in life. In turn, higher levels of perceived external control accounted substantially for associations between neglect and children's internalizing problems. Nonetheless, as the different types of maltreatment often co-occur, the range of symptoms of the affected children may, of course, be mixed in individual cases.

In the current study, we focused on neglect as the most prevalent and at the same time most underestimated type of maltreatment (McSherry, Reference McSherry 2007 ). A recent meta-analysis on the global prevalence of neglect has clearly indicated that most studies investigating neglect focused on samples emerging from what is defined by the International Monetary Fund ( 2007 ) as high-resource countries (Stoltenborgh et al., Reference Stoltenborgh, Bakermans-Kranenburg and van IJzendoorn 2013 ). As developing countries make up a large part of the world, more research in these countries is highly important to understand child neglect and its consequences from a global perspective. In addition, the very few studies from sub-Saharan Africa focused on at-risk groups, such as orphans or other vulnerable children (e.g., Hermenau, Eggert, Landolt, & Hecker, Reference Hermenau, Eggert, Landolt and Hecker 2015 ; Morantz, Cole, Ayaya, Ayuku, & Braitstein, Reference Morantz, Cole, Ayaya, Ayuku and Braitstein 2013 ). So far, there has been no study that examined neglect in a large community-based sample of children. Therefore, the first aim of this study was to examine the prevalence of neglect in a large community-based sample of children in Tanzania.

The literature on the consequences of neglect consistently showed that neglect can result in numerous severe consequences across the life span (Gilbert et al., Reference Gilbert, Widom, Browne, Fergusson, Webb and Janson 2009 ; Norman et al., Reference Norman, Byambaa, De, Butchart, Scott and Vos 2012 ). Though there is consensus that maltreatment has negative consequences for children's mental health, the potential individual contribution of different types of maltreatment to distinct mental health problems is as yet unclear (Hildyard & Wolfe, Reference Hildyard and Wolfe 2002 ). The deviating research findings could be explained by the fact that many studies did not control for the potential co-occurrence of abuse and neglect (Finkelhor et al., Reference Finkelhor, Ormrod and Turner 2007 ). The second aim of the study was thus to examine the relationship between child neglect and behavioral and emotional problems in a large community-based sample of children. As it often co-occurs with exposure to violence and abuse, we controlled for these types of maltreatment (e.g., family violence, peer violence, and sexual abuse). Based on our theoretical consideration (see above), we hypothesized that in a sample of primary school-aged children (ages 6–15) from a low-income country, child neglect would be associated with internalizing problems but not externalizing problems, when controlling the influence of exposure to violence and abuse.

Participants

A total of 409 children (52% male) living in a small town in southern Tanzania participated in the study. They ranged from 6 to 15 years of age ( M = 10.49, SD = 1.89). All children were in the second to seventh year of formal schooling. The majority (70%, n = 288) indicated that they were living together in one household with their mother and/or their father. Eighteen percent ( n = 75) of the children lived in institutional care or in foster families. Eighty-nine children (22%) reported that at least one parent had died. These numbers are comparable to official figures from Tanzania reported by UNICEF ( 2011 ). According to these sources, in 2009, 20% of the boys and 25% of the girls were orphans.

A team of five Tanzanian psychologists, two Tanzanian psychology students, as well as five psychologists from Germany conducted structured interviews with the children. The interviews took 1.5 hr on average and were conducted in Swahili. Before carrying out the individual interviews, all interviewers took part in an interactive 2-week training session that included theoretical input and practice, such as role-plays of challenging interview situations. They were taught interview skills and how to conduct interviews with children. In addition, the different concepts assessed in the study, such as externalizing and internalizing problems, were studied. Finally, the principal investigators trained interviewers and translators in the interpretation of the interview responses from Swahili to English. The interview teams rotated constantly and consisted either of one German interviewer and one Tanzanian interpreter or one or two Tanzanian interviewers. The team leaders continuously supervised the team to ensure the interviews were carried out properly. Prior to the first interview, all instruments were translated into Swahili and were discussed to ensure a precise translation. A blind back-translation into English guaranteed correct translation. One of the German researchers was fluent in Swahili and could ensure valid translations. To test interrater reliability, two independent assessors rated 33 interviews.

The study was conducted in close cooperation with the Tanzanian school the children attended. Written informed consent forms, as well as letters explaining the study's purpose, were sent to all caregivers of the children of Grades 2 to 7. The caregivers were informed that participation was voluntary and no monetary compensation would be provided. They were invited to ask further questions. Finally, only children whose parents or caregivers had signed and returned the informed consent form were included and interviewed. Following that, about 80% of the children could be included. Before the interview started, every child was verbally informed that he or she could end the interview at any time. In addition, the children were assured that everything they said to the interviewer would remain confidential. The interviews were conducted individually in a quiet setting in the school. A female interviewer interviewed girls. The Tanzanian Commission for Science and Technology as well as the Ethical Review Board of the University of Konstanz, Germany, approved the study.

All variables were assessed by means of a structured expert interview. This means that even young children could be included in the study. The interview started by collecting sociodemographic information such as age, grade, and gender.

Maltreatment

The Maltreatment and Abuse Chronology of Exposure—Pediatric Interview (pediMACE; Isele et al., Reference Isele, Hecker, Hermenau, Elbert, Ruf-Leuschner, Moran and Schauer 2017 ) was used to assess “neglect” and “exposure to violence.” The pediMACE is the child-appropriate version of the Maltreatment and Abuse Chronology of Exposure (Teicher & Parigger, Reference Teicher and Parigger 2015 ). The pediMACE contains 45 questions in total. In this study, we focused on the subsections assessing physical neglect (5 items), emotional neglect (3 items), violence and abuse in the family context (12 items), in the peer context (5 items), and sexual abuse (9 items; see Table 1 ). Only approval or negation of specific events was assessed, since the chances of a distorted memory regarding intensity or the number of occurrences are high (McNally, Reference McNally 2006 ). We calculated sum scores for both types of neglect by summing up all of the relevant question responses. The Cohen κ coefficient for physical neglect measuring the interrater reliability was >0.99 (>0.99–1). For emotional neglect, the Cohen κ coefficient was 0.96 (0.88–1). Sum scores for each type of violence were calculated for further analysis. The Cohen κ coefficient was >0.99 (>0.99–1) for violence in the family context, violence in the peer context, and sexual violence.

Table 1. Occurrences of neglect and abuse during the children's lifetime assessed with the Maltreatment and Abuse Chronology of Exposure Pediatric Interview

Note: Total sample, N = 409; younger subsample, N = 135; older subsample, N = 274. Maltreatment and Abuse Chronology of Exposure Pediatric Interview (Isele et al., Reference Isele, Hecker, Hermenau, Elbert, Ruf-Leuschner, Moran and Schauer 2017 ).

a Fisher's exact p values are in italic.

b Item was reversed for clarity.

* p ≤ .05. ** p ≤ .01. *** p ≤ .001.

Internalizing and externalizing problems

Self-reported internalizing and externalizing behavior problems were assessed with the Strength and Difficulties Questionnaire (SDQ; Goodman, Meltzer, & Bailey, Reference Goodman, Meltzer and Bailey 1998 ). The SDQ comes with good psychometric properties and has been used globally (Goodman, Reference Goodman 2001 ). The questionnaire has been successfully implemented in Tanzanian settings before (Hermenau et al., Reference Hermenau, Hecker, Ruf, Schauer, Elbert and Schauer 2011 ; Traube, Dukay, Kaaya, Reyes, & Mellins, Reference Traube, Dukay, Kaaya, Reyes and Mellins 2010 ). In the current study, the 25-item self-report version for children was used in interview form. The version consists of five subscales with 5 items each: conduct problems (e.g., “I am often accused of lying and cheating”), hyperactivity (e.g., “ I am easily distracted; I find it difficult to concentrate”), emotional symptoms (e.g., “I am often unhappy, depressed, or tearful”), peer problems (e.g., “ I get along better with adults than with people my own age”), and prosocial behavior (e.g., “I am kind to younger children”). The children had to choose between the answer opportunities 0 = not true , 1 = somewhat true , and 2 = certainly true . Each subscale of the SDQ ranges from 0 to 10. In the current sample, the Cohen κ coefficient was 0.99 (0.94–1). The Cronbach α coefficient for the total difficulties score (all subscales except prosocial behavior) was 0.67 in the present sample. This moderate score can be explained by the total score's heterogeneity. In the current study, the emotional symptom subscale and the peer problem subscale were used to assess parts of internalizing problems. The Cohen κ coefficient for the emotional symptom subscale was 0.99 (0.95–1) and >0.99 (>0.99–1) for the peer problem subscale. The conduct problem subscale and the hyperactivity subscale were used to assess parts of externalizing problems. The Cohen κ coefficient for the conduct problem subscale was 0.99 (0.94–1) and 0.99 (0.96–1) for the hyperactivity subscale. A score of 4 or higher on the peer problem subscale indicates significant levels of peer problems, and emotional symptoms were classified as high when the interviewees responses on the relevant subscale were 6 or higher. Similarly, peer problems were judged significant when scores on the peer problem scale were 4 or higher. On the conduct problems subscale, a score of 5 or higher indicates major conduct problems, and high levels of hyperactivity is marked by scores 8 or higher (SDQ, 2017 ).

The Children's Depression Inventory (Sitarenios & Kovacs, Reference Sitarenios, Kovacs and Maruish 1999 ) is a well-tested and reliable instrument for assessing clinically relevant depressive symptoms in school-aged children and adolescents (Sun & Wang, Reference Sun and Wang 2015 ). We assessed depressive symptoms as a third facet of internalizing problems. The inventory has been successfully implemented in Tanzanian settings (Hermenau et al., Reference Hermenau, Eggert, Landolt and Hecker 2015 ; Traube et al., Reference Traube, Dukay, Kaaya, Reyes and Mellins 2010 ). For each of the 27 items, the children were asked to pick one of three statements that best fit them. The different answer opportunities were rated 0, 1, and 2, which resulted in the highest possible score of 54. High scores indicated more clinically severe depressive symptoms. In the current sample the Cronbach α coefficient was 0.70. The Cohen κ coefficient was 0.99 (0.92–1). A cutoff point of 12 has been established as the ideal threshold discriminating children at risk of depression from nondepressed children (Kovacs, Reference Kovacs 2001 ; Traube et al., Reference Traube, Dukay, Kaaya, Reyes and Mellins 2010 ).

The Reactive–Proactive Questionnaire (RPQ; Raine et al., Reference Raine, Dodge, Loeber, Gatzke-Kopp, Lynam, Reynolds and Liu 2006 ) assesses specific aggressive behavior in the previous 4 weeks. We estimated current aggressive behavior as a third facet of externalizing problems. The original RPQ consists of 23 items. However, slight changes were implemented in this study, following Hermenau et al. ( Reference Hermenau, Hecker, Ruf, Schauer, Elbert and Schauer 2011 ). One of the items was not appropriate for our Tanzanian sample and was therefore removed (Item 18: “Made obscene phone calls for fun”). In addition, Item 9 was slightly rephrased to make it more understandable for the participants (“gang fight” was replaced with “fight”). The remaining 22 items had to be answered with 0 = never , 1 = sometimes , or 2 = often . It was possible to obtain a score ranging from 0 to 44. In the present sample the Cronbach α coefficient was 0.85 and the Cohen κ coefficient was 0.99 (0.94–1).

Data analysis

In total, 15 data sets were excluded from the structural equation model (SEM) due to missing data. To investigate the relationships between the exogenous variables neglect (physical and emotional) and exposure to violence (family violence, peer violence, and sexual abuse) and the endogenous variables internalizing problems (depressive symptoms, peer problems, and emotional symptoms) and externalizing problems (hyperactivity, aggressive symptoms, and conduct problems), we carried out a SEM analysis (see Figure 1 for a visual presentation) applying the robust weighted least squares means and variance adjusted (WLSMV) estimation. The WLSMV estimation was chosen because of the partly ordinal variables (Finney & DiStefano, Reference Finney, DiStefano, Hancock and Mueller 2013 ). All measurement models showed a reasonable fit. All except one individual item significantly predicted the corresponding latent variables (see online-only supplementary Table S.1).

Figure 1. Structural equation model testing the direct association between neglect and internalizing problems and externalizing problems (total sample). Note: Standardized weighted least squares means and variance adjusted (WLSMV) estimates (regression weights in bold and factor loadings in italics) are depicted. Paths with dotted line are not significant ( p >.05, one-tailed). The path between neglect and internalizing problems depicts a trend with p ≤ .10 († p ≤ .10, one-tailed). Error variables are omitted for clarity.

In our final SEM, we used sum scores for the different types of neglect, the different types of exposure to violence, the different types of externalizing problems, and the different types of internalizing problems, which is according to Little, Cunningham, Shahar, and Widaman ( Reference Little, Cunningham, Shahar and Widaman 2002 ) justified, since we aimed to model the effects of the manifest variables on latent variables at a given level of generality. To make coefficients comparable, we fixed the factor loading of every first manifest variable of each latent variable to 1 as a constant value. Assessment of model fit was based on the following indices: chi-square (χ 2 ); comparative fit index (CFI), and the Tucker–Lewis index (TLI), both with values >0.90 indicating reasonable fit and >0.95 indicating good fit; root mean square error of approximation (RMSEA), with values <0.08 indicating reasonable fit and <0.05 indicating close fit (indicated also by PClose > 0.5: a “p-value” for testing the HO- hypothesis that the RMSEA is not greater than .05); standardized root mean square residual (SRMR), with values <0.10 indicating reasonable fit and <0.05 indicating close fit (Hu & Bentler, Reference Hu and Bentler 1999 ). For moderately complex models such as ours, a sample size of approximately 200 participants is considered as appropriate for SEM using the robust maximum likelihood estimation WLSMV (Nussbeck, Eid, & Lischetzke, Reference Nussbeck, Eid and Lischetzke 2006 ). Visual inspection showed no significant deviations from normality or linearity. The assumption of collinearity was met. Potential outliers were retained, since they were meaningful values with regard to content. Missing value analysis was carried out and revealed no other missing values except the ones reported above. For all directed hypotheses, we used one-tailed and for undirected hypothesis two-tailed α = 0.05. Regarding the standardized regression coefficients and on the basis of Cohen ( Reference Cohen 1992 ), β ≥ 0.10 indicated a small effect, β ≥ 0.30 a medium effect, and β ≥ 0.50 a large effect. Data was analyzed with IBM SPSS Statistics Version 21 for Mac OS X and R Version 3.2.1 for Mac OS X (R Core Team, 2016 ) and its lavaan package (Version 0.5–12; Rosseel, Reference Rosseel 2012 ).

Descriptive statistics

The descriptive statistics are displayed in Table 2 . In the current study, 31% ( n = 128) of the children had experienced at least one type of physical neglect and 31% ( n = 127) at least one type of emotional neglect. In total, 93% ( n = 379) of the children experienced at least one type of family violence, 78% ( n = 326) at least one event of peer violence, and 8.3% ( n = 34) at least one form of sexual abuse.

Table 2. Descriptive statistics of all relevant variables

Note: Total sample, N = 409; younger subsample, N = 135; older subsample, N = 274.

a t, t -test statistic.

b U , Mann–Whitney U -test statistic.

† p ≤ .10. * p ≤ .05. ** p ≤ .01. *** p ≤ .001.

Regarding mental health problems, 18% reported a high level of emotional symptoms ( n = 72) and of peer problems ( n = 72), respectively. In total, 12% ( n = 50) showed a high level of conduct problems and 4% ( n = 15) a high level of hyperactivity. In the present sample, 14% ( n = 57) of the children were classified as being at risk of depression.

Associations between neglect and internalizing and externalizing problems

In the SEM we tested the association between child neglect and internalizing problems, as well as externalizing problems. In addition, we tested the association between exposure to violence and the two dependent variables to control for a possible influence of exposure to violence. All intercorrelations are displayed in online-only supplementary Table S.2. Our hypothesized model showed a good model fit, χ 2 (38, 394) = 72.97, p = .001, RMSEA = 0.048 (90% confidence interval (CI): 0.031 – 0.065, PClose = 0.540), SRMR = 0.041, CFI = 0.955, TLI = 0.935. All manifest variables loaded significantly on the latent variables (see Table 3 ). Neglect was not significantly related to internalizing problems or externalizing problems. However, the effect size of the association between neglect and internalizing problems indicated a small effect and the association was significant if one allowed a p value of .10. Exposure to violence correlated significantly with externalizing problems, indicating a large effect, as well as with internalizing problems, indicating a medium effect (see Figure 1 ).

Table 3. Weighted least squares means and variance adjusted estimates of the structural equation model (total sample)

Note: n = 394. Unstand. Est., unstandardized weighted least squares means and variance adjusted estimates; Stand. Est., standardized weighted least squares means and variance adjusted estimates; CR, critical ratio. Model fit: χ 2 (38, n = 394) = 72.97 ( p = .001), root mean square error of approximation = 0.048 (90% confidence interval: 0.031 – 0.065, PClose (test of close fit) = 0.540), standardized root mean square residual = 0.041, comparative fit index = 0.955, Tucker–Lewis index = 0.935.

† p ≤ .10 (one tailed). * p ≤ .05 (one tailed). ** p ≤ .01 (one tailed). *** p ≤ .001 (one tailed).

Differential associations in preadolescent and adolescent children

We exploratorily tested our model again using a multigroup SEM analysis that divided the total sample in one group of younger children (ages 6–9) and one group of older children (ages 10–15). The division into these two groups was based on two considerations. First, previous research indicated that the prevalence of internalizing and externalizing problems changes with age (Costello, Mustillo, Erkanli, Keeler, & Angold, Reference Costello, Mustillo, Erkanli, Keeler and Angold 2003 ) and that adolescence may be a developmental period, in which the way mental health problems are experienced and reported may change greatly. For example, preadolescent children are more likely to show externalizing whereas adolescents are more likely to show internalizing mental health problems (Costello et al., Reference Costello, Mustillo, Erkanli, Keeler and Angold 2003 ). Second, recent findings (Schalinski et al., Reference Schalinski, Teicher, Nischk, Hinderer, Müller, Rockstroh and Rockstroh 2016 ) showed that preschool (age 4–5) and preadolescent (age 8–9) ages may be particularly sensitive periods for the impact of neglect on mental health problems. By dividing the group into one preadolescent and one adolescent group, we aimed to compare the association between neglect and mental health problems in two groups that may differ greatly in the way they experienced and reported mental health problems. Moreover, we compared these associations between one group who experienced two potential sensitive periods, in which neglect may affect mental health strongly, and one group who experienced these two sensitive periods, too, but in addition may have been exposed to further experiences of neglect during adolescence.

We compared the two groups using χ 2 or Fisher exact (small sample per cell) tests for categorical data and t , Welch (variance heterogeneity), or (nonparametric) Mann–Whitney U tests for continuous data. The younger and older subsamples did not differ in their experiences of neglect. However, children in the younger sample were more likely to report being excluded by peers or being physically punished by their parents or caregivers. Yet, the two subsamples did not differ significantly concerning the number of experienced types of exposure to family violence, peer violence, or sexual abuse. The two subsamples did not differ regarding mental health problems, except for aggressive behavior, as reported in the RPQ. Here, the younger subsample reported a significantly higher level of aggressive behavior.

All measurement models showed a reasonable significance. The intercorrelations for both subsamples are provided in online-only supplementary Table S.2. The multigroup SEM showed a very good model fit, χ 2 (76, younger subsample, n = 130, older subsample, n = 264) = 101.39, p = .027, RMSEA = 0.041 (90% CI: 0.015 – 0.061, PClose = 0.745), SRMR = 0.051, CFI = 0.966, TLI = 0.951. In both subgroups, all manifest variables loaded significantly on the latent variables when considering α = 0.10 (see Table 4 ). In the younger subgroup (ages 6–9), neglect was significantly related to internalizing problems, indicating a large effect. The association between neglect and externalizing problems was also significant, indicating a medium effect. Exposure to violence was not significantly related to externalizing problems or internalizing problems. However, the effect size of the association between exposure to violence and externalizing problems indicated a medium effect, and the association was significant when considering a p value of .10 (see Figure 2 ). In the older subsample (ages 10–15), neglect was significantly related to neither internalizing nor externalizing problems. Exposure to violence correlated significantly with externalizing and with internalizing problems, both indicating large effects (see Table 4 and Figure 2 ).

Figure 2. Multi-group structural equation model testing the direct association between neglect and internalizing problems and externalizing problems in a) the subsample of the younger children (age 6 – 9) and b) the subsample of the older children. Note : Standardized weighted least squares means and variance adjusted (WLSMV) estimates (regression weights in bold and factor loadings in italics) are depicted. Paths with dotted line are not significant ( p >;.05, one-tailed). The path between exposure to violence and externalizing problems in a) depicts a trend with p ≤ .10 († p ≤ .10, one-tailed). Error variables are omitted for clarity.

Table 4. Weighted least squares means and variance adjusted estimates of the multigroup structural equation model (grouping variable = age)

Note: Unstand. Est., unstandardized weighted least squares means and variance adjusted estimates; Stand. Est., standardized weighted least squares means and variance adjusted estimates; CR, critical ratio. Model fit: χ 2 (76, n younger subsample = 130, n older subsample = 264), = 101.39 ( p = .027), root mean square error of approximation = 0.041 (90% confidence interval: 0.015 – 0.061, PClose (test of close fit) = 0.745), standardized root mean square residual = 0.051, comparative fit index = 0.966, Tucker–Lewis index = 0.951.

We found a high rate of neglect in our sample. Almost every third child reported experiencing at least one form of physical or emotional neglect at some point in his or her life. The prevalence rates are higher than those presented in a meta-analysis on the global prevalence of neglect (Stoltenborgh et al., Reference Stoltenborgh, Bakermans-Kranenburg and van IJzendoorn 2013 ). However, no study from the African continent was included in that meta-analysis.

Though the prevalence of neglect seems to be very high, studies investigating neglect in developing countries, particularly in sub-Saharan Africa, are still rare (Stoltenborgh et al., Reference Stoltenborgh, Bakermans-Kranenburg, Alink and van IJzendoorn 2015 ). The few studies that focused on neglect in sub-Saharan Africa targeted orphans or other at-risk groups (e.g., Hermenau et al., Reference Hermenau, Eggert, Landolt and Hecker 2015 ; Morantz et al., Reference Morantz, Cole, Ayaya, Ayuku and Braitstein 2013 ). This was the first study examining neglect in a large community-based sample in sub-Saharan Africa. In low-resource countries, caregivers often do not have enough food to feed their families and many are unable to take their children to a doctor when they are ill, as they cannot afford it. As such, neglect is frequently unintentional. Nevertheless, regardless of the intention of parents and caregivers, the consequences are still severe (Mbagaya, Reference Mbagaya 2010 ). For example, Hildyard and Wolfe ( Reference Hildyard and Wolfe 2002 ) found evidence that neglect, especially when it occurs early in life, can lead to mental health problems and cognitive dysfunction. As neglect has received little attention (McSherry, Reference McSherry 2007 ), future research on this subtype of maltreatment is particularly necessary in resource-poor countries. One important reason for this is to contribute to a definition of neglect that fits the context and living realities in low-resource countries.

Following the developmental traumatology model (de Bellis, Reference de Bellis 2001 ) and social learning theory (Bandura, Reference Bandura 1978 ; Hecker et al., Reference Hecker, Hermenau, Isele and Elbert 2014 ), we argue that experiences of abuse may be particularly associated with externalizing problems. In addition to this, the theory of learned helplessness (Abela, Reference Abela 2001 ; Abramson et al., Reference Abramson, Seligman and Teasdale 1978 ) may predict that neglect would be particularly related to internalizing problems. In line with these two predictions, prior research showed some support for the association between abuse and externalizing problems (Hecker et al., Reference Hecker, Hermenau, Isele and Elbert 2014 ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ; Sugaya et al., Reference Sugaya, Hasin, Olfson, Lin, Grant and Blanco 2012 ) and also between neglect and internalizing problems (Bolger & Patterson, Reference Bolger and Patterson 2001 ; Hildyard & Wolfe, Reference Hildyard and Wolfe 2002 ; Kotch et al., Reference Kotch, Lewis, Hussey, English, Thompson, Litrownik and Dubowitz 2008 ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ). We argue that deviating findings may be explained by the fact that many studies did not control for the potential co-occurrence of abuse and neglect. Nevertheless, in contrast to this idea and our hypothesis, we did not find a significant association between neglect and internalizing problems (though the effect size indicated a small effect) in the total sample. Exposure to violence was related to externalizing problems. It was also significantly related to internalizing problems, though our models controlled for the impact of neglect.

However, in contrast to this, for the younger subsample, the association between neglect and internalizing problems showed a large and significant effect. This is in accord with prior research findings investigating this association (Hildyard & Wolfe, Reference Hildyard and Wolfe 2002 ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ; Widom et al., Reference Widom, DuMont and Czaja 2007 ). These findings are congruent with previous findings that children who experienced more neglect in their lives had an increased risk of experiencing internalizing problems, like depressive symptoms, peer problems, and inferior emotion regulation skills. For example, neglected children reported higher levels of perceived external control. In addition, higher levels of perceived external control mediated the association between neglect and internalizing problems (Bolger & Patterson, Reference Bolger and Patterson 2001 ). Furthermore, neglect entails few social interactions and thereby a decreased chance of receiving social support (Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ). For example, children who experienced neglect at home have a smaller chance of compensating for the lack of social support through friends in general or peers at school. As we controlled for the influence of exposure to violence and abuse, our findings suggest a unique contribution of neglect to the overall consequences maltreatment, at least in the younger sample. Nonetheless, in the younger subsample, we also found a significant association between neglect and externalizing problems indicating a medium effect, which is in line with previous findings that neglected children show more aggressive behavior and violent criminal behavior compared to nonneglected children (e.g., Kotch et al., Reference Kotch, Lewis, Hussey, English, Thompson, Litrownik and Dubowitz 2008 ; Manly et al., Reference Manly, Kim, Rogosch and Cicchetti 2001 ).

In the older subsample, however, neglect was neither associated with internalizing nor with externalizing problems. These unexpected findings raise the question of whether the maltreatment type, the age, or an interaction of both best determine whether a child develops internalizing or externalizing problems. Previous research has already indicated that it is difficult to pinpoint the specific consequences following neglect and abuse (Korbin & Krugman, Reference Korbin and Krugman 2014 ). In contrast to our hypothesis and a priori line of argument, our findings demonstrate the importance of considering the current age (potentially also the age of occurrence) in predicting whether a child develops internalizing or externalizing problems. Age is a contributing factor to future problems, or at least something to be controlled when investigating consequences of maltreatment. Future research is needed to investigate the interaction between current age, age at maltreatment and maltreatment type, and its effect on the development of different mental health problems. The sensitive period of exposure model (Schalinski et al., Reference Schalinski, Teicher, Nischk, Hinderer, Müller, Rockstroh and Rockstroh 2016 ; Teicher & Samson, Reference Teicher and Samson 2016 ) may be a helpful model to examine this unresolved question further.

Practical implications and future research

As neglect has received very little attention so far, the results of our current study emphasize the necessity of advancing research on neglect as one specific type of maltreatment. The association between neglect and internalizing and externalizing problems in the younger subsample underlines the importance of recognizing neglect as one discrete type of maltreatment in addition to exposure to violence and abuse. Yet, assessing something that is absent is complex and challenging compared to (visible) acts of violence and abuse. Therefore, instruments measuring neglect still need be improved. As suggested by Reynolds and Suzuki ( Reference Reynolds, Suzuki, Reynolds and Ramsay 2003 ) and supported by our study, cultural and particularly developmental aspects need to be considered when designing instruments that assess child neglect.

Besides the detrimental consequences for the children affected, high costs for the health care system could potentially be avoided (Maher, Corwin, Hodnett, & Faulk, Reference Maher, Corwin, Hodnett and Faulk 2012 ) when people and institutions become aware of the major possible consequences. This is of special importance with regard to low-resource countries. A first step will be to inform caregivers, social workers, institutions, governmental organizations, and the population at large about the potentially deleterious consequences of neglectful acts. Support should be offered to parents and caregivers who may be at risk of neglecting the children in their care (Guterman, Reference Guterman 1997 ). Enhanced knowledge in this field can lead to the development and implementation of effective prevention programs. Studies detecting risk factors of parents and caregivers for neglecting their children, such as the study conducted by Schumacher, Smith Slep, and Heyman ( Reference Schumacher, Smith Slep and Heyman 2001 ), could be used to develop prevention programs. Future research needs to extend studies like the current one with longitudinal and prospective approaches.

Limitations

This was the first study that investigated neglect in a large community-based sample of primary school-aged children in sub-Saharan Africa. Unlike many other studies, we aimed to disentangle the consequence of different types of maltreatment and exploratively considered the potential influence of current age. However, some limitations should be noted. The cross-sectional design does not allow for the establishment of causal directionality. For example, instead of neglect increasing the prevalence of internalizing problems, the reverse is also conceivable. However, past research has established depressive symptoms as one frequent consequence of neglect (Widom et al., Reference Widom, DuMont and Czaja 2007 ). Our sampling approach restricts the generalizability of our results. However, the sample was comparatively large and included children from different school grades and various social backgrounds. Nevertheless, our exploratory findings should be interpreted with caution considering the rather small sample size of the subsample of younger children. A replication of our findings in future studies is therefore required. We did not assess the socioeconomic status of the children's families or caregivers. This is a limitation as it denies us the possibility of investigating the influence of the socioeconomic status on mental health. A recent study by Hecker, Radtke, Hermenau, Papassotiropoulos, and Elbert ( Reference Hecker, Radtke, Hermenau, Papassotiropoulos and Elbert 2016b ) found support for the idea that children are capable of communicating their maltreatment experiences. Nevertheless, we cannot rule out a memory bias (i.e., recent maltreatment experiences are reported more reliably compared to those that occurred long time ago). Our sample consisted of about 20% orphans. Though this is comparable to the official figures from Tanzania, it may have affected the results in an unknown way. This limitation is particularly important considering that the number of orphans differed between the two subsamples. Moreover, we included children of the age of 6 years and older, though some of the instruments are only validated for older children. This may have impacted our results. However, as we assessed all variables by means of a structured expert interview, we tried to keep this potential impact to a minimum.

Conclusions

In concordance with previous findings, the current study found support for the idea that children who have experienced more neglect types are more likely to suffer from mental health problems. However, this association could only be detected in younger children (ages 6–9), whereas in older children (ages 10–15), mental health problems were significantly related to experiences of violence and abuse. Our findings indicate that the current age (and potentially the age at maltreatment) may influence the association between maltreatment type and the development of internalizing and/or externalizing problems. In addition, a more complex interaction between the developmental stage of the child (biologically and psychosocial) and the type of maltreatment (physical violence, abuse, or neglect) may be possible and should be investigated in the future. Furthermore, it could be examined whether effects of violence over time may cover the psychological wounds from early neglect. As neglect has been neglected thus far, future research needs to focus more on this type of maltreatment. Especially in low-resource countries, educational advertising and prevention programs with regard to neglect are of great importance in reducing the prevalence rates and serious long-term consequences. These steps would give the affected children a chance for a better future and age-appropriate, healthy development.

Supplementary Material

To view the supplementary material for this article, please visit https://doi.org/10.1017/S0954579417001882 .

This research was supported by the Deutsche Forschungsgemeinschaft and by the nongovernmental organization vivo international. We thank all of the children who participated in this study for their willingness to discuss intimate and painful subjects. We are very grateful to our highly motivated and reliable research team, including Manswab Geho, Dorothea Isele, Huruma Kipagile, Getrude Mkinga, Andrew Mtitu, Zephania Ngowi, Lulu Nziku, Astrid Pabst, Charlotte Salmen, and Leila Samson. We appreciated the statistical support of Daniel Seddig, Terrence D. Jorgensen, and Yves Rosseel. We also thank James Moran who critically reviewed the manuscript and Thomas Elbert for his continuous support.

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• DOI: https://doi.org/10.1017/S0954579417001882

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Problem-solving matter

Life is starting to look a lot less like an outcome of chemistry and physics, and more like a computational process.

by David C Krakauer & Chris Kempes   + BIO

What makes computation possible? Seeking answers to that question, a hardware engineer from another planet travels to Earth in the 21st century. After descending through our atmosphere, this extraterrestrial explorer heads to one of our planet’s largest data centres, the China Telecom-Inner Mongolia Information Park, 470 kilometres west of Beijing. But computation is not easily discovered in this sprawling mini-city of server farms. Scanning the almost-uncountable transistors inside the Information Park, the visiting engineer might­ be excused for thinking that the answer to their question lies in the primary materials driving computational processes: silicon and metal oxides. After all, since the 1960s, most computational devices have relied on transistors and semiconductors made from these metalloid materials.

If the off-world engineer had visited Earth several decades earlier, before the arrival of metal-oxide transistors and silicon semiconductors, they might have found entirely different answers to their question. In the 1940s, before silicon semiconductors, computation might appear as a property of thermionic valves made from tungsten, molybdenum, quartz and silica – the most important materials used in vacuum tube computers.

And visiting a century earlier, long before the age of modern computing, an alien observer might come to even stranger conclusions. If they had arrived in 1804, the year the Jacquard loom was patented, they might have concluded that early forms of computation emerged from the plant matter and insect excreta used to make the wooden frames, punch cards and silk threads involved in fabric-weaving looms, the analogue precursors to modern programmable machines.

But if the visiting engineer did come to these conclusions, they would be wrong. Computation does not emerge from silicon, tungsten, insect excreta or other materials. It emerges from procedures of reason or logic.

This speculative tale is not only about the struggles of an off-world engineer. It is also an analogy for humanity’s attempts to answer one of our most difficult problems: life. For, just as an alien engineer would struggle to understand computation through materials, so it is with humans studying our distant origins.

Today, doubts about conventional explanations of life are growing and a wave of new general theories has emerged to better define our origins. These suggest that life doesn’t only depend on amino acids, DNA, proteins and other forms of matter. Today, it can be digitally simulated, biologically synthesised or made from entirely different materials to those that allowed our evolutionary ancestors to flourish. These and other possibilities are inviting researchers to ask more fundamental questions: if the materials for life can radically change – like the materials for computation – what stays the same? Are there deeper laws or principles that make life possible?

O ur planet appears to be exceptionally rare. Of the thousands that have been identified by astronomers, only one has shown any evidence of life. Earth is, in the words of Carl Sagan , a ‘lonely speck in the great enveloping cosmic dark’. This apparent loneliness is an ongoing puzzle faced by scientists studying the origin and evolution of life: how is it possible that only one planet has shown incontrovertible evidence of life, even though the laws of physics are shared by all known planets, and the elements in the periodic table can be found across the Universe?

The answer, for many, is to accept that Earth really is as unique as it appears: the absence of life elsewhere in the Universe can be explained by accepting that our planet is physically and chemically unlike the many other planets we have formally identified. Only Earth, so the argument goes, produced the special material conditions conducive to our rare chemistry, and it did so around 4 billion years ago, when life first emerged.

Stanley Miller in his laboratory in 1970. Courtesy and © SIO Photographic Laboratory Collection, SAC 44, UC San Diego

In 1952, Stanley Miller and his supervisor Harold Urey provided the first experimental evidence for this idea through a series of experiments at the University of Chicago. The Miller-Urey experiment, as it became known, sought to recreate the atmospheric conditions of early Earth through laboratory equipment, and to test whether organic compounds (amino acids) could be created in a reconstructed inorganic environment. When their experiment succeeded, the emergence of life became bound to the specific material conditions and chemistry on our planet, billions of years ago.

Genetic evolution also involves problem-solving: insect wings solve the ‘problem’ of flight

However, more recent research suggests there are likely countless other possibilities for how life might emerge through potential chemical combinations. As the British chemist Lee Cronin , the American theoretical physicist Sara Walker and others have recently argued , seeking near-miraculous coincidences of chemistry can narrow our ability to find other processes meaningful to life. In fact, most chemical reactions, whether they take place on Earth or elsewhere in the Universe, are not connected to life. Chemistry alone is not enough to identify whether something is alive, which is why researchers seeking the origin of life must use other methods to make accurate judgments.

Today, ‘adaptive function’ is the primary criterion for identifying the right kinds of biotic chemistry that give rise to life, as the theoretical biologist Michael Lachmann (our colleague at the Santa Fe Institute) likes to point out. In the sciences, adaptive function refers to an organism’s capacity to biologically change, evolve or, put another way, solve problems. ‘Problem-solving’ may seem more closely related to the domains of society, culture and technology than to the domain of biology. We might think of the problem of migrating to new islands , which was solved when humans learned to navigate ocean currents, or the problem of plotting trajectories , which our species solved by learning to calculate angles, or even the problem of shelter, which we solved by building homes. But genetic evolution also involves problem-solving. Insect wings solve the ‘problem’ of flight. Optical lenses that focus light solve the ‘problem’ of vision. And the kidneys solve the ‘problem’ of filtering blood. This kind of biological problem-solving – an outcome of natural selection and genetic drift – is conventionally called ‘adaptation’ . Though it is crucial to the evolution of life, new research suggests it may also be crucial to the origins of life.

This problem-solving perspective is radically altering our knowledge of the Universe. Life is starting to look a lot less like an outcome of chemistry and physics, and more like a computational process.

T he idea of life as a kind of computational process has roots that go back to the 4th century BCE, when Aristotle introduced his philosophy of hylomorphism in which functions take precedence over forms. For Aristotle, abilities such as vision were less about the biological shape and matter of eyes and more about the function of sight. It took around 2,000 years for his idea of hylomorphic functions to evolve into the idea of adaptive traits through the work of Charles Darwin and others. In the 19th century, these naturalists stopped defining organisms by their material components and chemistry, and instead began defining traits by focusing on how organisms adapted and evolved – in other words, how they processed and solved problems. It would then take a further century for the idea of hylomorphic functions to shift into the abstract concept of computation through the work of Alan Turing and the earlier ideas of Charles Babbage.

In the 1930s, Turing became the first to connect the classical Greek idea of function to the modern idea of computation, but his ideas were impossible without the work of Babbage, a century before. Important for Turing was the way Babbage had marked the difference between calculating devices that follow fixed laws of operation, which Babbage called ‘Difference Engines’, and computing devices that follow programmable laws of operation, which he called ‘Analytical Engines’.

Using Babbage’s distinction, Turing developed the most general model of computation: the universal Turing Machine. In 1936, he imagined this machine much like a tape recorder, comprising a reading and erasing head fed with an infinitely long tape. As this tape passes through the machine, single bits of information (momentarily stored in the machine) are read or written onto it. Both machine and tape jointly determine which bit will be read or written next.

It can be difficult for outsiders to understand how these incommensurable ideas are connected to each other

Turing did not describe any of the materials out of which such a machine would be built. He had little interest in chemistry beyond the physical requirement that a computer store, read and write bits reliably. That is why, amazingly, this simple (albeit infinite) programmable machine is an abstract model of how our powerful modern computers work. But the theory of computation Turing developed can also be understood as a theory of life. Both computation and life involve a minimal set of algorithms that support adaptive function. These ‘algorithms’ help materials process information, from the rare chemicals that build cells to the silicon semiconductors of modern computers. And so, as some research suggests, a search for life and a search for computation may not be so different. In both cases, we can be side-tracked if we focus on materials, on chemistry, physical environments and conditions.

In response to these concerns, a set of diverse ideas has emerged to explain life anew, through principles and processes shared with computation, rather than the rare chemistry and early Earth environments simulated in the Miller-Urey experiment. What drives these ideas, developed over the past 60 years by researchers working in disparate disciplines – including physics, computer science, astrobiology, synthetic biology, evolutionary science, neuroscience and philosophy – is a search for the fundamental principles that drive problem-solving matter. Though researchers have been working in disconnected fields and their ideas seem incommensurable, we believe there are broad patterns to their research on the origins of life. However, it can be difficult for outsiders to understand how these seemingly incommensurable ideas are connected to each other or why they are significant. This is why we have set out to review and organise these new ways of thinking.

Their proposals can be grouped into three distinct categories, three hypotheses, which we have named Tron, Golem and Maupertuis. The Tron hypothesis suggests that life can be simulated in software, without relying on the material conditions that gave rise to Earth’s living things. The Golem hypothesis suggests that life can be synthesised using different materials to those that first set our evolutionary history moving. And, if these two ideas are correct and life is not bound to the rare chemistry of Earth, we then have the Maupertuis hypothesis, the most radical of the three, which explores the fundamental laws involved in the origins of complex computational systems.

These hypotheses suggest that deep principles govern the emergence of problem-solving matter, principles that push our understanding of modern physics and chemistry towards their limits. They mark a radical departure from life as we once knew it.

I n 1982, the science-fiction film Tron was released in the United States. Directed by Steven Lisberger, it told the story of biological beings perfectly and functionally duplicated in a computer program. The hero, Tron, is a human-like algorithm subsisting on circuits, who captures the essential features of living without relying on biotic chemistry. What we have called the ‘Tron hypothesis’ is the idea that a fully realised simulation of life can be created in software, freed from the rare chemistry of Earth. It asks what the principles of life might be when no chemical traces can be relied upon for clues. Are the foundations of life primarily informational?

Five years after Tron was first released in cinemas, the American computer scientist Christopher Langton introduced the world to a concept he called ‘artificial life’ or ‘ALife’ at a workshop he organised on the simulation of living systems. For Langton, ALife was a way of focusing on the synthesis of life rather than analytical descriptions of evolved life. It offered him a means of moving beyond ‘life as we know it’ to what he called ‘life as it could be’. The goal, in his own words , was to ‘recreate biological phenomena in alternative media’, to create lifelike entities through computer software.

Langton’s use of computers as laboratory tools followed the work of two mathematicians: Stanisław Ulam and John von Neumann, who both worked on the Manhattan Project. In the late 1940s, Ulam and von Neumann began a series of experiments on early computers that involved simulating growth using simple rules. Through this work, they discovered the concept of cellular automata, a model of computation and biological life. Ulam was seeking a way of creating a simulated automaton that could reproduce itself, like a biological organism, and von Neumann later connected the concept of cellular automata to the search for the origins of life. Using this concept, von Neumann framed life’s origins as Turing had earlier done with computation, by looking for the abstract principles governing what he called ‘construction’: ie, biological evolution and development. Complicated forms of construction build patterns of the kind that we associate with organismal life, such as cell growth, or the growth of whole individuals. A much simpler form of construction can be achieved on a computer using a copy-and-paste operation. In the 20th century, von Neumann’s insights about a self-replicating cellular automaton, a ‘universal constructor’, were deemed too abstract to help our understanding of life’s chemical origins. They also seemed to have little to say about biological processes such as adaptation and natural selection.

A computer program called Avida simulated evolutionary processes

The ALife research that followed the work of Ulam, von Neumann and Langton generated a slew of fascinating formal and philosophical questions. But, like the work of von Neumann, these questions have had a limited and short-lived impact on researchers actively working on the origins of life. At the end of the 20th century, several pioneers in ALife, including the American philosopher Mark Bedau, lamented the lack of progress on these questions in an influential paper titled ‘Open Problems in Artificial Life’. The unanswered problems identified by Bedau and his eight co-authors included generating ‘a molecular proto-organism in vitro’, achieving ‘the transition to life in an artificial chemistry in silico’, demonstrating ‘the emergence of intelligence and mind in an artificial living system’ and, among other things, evaluating ‘the influence of machines on the next major evolutionary transition of life’.

These open problems went unanswered, and this paper is coincident with the decline of the field. Following its publication, many of the authors embarked on different research careers, either jumping from artificial life into the adjacent field of evolutionary theory, or pursuing research projects involving chemistry rather than software and hardware.

Nevertheless, ALife produced some very sophisticated models and ideas. In the same year that Bedau and his colleagues identified problems, another group of researchers demonstrated the heights that artificial life had reached at the turn of the century. In their research paper ‘Evolution of Biological Complexity’ (2000), this group, led by the physics theorist Christoph Adami, wrote about a computer program called Avida that simulated evolutionary processes. ‘The Avida system,’ Adami and his co-authors wrote, ‘hosts populations of self-replicating computer programs in a complex and noisy environment, within a computer’s memory.’ They called these programs ‘digital organisms’, and described how they could evolve (and mutate) in seconds through programmed instructions. Each Avida organism was a single simulated genome composed of ‘a sequence of instructions that are processed as commands to the CPU of a virtual computer.’

A screenshot of the Avida software that simulates evolutionary processes. Courtesy Wikipedia

The Tron hypothesis seemed to hold promise. But, in the end, the work of Adami and others made more important contributions to population genetics and theoretical ecology rather than research on the origins of life. This work helped bridge fundamental theorems in computation with abstract biological concepts, such as birth, competition and death, but has not broken prebiotic chemistry’s hold over dominant conceptions of life.

In recent years, things have begun to change as new concepts from physics are expanding the standard Tron hypothesis. In 2013, the physicist David Deutsch published a paper on what he called ‘constructor theory’. This theory proposed a new way of approaching physics in which computation was foundational to the Universe, at a deeper level than the laws of quantum physics or general relativity. Deutsch hoped the theory would renovate dominant ideas in conventional physics with a more general framework that eliminated many glitches, particularly in relation to quantum mechanics and statistical mechanics, while establishing a foundational status for computation. He also wanted to do all of this by providing a rigorous and consistent framework for possible and impossible transformations, which include phenomena like the movement of a body through space or the transition from a lifeless to a living planet. Constructor theory does not provide a quantitative model or offer predictions for how these transformations will happen. It is a qualitative framework for talking about possibility; it explains what can and can’t happen in the Universe in a way that goes beyond the laws of conventional physics. Deutsch’s theory is a provocative vision, and many questions remain about its utility.

Deutsch’s theory builds on von Neumann’s construction-replication model for life – the original Tron hypothesis – which in turn is built on Turing’s model of computation. Through Deutsch’s theory we begin moving away from principles of simulation as pursued through Avida organisms and silicon-based evolution, and head toward larger conceptual ideas about how life might form. Constructor theory, and other similar ideas, may be necessary for understanding the deeper origins of life, which conventional physics and chemistry have failed to adequately explain.

I t is one thing to simulate life or identify the principles inherent in these simulations. It is another thing to synthesise life. In comparison with life simulated through software, the Golem hypothesis states that a synthetic life-form can be built from novel chemical constituents different to those that gave rise to the complex forms of life on Earth. This hypothesis is named after a mythical being from Jewish folklore that lives and breathes despite being wholly made from inanimate materials, typically mud. Brought to life by inscribing its forehead with a magical word, such as emét (‘truth’ in Hebrew), the golem is a form of engineered life constructed from a process different from evolution. If Tron emphasises information, then the Golem emphasises energy – it’s a way of binding information to metabolism.

In the novel The Golem (1913-14), Gustav Meyrink wrote: ‘There is nothing mysterious about it at all. It is only magic and sorcery – kishuf – that frighten men; life itches and burns like a hairshirt.’ For our purposes, the golem is an analogy for synthetic life. It is a living thing grounded in generative mud, and an abstract representation of what is possible with synthetic biology and protocells.

In the early 21st century, interest in such ‘mud’ became more popular as the limitations of ALife inspired a renewed interest in the role of different kinds of materials and metabolism to those found on the prebiotic Earth. In 2005, the American chemists Steven A Benner and Michael Sismour described the two kinds of synthetic biologists who were working on problems of life: ‘One uses unnatural molecules to reproduce emergent behaviours from natural biology, with the goal of creating artificial life. The other seeks interchangeable parts from natural biology to assemble into systems that function unnaturally.’ If the latter are testing the Tron hypothesis, the former are testing the Golem hypothesis.

Assembly theory helps us understand how all the objects of chemistry and biology are made

One of the best examples of life-like synthetic biology is the creation of genetic systems in which synthetic DNA alphabets are supported by an engineered expansion of the Watson-Crick double-stranded base-pairing mechanism. This does not involve the creation of an alternative biochemistry in a laboratory but simply the chemical synthesis of an augmented, evolvable system. In fact, all successful efforts to date in synthetic biology derive from augmentation, not creation.

The Golem hypothesis raises important questions: if life can be made from materials unlike those that gave rise to life as we know it, what are the shared principles that give rise to all living things? What are the universal properties of life-supporting chemistry?

The recent development of assembly theory offers us a way to begin answering these questions. Assembly theory helps us understand how all the objects of chemistry and biology are made. Each complex object in the Universe, from microscopic algae to towering skyscrapers, is built from unique parts, involving combinations of molecules. Assembly theory helps us understand how these parts and objects are combined, and how each generation of complexity relies on earlier combinations. Because this theory allows us to measure the ‘assembly index’ of an object – how ‘assembled’ it is; how complex its parts are – we can make determinations about evolution that are separate from those normally used to define life.

In this framework, one can identify objects that are the outcome of an evolutionary process through the number of assembly steps that have been taken, without having a prior model or knowing the details of the process. The requirements are: first, that an object can be decomposed into building blocks; second, a minimal rule-set exists for joining blocks together; and third, sequences exist that describe the assembly of these building blocks into the object, where intermediate objects can be reused as new building blocks in the construction process. Very small assembly indices are characteristic of the pure physical and chemical dynamics that produce crystals or planets, but large indices in a large population of objects are taken as evidence for an evolutionary process – and a sign of life . In some ways, assembly theory is a version of the Golem hypothesis: through it we can potentially locate forms of life constructed from a process other than evolution. The idea is that a complex entity, such as a golem, requires a significant amount of time, energy and information to be assembled, and the assembly index is a measure of these requirements. This theory allows us to map certain computational concepts in such a way that we can find the shared signature of a problem-solving process.

The golem shows us how varied living materials are likely to be in the Universe, and how the focus on a limited set of materials is likely to be overly narrow. Assembly theory shows us how any historical process will leave universal imprints on materials, no matter how diverse those materials are.

T he Tron and Golem hypotheses are challenging and bold, but there are perhaps even more radical ideas about the origins of life. These ideas suggest that the emergence of complex computational systems (ie, life) in the Universe may be governed by deeper principles than we previously assumed. Organisms may have a more general objective than adaptation. What if life-forms arise not from a series of adaptive accidents, such as mutation and selection, but by attempting to solve a problem? We call this the Maupertuis hypothesis. It addresses how life might proliferate across the Universe even without the specific conditions found on Earth. So, what is this shared problem? The Maupertuis hypothesis suggests that, building on the second law of thermodynamics, life might be the Universe’s way of reaching thermodynamic equilibrium more quickly. It might be how the Universe ‘solves’ the problem of processing energy more effectively.

Pierre-Louis Moreau de Maupertuis was an 18th-century French mathematician and philosopher who formulated the ‘principle of least action’, which explains the simple trajectories of light and physical objects in space and time. In both cases, nature reveals an economy of means: light follows the fastest path between two points; physical objects move in a way that requires the least energy. And so, according to what we are calling the Maupertuis hypothesis, life can also be understood in a similar way, as the minimisation or maximisation of certain quantities. Research into the origins of life can be thought of as a search for these quantities.

For example, evolution by natural selection is a process in which repeated rounds of survival cause dominant genotypes to encode more and more information about their environment. This creates organisms that seem to be maximising adaptive information while conserving metabolic energy. And, in the process, these organisms hasten the production of entropy in the Universe. It is possible to abstract this dynamic in terms of Bayesian statistics. From this perspective, a population of evolving organisms behaves like a sampling process, with each generation selecting from the possible range of genetic variants. Over many generations, the population can update its collective ‘knowledge’ of the world through repeated rounds of differential survival (or ‘natural selection’).

‘Free energy’ is a kind of measurement of uncertainty: the difference between a prediction and an outcome

This Bayesian thinking led to the free-energy principle, proposed by the neuroscientist Karl Friston in 2005. His principle has become foundational to what we are calling the Maupertuis hypothesis. Like constructor theory, the free-energy principle seeks to provide a unifying framework for all living systems. Friston’s principle extends ideas from Bayesian statistics (estimating parameters) and statistical mechanics (minimising cost functions) to describe any process of learning or adaptation, whether in humans, organisms or other living systems.

His framework seeks to explain how these living systems are driven to minimise uncertainty about their environment by learning to make better predictions. For Friston, ‘free energy’ is a kind of measurement of uncertainty: the difference between a prediction and an outcome. The larger the difference, the higher the free energy. In Friston’s framework, a living system is simply any dynamical system that can be shown to minimise free energy, to minimise uncertainty. A rock rolling down a hill is minimising potential energy but certainly not Fristonian free energy – rocks do not learn to make better predictions about their environments. However, a bacterium swimming along a nutrient gradient is minimising free energy as it extracts information from its environment to record the position of its food. A bacterium is like a rock that infers.

If one is willing to accept the idea that modelling the world – by extracting information and making inferences about the environment – is constitutive of life, then life should arise everywhere and rather effortlessly. Like the principle of least action, which underpins all theories in physics, Friston’s idea suggests that minimising free energy is the action supporting every candidate form of life. And this includes biological organisms, societies and technologies. From this perspective, even machine learning models such as ChatGPT are candidate life-forms because they can take action in the world (fill it with their texts), perceive these changes during training, and learn new internal states to minimise free energy.

A ccording to the Maupertuis hypothesis, living things are not limited to biological entities, but are, in a more general sense, machines capable of transmitting adaptive solutions to successive generations through the minimisation of free energy. Put another way, living things are capable of transmitting information from their past to their future. If that is true, then how do we define the boundaries of living things? What counts as an individual?

The information theory of individuality, developed by David Krakauer and colleagues from Santa Fe Institute in New Mexico and collaborators from the Max Planck Institute in Leipzig in 2020, addresses this question. Responding to ideas such as Friston’s free-energy principle, we proposed that there are more fundamental ‘individuals’ than the seemingly discrete forms of life around us. These individuals are defined by their ability to transmit adaptive information through time. We call them ‘Maupertuis particles’ for the way they play a role comparable to particles moving within fields in a physical theory – like a mass moving in a gravitational field. These individuals do not need to be biological. All they need to do is transmit adaptive solutions to successive generations.

Individuals are dynamical processes that encode adaptive information

Life relies on making copies, which progressively adjust to their environment with each new generation. In traditional approaches to the origin of life, mechanisms of replication are particularly important, such as the copying of a gene within a cell. However, replication can take many other forms. The copying of a gene within a cell is just chemistry’s way of approximating the broader informational function of Maupertuis particles. Even within biology, there are many kinds of individuals: viruses that outsource most of their replication machinery to host genomes, microbial mats in which horizontal gene-transfer erodes the informatic boundary of the cell, and eusocial insects where sterile workers support a fertile queen who produces future descendants. According to the information theory of individuality, individuals can be built from different chemical foundations. What matters is that life is defined by adaptive information. The Maupertuis hypothesis allows new possibilities for what counts as a living thing: new forms and degrees of individuality.

So how do we find these individuals? According to the information theory of individuality, individuals are dynamical processes that encode adaptive information. To understand how these might be discovered, consider how different objects in our Universe are detected at different wavelengths of light. Many features of life, such as the heat signatures of metabolic activity, become visible only at higher wavelengths. Others, such as carbon flux, are visible at lower wavelengths. In the same way, individuals are detected by different ‘informational frequencies’. Each life form possesses a different frequency-spectrum, with each type forming increasingly strong correlations in space (larger and larger adaptations) and time (longer and longer heredity). Even within the same chemical processes, multiple different individuals can be found depending on the choice of informational filter used. Consider a multicellular organism – a human being. Viewed at a distance (using a kind of coarse-grain filter), it is a single coordinated entity. However, viewed up close (using a fine-grain filter), this single entity is teeming with somewhat independent tissues, cells and proteins. There are multiple scales of individuality.

So, what is the shared goal of these proliferating individuals? As they each expend metabolic energy to ensure reliable information-propagation, they accelerate the production of environmental entropy. In this way, by sharing adaptive information, each individual indirectly hastens the heat death of the Universe. By solving small problems locally, life creates big problems globally.

I s life problem-solving matter? When thinking about our biotic origins, it is important to remember that most chemical reactions are not connected to life, whether they take place here or elsewhere in the Universe. Chemistry alone is not enough to identify life. Instead, researchers use adaptive function – a capacity for solving problems – as the primary evidence and filter for identifying the right kinds of biotic chemistry. If life is problem-solving matter, our origins were not a miraculous or rare event governed by chemical constraints but, instead, the outcome of far more universal principles of information and computation. And if life is understood through these principles, then perhaps it has come into existence more often than we previously thought, driven by problems as big as the bang that started our abiotic universe moving 13.8 billion years ago.

The physical account of the origin and evolution of the Universe is a purely mechanical affair, explained through events such as the Big Bang, the formation of light elements, the condensation of stars and galaxies, and the formation of heavy elements. This account doesn’t involve objectives, purposes, or problems. But the physics and chemistry that gave rise to life appear to have been doing more than simply obeying the fundamental laws. At some point in the Universe’s history, matter became purposeful. It became organised in a way that allowed it to adapt to its immediate environment. It evolved from a Babbage-like Difference Engine into a Turing-like Analytical Engine. This is the threshold for the origin of life.

In the abiotic universe, physical laws, such as the law of gravitation, are like ‘calculations’ that can be performed everywhere in space and time through the same basic input-output operations. For living organisms, however, the rules of life can be modified or ‘programmed’ to solve unique biological problems – these organisms can adapt themselves and their environments. That’s why, if the abiotic universe is a Difference Engine, life is an Analytical Engine. This shift from one to the other marks the moment when matter became defined by computation and problem-solving. Certainly, specialised chemistry was required for this transition, but the fundamental revolution was not in matter but in logic.

In that moment, there emerged for the first time in the history of the Universe a big problem to give the Big Bang a run for its money. To discover this big problem – to understand how matter has been able to adapt to a seemingly endless range of environments – many new theories and abstractions for measuring, discovering, defining and synthesising life have emerged in the past century. Some researchers have synthesised life in silico. Others have experimented with new forms of matter. And others have discovered new laws that may make life as inescapable as physics.

It remains to be seen which will allow us to transcend the history of our planet.

Published in association with the Santa Fe Institute, an Aeon Strategic Partner.

For more information about the ideas in this essay, see Chris Kempes and David Krakauer’s research paper ‘ The Multiple Paths to Multiple Life ’ (2021), and Sara Imari Walker’s book Life as No One Knows It: The Physics of Life’s Emergence (2024).

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Students With Emotional and Behavioral Problems in Inclusive Classes: A Critical Incident Analysis

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Main page content, connected and strong compendium: 10 technical assistance briefs to foster unity and strengthen continuity across crisis response and treatment systems.

Together, these papers lay out recommendations and highlight specific strategies to connect the oftentimes fragmented crisis care system, and strengthen America’s approach to providing behavioral healthcare overall, in accordance with President Biden’s Unity Agenda.

The papers are:

• Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services
• Peer Support Services Across the Crisis Continuum
• Growing and Strengthening the Behavioral Health Crisis Response Workforce
• Crisis Services: General Medical and Psychiatric Approaches to Care Delivery
• Innovative Uses of Technology to Enhance Access to Services Within the Crisis Continuum
• Crisis Systems Coordination and Collaboration: Leveraging Strengths and Opportunity of 988 and 911
• Facilitating Rapid Access to Outpatient Mental Health and Substance Use Care
• Increasing Equitable Access to Care for Co-Occurring Mental Health and Substance Use Disorders
• Intersectionality: Faith, Mental Health, and Community Partnerships
• Long COVID and High-risk Populations

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Role of Parenting Style in Children’s Behavioral Problems through the Transition from Preschool to Elementary School According to Gender in Japan

Rikuya hosokawa.

1 School of Nursing, Nagoya City University, Nagoya 467-8601, Japan

2 Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan; pj.ca.u-otoyk.dem.sh@arustakt

Toshiki Katsura

While ineffective discipline can be attributed to authoritarian and permissive parenting styles, little research has examined the role of gender in the association between parenting style and early childhood behavioral problems. Thus, this study aimed to clarify the effects of authoritarian and permissive parenting on children’s externalizing and internalizing behaviors during the preschool-to-elementary-school transition according to gender in Japan. A sample of 1668 Japanese children (853 boys and 815 girls) were followed longitudinally over one-year intervals, and assessed based on parenting styles (the Parenting Scale), children’s behavioral problems (the Strengths and Difficulties Questionnaire), and family characteristics. Multivariate analyses revealed that, when analyzed by gender, authoritarian discipline influenced externalizing problems in boys (β = 0.048, p = 0.047) and girls (β = 0.067, p = 0.023), while permissive discipline influenced externalizing problems in boys only (β = 0.049, p = 0.038). The results document the relationship between family processes and the development of disruptive behavior disorders in children. Support for parents employing such child-rearing styles in early childhood may be effective in reducing school maladjustment.

1. Introduction

Behavioral problems including externalizing problems (e.g., hyperactivity, rule-breaking behaviors, and aggression) and internalizing problems (e.g., anxiety, withdrawal, and depression) are among the most common mental health issues in early childhood [ 1 , 2 , 3 ]. Moreover, behavioral problems in early childhood are a significant predictor of negative mental health outcomes in later life [ 4 , 5 , 6 ]. For example, they are highly predictive of a range of difficulties during childhood, such as conduct disorder, poor scholastic achievement, and peer rejection [ 7 , 8 , 9 ], as well as negative outcomes in adolescence and adulthood, such as mental health problems, poor employment prospects, and antisocial behavior [ 10 , 11 , 12 ]. During early childhood, several developmental trajectories emerge [ 13 , 14 ]. Behavioral problems in early childhood may also hinder the development of a range of social, emotional, and cognitive competences in children [ 15 , 16 ], and early childhood is a critical period for the development of behavioral problems related to social maladaptation. Finally, untreated behavioral problems during early childhood are considered disadvantageous [ 17 , 18 , 19 ]. Thus, to prevent the development of behavioral problems, it is necessary to understand the early childhood development of these problems as well as their etiology and developmental course.

Early childhood child-rearing environments can significantly affect the incidence of children’s behavioral problems. The family is a social arrangement that exerts significant influence on children’s development and parenting styles, and in particular, influences the social environments of children within the family. Moreover, parenting is an ecological variable that significantly influences a child’s personality development [ 20 , 21 , 22 ]. Some previous studies have suggested that maternal and paternal parenting styles play a central role in understanding the development of externalizing and internalizing behaviors [ 23 , 24 ], since parenting style exacerbates or reduces children’s behavioral problems [ 25 , 26 , 27 ]. The effects on development of parenting behaviors in childhood tend to be stable over time [ 28 , 29 ]. Depending on the parenting style they adopt, parents elect to use different discipline strategies to manage their children’s behavior and such strategies are considered a fundamental aspect of parenting [ 30 ].

The most frequent categorization of ineffective discipline includes the two styles of parenting identified by Baumrind—the authoritarian and permissive styles—each of which is theorized to differentially influence offspring [ 31 , 32 , 33 ]. According to Baumrind’s typology, parenting styles vary on a two-dimensional framework of parental demandingness (e.g., control, supervision, maturity demands), which refers to the role parents play in promoting respect for rules and social conventions, and responsiveness (e.g., warmth, acceptance, involvement), which is related to the level of parental involvement between children and parents. Ineffective discipline can be attributed to two parental authority prototypes or styles, authoritarian and permissive, which are characterized as being either high or low on the two parenting dimensions (i.e., demandingness and responsiveness).

The authoritarian style has high demandingness and low responsiveness and is characterized by firmly enforced rules and edicts decided by parents as well as strong control over children’s autonomy [ 34 , 35 , 36 , 37 ]. Parents with an authoritarian style attempt to control the behavior of their children in accordance with a set standard of conduct, usually an absolute standard [ 33 ]. Authoritarian parents tend to use demands to discipline their children and only allow them minimal autonomy. They also demonstrate low affection and emotional warmth in their parent–child relationships [ 36 , 37 ]. This type of parenting is likely to be negatively associated with children’s psychosocial development; that is, children of authoritarian parents are likely to have low self-esteem, be less content and less secure, and have negative attitudes toward the world; conversely, they are likely to do well in terms of obedience to standards [ 37 , 38 ].

Permissive parenting, on the other hand, has low demands and high responsiveness. It is characterized by a lack of monitoring, control, and discipline, yet it is warm and nurturing [ 39 , 40 ]. Permissive parents attempt to behave in a nonpunitive and accepting manner toward their children’s desires and actions and allow their children to regulate their own activities as much as possible [ 33 ]. Permissive parenting occurs when parents fail to set limits and do not expect developmentally appropriate behavior of their children. As a consequence, this type of parenting is likely to be negatively associated with children’s psychosocial development and children of permissive parents exhibit characteristics such as narcissistic tendencies, social irresponsibility, and self-centered motivation [ 41 , 42 ]. Consequently, both authoritarian and permissive disciplinary styles are potentially harmful for children’s psychosocial development. Furthermore, such parental styles have been linked consistently with a variety of negative developmental outcomes including behavioral problems over time [ 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

Although several studies focusing on parenting styles and behavioral problems and involving mixed samples (i.e., including both boys and girls) have linked ineffective discipline to disruptive behavioral problems in children, these studies did not differentiate between boys and girls. That is, the research has not sufficiently examined how parenting styles influence child outcomes within the context of child gender dyads. Children’s gender has been found to be important in the emergence of child behavior problems and how children respond to parenting styles, and several studies have suggested the role of gender differences in internalizing versus externalizing problems [ 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. Early childhood is a critical period for child development related to social adaptation. Because gender can play a role in discipline-associated outcomes in early childhood, it is important to clarify the effects of authoritarian and permissive parenting on behavioral problems according to gender in this period. Furthermore, there is consistent evidence with mixed samples in North American and European families that authoritarian and permissive parenting in early childhood are associated with poor child outcomes. Although it has been debated whether these relationships can be generalized to families in East Asian cultures, several studies using East Asian subjects have produced similar results to those using Western subjects. For instance, concerning school performance, one study focusing on Chinese children (mean age 7 years) demonstrated a negative effect of authoritarian parenting [ 57 ]. Another study on Chinese children (mean age 9 years) demonstrated that authoritarian parenting led to low self-regulation and learning problems in children [ 58 ]. However, while many studies have shown the cultural differences between East Asian and Western parenting styles, there has been limited research on the effect of authoritarian and permissive parenting on behavioral problems in early childhood in Japan. Japanese and Chinese parents are more likely to endorse an authoritarian parenting style, such as strictness and parental control, than parents from Western cultures [ 59 , 60 ]. Moreover, children in East Asian countries are more likely to be required to be obedient and polite than those in Western countries [ 61 , 62 ]. Thus, cultural differences can play a role in discipline-associated child outcomes in early childhood and it is important to clarify the effects of authoritarian and permissive parenting on behavioral problems according to gender in early childhood in Japan.

In summary, authoritarian and permissive parenting directly impact children’s behavioral problems. Although many studies have focused on this relationship, to date, not enough research has examined the association between parenting style and children’s behavioral problems in early childhood, with a focus on the role of child gender. In Japan specifically, limited research has examined the effect of authoritarian and permissive parenting style in early childhood on behavioral problems. Therefore, the present study attempts to clarify the effects of authoritarian and permissive parenting respectively in early childhood on the externalizing and internalizing problem behaviors of children in elementary school, focusing on gender, in Japanese children. The influence of different negative parenting styles in preschool on the presence of externalizing and internalizing problem behaviors in elementary school could differ between boys and girls. We hypothesized that in a mixed sample using Japanese subjects, authoritarian and permissive parenting in early childhood would be associated with poor child outcomes, producing similar results to studies conducted in other countries. We also hypothesized that authoritarian parenting would be more strongly associated with behavioral problems in girls than in boys and that permissive parenting would be more strongly associated with behavioral problems in boys than in girls.

2. Materials and Methods

2.1. participants.

The children targeted by this study, all of whom were five years old, were recruited from 52 kindergartens and 78 nursery schools. Recruitment was conducted in 2014 in Nagoya City, which is a major urban area in Aichi Prefecture in Japan. The targeted children and their parents participated in the longitudinal project designed to examine the influence of family factors on children’s social developmental outcomes. The first two cohorts (2014: T1; 2015: T2) of participants were included in this study. A total of 3314 of the 5024 target families completed the baseline assessment (T1), and of these, 1787 completed both the baseline (T1) and follow-up assessments (T2), indicating a retention rate of 53.9%.

To recruit participants, self-report questionnaires were distributed to all parents of the targeted children ( n = 5024) at T1 when the children were five years old and in preschool, and the response rate was 66.0% ( n = 3314). At T2, when the children were six years old and in first grade, a second questionnaire was distributed to the families ( n = 3314) and the response rate was 53.9% ( n = 1787). Thus, the attrition rate from T1 to T2 was 46.1%, with 44.7% not responding at T2 and 1.4% ( n = 46) having relocated.

There were a number of significant differences between those who participated in the baseline and one-year follow-up assessments ( n = 1787) and those who did not respond to the T2 assessments ( n = 1527), with the latter being more likely to have lower socioeconomic status (SES) (i.e., lower household income and parents with lower levels of education). A comparison of the demographic features between the non-returning and returning participants revealed that 16.2% of the non-returning participants’ annual household income was less than Ұ3,000,000, while this was true of only 10.0% of the returning participants; the household income of the non-returning participants was significantly lower than that of the returning participants, as measured by a chi-square test. In addition, 5.8% of the non-returning participants’ maternal educational background comprised compulsory education, while this was true of only 2.4% of the returning participants; furthermore, 7.6% of the non-returning participants’ paternal educational background comprised compulsory education, while this was true of only 4.7% of the returning participants. Both the maternal and paternal educational levels of non-returning participants were significantly lower than those of the returning participants, as measured by a chi-square test. Thus, the non-returning participants tended to have relatively lower SES than did returning participants, meaning that there was a lower response rate of individuals with low SES compared to those with high SES. Hence, those participants lost from the sample comprised families with higher rates of lower sociodemographic factors, meaning that these families were underrepresented in our sample and our results may be less generalizable to families with a lower socioeconomic background.

To accurately clarify the associations between parenting attitude and child developmental outcomes, we then chose to exclude children with developmental problems ( n = 75) and children whose mothers did not complete question items regarding parenting attitude and child developmental outcomes ( n = 44). Consequently, of the 1787 children for whom data were received at both T1 and T2, 1668 (93.3%) met the inclusion criteria.

2.2. Ethics Statement

The researchers obtained written, informed consent from all participants. Written, informed consent was obtained on behalf of the children from their parents. Ethical approval for this study was obtained from Kyoto University’s Ethics Committee in Kyoto, Japan (E2322). All procedures performed in studies involving human participants were in accordance with the standards of the ethics committee.

2.3. Measures

2.3.1. parenting behavior: parenting scale (ps).

The Parenting Scale (PS) is a questionnaire that measures dysfunctional discipline styles in parents to manage children’s behavior [ 63 ]. The PS Japanese version was used in this study [ 64 ]. At the baseline assessment, parents completed the PS. Each of the 30 items is rated on a 7-point scale. Two subscales from the PS were used to assess dysfunctional discipline practices when faced with problem situations. Ratings of parental behavior are obtained with regard to ineffective discipline styles: laxness (i.e., permissive discipline) and over-reactivity (i.e., authoritarian discipline). The scale shows adequate internal consistency and also correlates closely with direct observations of mother–child interactions [ 63 , 64 ]. The Cronbach’s alphas for laxness and over-reactivity in this sample were 0.70 and 0.86, respectively; the scale demonstrated adequate internal consistency (see Table 1 ).

Descriptive statistics for the study variables ( n = 1668).

Abbreviations: Standard Deviation (SD); Cronbach’s Alpha (α).

For the PS Japanese version, the items of over-reactivity were similar to those of the original version [ 63 ]. Regarding laxness, although the concept was similar, slight differences were observed in the items. Specifically, although the original version included “ If saying ‘No’ doesn’t work, I offer my child something nice so he/she will behave ” as one of the laxness items, the Japanese version did not include this item and instead included “ When my child pesters me, I can’t ignore the pestering .” In Japanese, “laxness” is likely to mean that parents are at their children’s beck and call rather than that parents make a deal with children to temporarily handle the situation. Thus, adjustments to the PS were made to account for the difference between Japanese and Western permissive parenting styles.

2.3.2. Child Behavioral Problems: The Strengths and Difficulties Questionnaire (SDQ)

The Strengths and Difficulties Questionnaire (SDQ) measures child behavioral problems [ 65 ]. The SDQ Japanese version was used in this study [ 66 ]. Parents completed the SDQ at both the baseline assessment (T1) and at the one-year follow-up assessment (T2). The SDQ is a 25-item measure of parents’ perceptions of prosocial and difficult behaviors in their children, designed to assess the frequency of positive and negative behaviors in children [ 65 ]. It comprises five subscales (i.e., emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial behavior), and the score for each subscale is computed by adding the scores for the five items. The difficult behavior score in the SDQ is calculated as the sum of the scores obtained on the emotional symptoms, conduct problems, hyperactivity, and peer problems subscales. In this study, the emotional symptoms and peer problems subscales of the SDQ were combined to form an internalizing problems scale, while the conduct problems and hyperactivity-inattention subscales were combined to form an externalizing problem scale, as suggested by Goodman et al. [ 67 ]. The scale has been validated as having adequate internal reliability [ 66 ]. In this sample, the Cronbach’s alphas for internalizing and externalizing problems were 0.65–0.71 and 0.74–0.77, respectively; the scale demonstrated adequate internal consistency (see Table 1 ).

2.3.3. Demographic Covariates

Parents provided their demographic information, including child’s sex, family structure (single-parent or two-parent family), attending institution (kindergarten or nursery school), annual household income, maternal education level, and paternal education level. Regarding family income, parents reported their annual household income in Japanese yen (JPY). In this study, the median household income was between 5.00 and 5.99 million JPY, and the average number of people per household was 4.3. In Japan, the median income of a four-person household is approximately 6.00 million JPY, so the household income of participants in this study was relatively similar to the typical Japanese distribution. The threshold for four-person households in Japan, calculated based on the Organisation for Economic Co-operation and Development’s standard for the poverty line (i.e., half the median income of the total population), is an annual income of approximately 3.00 million JPY [ 68 ]. Therefore, with reference to those values, we created four categories of income: <3 million, 3–5 million, 6–8 million, and ≥9 million JPY. Regarding parental education, both parents were asked to report their education in years, as well as the highest level of education completed. The Japanese education system comprises elementary school (6 years), junior high school (3 years), and high school (3 years), and education is compulsory until the end of junior high school (9 years). Based on the data, we created four categories of education level: compulsory education (9 years), upper secondary school (12 years), up to four years of college/university (13–15 years), and four or more years of college/university (≥16 years). At the baseline assessment, parents provided complete information regarding these factors (see Table 2 ).

Participant characteristics at preschool (T1).

Abbreviations: Japanese Yen (JPY).

2.4. Data Analyses

First, the relationships between participant characteristics and children’s behavioral problems were analyzed via t -test or one-way analysis of variance (ANOVA) as shown in Table 3 . Second, the effects of parenting practices during preschool (T1) on children’s outcomes in first grade (T2) were assessed using multiple linear regression, with PS scores of laxness (i.e., permissive discipline) and over-reactivity (i.e., authoritarian discipline) as predictors and SDQ scores of internalizing or externalizing problems as the outcome (see Table 4 , Table 5 and Table 6 ). Table 4 shows the entire sample of both boys and girls ( n = 1668), Table 5 shows only boys ( n = 853), and Table 6 shows only girls ( n = 815). Multivariate regression analyses were performed as follows: in Models 1–2, each predictor was entered individually to assess its univariate association with each outcome (i.e., laxness (Model 1), over-reactivity (Model 2)). In Model 3, both predictors (i.e., laxness and over-reactivity) were entered simultaneously. As several participant characteristics at T1 were significantly associated with behavioral problems at T1 in the analyses (see Table 3 ), we included the factors as covariates in each analysis (see Table 4 , Table 5 and Table 6 ). Multicollinearity among the predictors was assessed, and no problems were found. IBM SPSS Statistics 23.0 (IBM Corporation, New York, NY, USA) was used for all statistical analyses with a significance level of 5%.

Participant characteristics at preschool (T1) and behavioral problems in first grade (T2).

Abbreviations: Standard Deviation (SD); p -value ( p ); * significance at p < 0.05; ** significance at p < 0.01; *** significance at p < 0.001.

Effect of parenting practices at preschool (T1) on behavioral problems at first grade (T2) in both boys and girls.

Note: Internalizing problems: Controlled for sex, family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 internalizing problems. Externalizing problems: Controlled for sex, family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 externalizing problems. Abbreviations: Unstandardized coefficient (B); Standard Error (SE); Standardized coefficient (β); p -value ( p ); * significance at p < 0.05; ** significance at p < 0.01.

Effect of parenting practices at preschool (T1) on behavioral problems at first grade (T2) boys only.

Note: Internalizing problems: Controlled for family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 internalizing problems. Externalizing problems: Controlled for family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 externalizing problems. Abbreviations: Unstandardized coefficient (B); Standard Error (SE); Standardized coefficient (β); p -value ( p ); * significance at p < 0.05; ** significance at p < 0.01.

Effect of parenting practices at preschool (T1) on behavioral problems at first grade (T2) girls only.

Note: Internalizing problems: Controlled for family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 internalizing problems. Externalizing problems: Controlled for family structure, attending institution, annual household income, maternal education level, paternal education level, and T1 externalizing problems. Abbreviations: Unstandardized coefficient (B); Standard Error (SE); Standardized coefficient (β); p -value ( p ); * significance at p < 0.05.

3.1. Study Population

Participants’ demographic characteristics at preschool (i.e., at baseline) are shown in Table 2 , and the relationships between participants’ demographic characteristics and emotional/behavioral problems at first grade are shown in Table 3 . The children’s average age was 6.09 years (SD = 0.30), with 51.1% boys ( n = 853) and 48.9% girls ( n = 815). Regarding family structure, in the mixed sample and girls sample, the internalizing problem scores of children from single-parent families were significantly higher than those of children from two-parent families; similarly, in the mixed sample and girls sample, externalizing problem scores of children from single-parent families were significantly higher than those of children from two-parent families. Regarding attending institution, in the mixed sample, nursery school children’s internalizing problem scores were significantly higher than kindergarten children’s internalizing problem scores; in the mixed sample, boys sample, and girls sample, nursery school children’s externalizing problem scores were significantly higher than kindergarten children’s externalizing problem scores. Regarding annual household income, in the mixed, boys, and girls samples, the internalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households; similarly, in the mixed, boys, and girls samples, the externalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households. Regarding maternal education level, in the mixed, boys, and girls samples, the internalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households; similarly, in the mixed, boys, and girls samples, the externalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households. Regarding paternal education level, in the mixed sample, the internalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households; in the mixed and boys samples, the externalizing problem scores of children from lower-income households were significantly higher than those of children from higher-income households.

3.2. Effect of Parenting Practices on Behavioral Problems

The associations between parenting practices and children’s outcomes were assessed using multiple linear regression, with PS scores of laxness (i.e., permissive discipline) and over-reactivity (i.e., authoritarian discipline) as predictors and SDQ scores of internalizing or externalizing problems as the outcome (see Table 4 , Table 5 and Table 6 ). First, regarding analysis targeting boys and girls ( n = 1668), the results of the multivariate analysis between parenting practices and behavioral problems are shown in Table 4 . Regarding internalizing problems as the outcome, in the models that included individual predictors (i.e., Models 1 and 2), each predictor (i.e., laxness and over-reactivity) was not significantly associated with internalizing problems. Further, in Model 3 (which contained both predictors), no predictor was significantly associated with internalizing problems. On the other hand, regarding externalizing problems as the outcome, in Models 1 and 2, each predictor was significantly associated with externalizing problems. Further, in Model 3, both laxness (β = 0.040, p = 0.034) and over-reactivity (β = 0.055, p = 0.005) were significantly associated with externalizing problems.

Second, regarding analysis targeting only boys ( n = 853), the results of the multivariate analysis between parenting practices and behavioral problems are shown in Table 5 . Regarding internalizing problems as the outcome, in Models 1 and 2, laxness and over-reactivity were not significantly associated with internalizing problems. Further, even in Model 3, these predictors were not significantly associated with internalizing problems. On the other hand, regarding externalizing problems as the outcome, in Models 1 and 2, each predictor was significantly associated with externalizing problems. Further, in Model 3, both laxness (β = 0.049, p = 0.038) and over-reactivity (β = 0.048, p = 0.047) were significantly associated with externalizing problems.

Finally, regarding analysis targeting only girls ( n = 815), the results of the multivariate analysis between parenting practices and behavioral problems are shown in Table 6 . Regarding internalizing problems as the outcome, in Models 1 and 2, laxness and over-reactivity were not significantly associated with internalizing problems. Further, even in Model 3, both these predictors were not significantly associated with internalizing problems. On the other hand, regarding externalizing problems as the outcome, in Models 1 and 2, over-reactivity but not laxness was significantly associated with externalizing problems. Further, in Model 3, laxness was not significantly associated with externalizing problems, whereas over-reactivity was significantly associated with externalizing problems (β = 0.067, p = 0.023).

4. Discussion

Based on our longitudinal observation, the findings of the present study highlighted the significant impact of parenting styles on children’s behavioral problems, focusing on the role of child gender. Our results demonstrate a clear relationship between discipline styles in preschool for five-year-old children and behavioral problems in first grade for six-year-old children. These findings are consistent with previous studies that suggest that authoritarian and permissive disciplinary styles are associated with disruptive behavioral problems [ 69 , 70 , 71 , 72 , 73 ]. Specifically, multivariate analyses in the mixed sample revealed that not only higher over-reactivity (i.e., high authoritarian discipline) but also higher laxness (i.e., high permissive discipline) predicted clinically significant externalizing problems. In addition, based on an analysis of gender, authoritarian discipline was found to be related to externalizing problems in both boys and girls, whereas permissive discipline was related to externalizing problems only in boys. It is important to note that in our study, the relationships between parenting and child behavioral problems were found after controlling for child characteristics as well as demographic characteristics such as family structure and family SES at baseline. As these analyses controlled for these variables, the relationships between parenting and child behavioral problems were independent of the effect of child and demographic characteristics. Many studies have also suggested that behavior development identifies major risk factors for childhood behavioral problems; for example, not only parenting techniques but also child characteristics and family adversities such as low SES and single parenting have been shown to increase the risk of developing childhood behavioral difficulties [ 74 , 75 , 76 , 77 , 78 , 79 ]. A finding of note in the present study was gender difference that permissive discipline was related to externalizing behavioral problems for boys but not girls. Several of the mechanisms involved in this relationship between disciplinary styles and the risk of behavioral problems are likely to differ among boys and girls in early childhood.

4.1. Effects of Authoritarian Parenting Style on Behavioral Problems

The current findings suggest that the authoritarian parenting style was detrimental for both boys and girls. This finding is consistent with previous studies that also suggest that the authoritarian parenting style is linked to externalizing problems [ 69 , 70 , 80 , 81 , 82 , 83 ]. However, although most previous studies have analyzed mixed samples, they did not differentiate between boys and girls. This study, however, found that authoritarian discipline predicted clinically significant externalizing problems for both boys and girls. There was no gender difference in this relationship. Authoritarian discipline encompasses a restrictive style of interaction with children, which does not take the children’s views and wishes into account. Authoritarian parents can influence the behaviors of their children in society, who tend to be unsuccessful because prohibition and power assertion are likely to be related to anxiety, fear, and frustration in children; moreover, such parents are likely to be subjected to their children’s misbehaviors and other psychosocial behaviors. Indeed, children of parents with high-control parenting styles such as power-assertive, prohibitive, and punitive strategies have been shown to be less content, less secure, and more likely to become hostile or regressive and have greater difficulties dealing with somatic distress or psychological issues when under high stress than other children [ 84 , 85 ]. Moreover, coercive parenting styles are likely to prevent children from learning to self-regulate their own behaviors [ 86 , 87 ]. In addition, lack of parental warmth is also a risk factor for aggressive and disruptive behavioral problems in children [ 88 ] and could contribute to the development of deviant behaviors and adjustment problems. Therefore, in this study, children who received authoritarian parenting including high control and low warmth appear to be at an increased risk of externalizing behavioral problems.

Authoritarian parenting style tends to be more common in Japan than in Western countries [ 64 ], perhaps due to parents’ expectations or environmental conditions. In Japan, children are required to be more obedient and polite than in Western countries [ 61 ]. For instance, when children make noise, parents may overreact from worry about bothering others. Therefore, parents in Japan may be more severe than Western parents in punishing bad behaviors and thus use a more control-oriented parenting style. Although we hypothesized that authoritarian parenting was more associated with behavioral problems in girls than in boys, we found that it was associated with behavioral problems in both boys and girls, perhaps influenced by the Japanese cultural background.

4.2. Effects of Permissive Parenting Style on Behavioral Problems

Permissive parenting was found to be related to disruptive behavior in boys but not in girls. Permissive parents dislike having control and authority over their children and therefore do not guide them to regulate their behaviors and allow them to make decisions alone. Because they are not comfortable imposing restrictions on their children, they tend to avoid and tolerate their children’s misbehavior. This type of parenting style can allow the children to control their parents through coercion and thus indulges their low self-control and aggressive behaviors [ 41 , 42 , 89 ]. Consequently, it is assumed that the permissive parenting style will be positively associated with children’s externalizing behavioral problems.

In this study, there was significant gender difference; permissive discipline was related to externalizing behavioral problems in boys but not in girls. Some sources suggest that non-permissive (i.e., firm) disciplinary strategies may be particularly important primarily for boys. For instance, the early parenting model for the development of disruptive behavior focuses primarily on boys and emphasizes the importance of non-permissive discipline to deal with disruptive behaviors [ 90 , 91 ]. The model focusing on gender in early intervention programs suggests that permissive discipline may be particularly detrimental for boys, perhaps because boys have less well-developed self-regulation processes than similarly aged girls [ 92 , 93 ]. This may also be attributed to the gender differences among children in accepting parenting style. How children rate fathers’ or mothers’ parenting styles may depend on the child’s gender. A previous study suggested that boys perceived permissive parenting more than girls [ 94 ]. In addition, boys were likely to rate permissive styles less positively than girls [ 95 ]. These tendencies can more strongly influence the effect of permissive parenting on outcomes for boys than for girls. This study also found that respondents on parenting style were mothers. Boys, rather than girls, were more likely to rate mothers as permissive [ 94 ]. Thus, in this study, boys were more influenced by the permissive discipline of their mothers and in turn may be more exposed to the risk of behavioral problems from permissive parenting than girls. Therefore, in this study, there was likely to be gender difference; permissive discipline was related to externalizing behavioral problems in boys but not in girls.

On the other hand, as mentioned in the Materials and Methods section, although in the present study, the concept of laxness (i.e., permissive discipline) was similar in the PS Japanese version to the original version, slight differences were observed in the items. In Japanese, “laxness” is used to mean that parents are at their children’s disposal rather than that parents negotiate with children to temporarily manage a given situation. Thus, the Japanese permissive parenting style may differ from Western countries’ version thereof, meaning that this trend (i.e., permissive discipline’s relation to externalizing behavioral problems in boys but not in girls) may differ in Western countries.

4.3. Limitations

There are several limitations to this study, which need to be addressed in future research. First, this study was designed as an observational study. It is reasonable to assume that children’s problem behaviors interact with parenting styles in predicting developmental outcomes. Many studies have reported that there are bidirectional relationships between children’s conduct problems and negative parenting behaviors such as the use of harsh and coercive disciplinary strategies [ 70 , 96 , 97 ]. Negative parenting practices have often interacted with child oppositional and aggressive behavior, such that parents of children with behavioral problems were found to practice more negative parenting styles than parents of children without such problems [ 96 , 97 ]. Although this study included child behavioral problems as a baseline survey (T1) and a follow-up survey (T2), parenting style was only included in the baseline survey and therefore the transactional influence could not be estimated. Furthermore, although this study included child and family characteristics as moderator variables in the baseline survey to control for interaction effects, we did not include other multifaceted moderator variables. Therefore, further explorations should include parenting style in both the baseline and follow-up surveys and more multifaceted moderator variables or should conduct an intervention study.

Second, the present study did not include genetic factors. Child temperament has been conceptualized as a pathway through which children’s genotypes affect parenting style because child temperament is genetically influenced [ 98 ]. For instance, children’s negative emotionality was moderately associated with parental negativity and accounted for some part of the total child-based genetic contributions to parental negativity [ 99 ]. Further study should use a genetically informed design to include genetic factors; alternatively, twin studies could be conducted.

Third, in this study, to assess child behavioral problems, the SDQ was completed by parents only, which likely introduced reporting bias. Teachers’ reports might be needed to evaluate this more accurately and further explorations should combine teacher as well as caregiver SDQ ratings. Furthermore, in this study, only mothers were asked about their parenting styles and the parenting styles of mothers and fathers are likely to differ. Apart from the fact that the quantity of time fathers and mothers spend with their children is different, there are indications that parental involvement is also qualitatively different; for instance, mothers were more likely to use an authoritative style, whereas fathers were more likely to use an authoritarian style [ 100 , 101 ]. In addition, children pick up parenting style differently from fathers and mothers; for instance, boys were more likely than girls to rate mothers as permissive and fathers as authoritarian, while girls tended to rate their mothers as more authoritative and fathers as more permissive [ 94 ]. Thus, the parenting styles of fathers and mothers are likely to differ, while boys and girls are likely to have different views on their mothers’ and fathers’ parenting styles. In future research, it is necessary to grasp the child-rearing styles of both fathers and mothers.

Finally, these findings may not be generalizable to all families due to a risk of attrition bias. The retention rate from T1 to T2 was 53.9%, and the returning participants in T2 tended to have relatively higher SES than the non-returning participants, meaning that families with lower SES were underrepresented in our sample, and our results may be less generalizable to families with a lower socioeconomic background. This is a relatively universal problem in parenting research in general—parenting is sufficiently stressful that it is difficult to get the population of parents to participate. Future research would benefit from a study design using samples with higher retention rates (in particular, participants with lower SES).

5. Conclusions

This longitudinal study of a large sample of Japanese children found evidence that, during the important transition period between preschool and elementary school (age five to six), parenting style is associated with children’s behavioral problems at age six. Authoritarian and permissive parenting styles are likely to continue to negatively influence children’s development beyond childhood. In addition, authoritarian discipline was related to disruptive behaviors in both boys and girls, whereas permissive discipline was related to disruptive behaviors in boys but not in girls. The permissive parenting style will be associated positively with externalizing behavior in boys rather than girls because of gender deference. Few studies have examined the way parental authority influences the later development of behavioral problems in children, specifically with a focus on gender. These findings add to the substantial literature documenting the relationship between family processes and the development of disruptive behavior disorders in early childhood, specifically with a focus on gender. Therefore, support for parents that focuses on the negative effects of such child-rearing styles in early childhood according to child gender may be effective in preventing school maladjustment.

Acknowledgments

We gratefully acknowledge all the children, parents, and preschool teachers who participated in this study.

Author Contributions

R.H. designed the study, conducted the analyses, assisted with the literature review and discussion, and completed the journal revisions. T.K. contributed to the project administration and assisted with the review and editing of the manuscript.

This research was funded by JSPS KAKENHI Grant Number 26893224 and JSPS KAKENHI Grant Number 16K20858.

Conflicts of Interest

The authors declare no conflict of interest.

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One Blue Feather. A Changed World?

By Margaret Renkl

Ms. Renkl is a contributing Opinion writer who reports from Nashville on flora, fauna, politics and culture in the American South.

It was lying in the street, rocking gently with the turns of a placid wind. At first I thought it was some bit of detritus set free by a garbage truck, the driver hurrying to complete his rounds before the temperature reached that day’s brutal high. By the time I got close enough to see that it wasn’t any sort of trash at all, the wind had lifted it and tossed it into our yard: a blue jay’s tail feather, newly molted .

In late summer, many resident songbirds undergo a full molt, leaving behind their old, battered feathers and growing gleaming new ones in their place. The new feathers will be needed to offer the best insulation against the cold in winter, and to make the bird’s best case for a mate come spring. The blue jay this feather once belonged to was already in the process of gaining a shiny new version of itself.

But the time between old feathers and new is hard for birds. They feel bad. They’re cross with one another. Blue jays and cardinals, especially, tend to lose many feathers at once. Sometimes they spend a few weeks completely bald . A bird without a full set of feathers is vulnerable. During the molt, they keep quiet and close to the shadows.

I left the blue jay feather where I found it last week. In nature, someone always makes use of what someone else doesn’t need. Another creature will use it to line a nest or a burrow.

I carried that feather with me all week in other ways, though. As with Wordsworth , the world has been too much with me lately, and I welcomed the reminder of the blue jay’s world. Though threatened, at least some things in nature are still timeless, proceeding exactly as they should. I wish I could say the same of us.

In our world, just days after a 14-year-old is alleged to have killed four people in Apalachee High School in Georgia and wounded nine others, a 6-year-old in Memphis brought a loaded gun to school , passing it around for classmates to handle. Days after that, schools were closed in southern Kentucky while authorities searched for an assailant who shot five strangers driving on Interstate 75. In the 25 years since the massacre at Columbine High School, advocates for common-sense gun laws have been indefatigable, their ranks continually growing , yet here we are again.

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By Eric Roberts St. Martin’s Press: 304 pages, $30 If you buy books linked on our site, The Times may earn a commission from Bookshop.org , whose fees support independent bookstores.

The entertainment industry is facing an existential crisis , with less content being produced and far fewer jobs for the taking . Fortunately, Eric Roberts got wise to this state of affairs well before anyone else did, even before we binged TV shows as a source of pride. “They now give you no time to rehearse and they pay you less,” says Roberts, who is best known for his live-wire films. “You can’t sit around and wait for the big paycheck anymore.”

As Roberts writes in his new memoir, ”Runaway Train: Or, the Story of My Life So Far” — out now — he leaned hard into this new normal years before everyone else was scrambling for scarce jobs. Roberts too feels that pinch, which is why he “says yes to everything.” “We are often overdrawn, broke and scared. I know people who were in the cast of ‘Titanic’ [who] can’t pay their rent,” Roberts writes in his memoir.

But Roberts has no use for fame anymore; he just wants to work. In the book, which Roberts wrote with journalist and novelist Sam Kashner, he boasts of having 750 credits on his IMDb page. By the time he sat down for this interview in August, that credit list had ticked up to nearly 850. “I’m an actor, first and foremost,” he says. “Everything else is secondary.”

A standout among a generation of New York theater actors who transitioned into film in the 1970s, Roberts burst into public consciousness in Bob Fosse’s 1983 biopic “Star 80” as Paul Snider, the homicidal husband of Playboy playmate Dorothy Stratten (portrayed by Mariel Hemingway). Roberts dissolved into his character, a manipulative small-time hustler whose self-hatred metastasizes into murderous rage.

Other high-profile roles followed, such as fugitive Buck McGeehy in Andrei Konchalovsky’s 1985 action thriller “Runaway Train.” The actor received an Oscar nomination for that role, and it transported him onto talk-show couches and tabloid covers. Flush and feeling himself, Roberts bought a penthouse apartment on Manhattan’s Upper East Side and a house in Greenwich, Conn. He also began to abuse cocaine. In time, he would lose the apartment and the house; the drugs remained.

But “Runaway Train” the book is not some weepy expiation for past sins, a Hollywood reclamation job designed to kick-start a once-buzzy career. Roberts knows all too well that he has made horrible choices, that his erratic behavior damaged his relationships with friends and family, including his sister Julia Roberts (their relationship remains touch and go; Roberts avers that “we have agreed not to talk about each other’s careers.”) Still, Hollywood lore is lousy with addicts who have thrived despite their bad habits, and for a while, Roberts walked the tightrope.

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As Roberts describes in cringey detail in the book, his fall from grace came a little bit at a time, then all at once. He consistently wrested defeat from the jaws of victory, arguing himself out of acting roles with Quentin Tarantino and Oliver Stone, among others. “I was high when I showed up for my audition with Ron Howard,” says Roberts.

Roberts was an erratic maniac, no doubt, but much of what he learned about the dark arts of self-immolation came from his father, Walter, a screenwriter during the glory days of radio drama who then started his own theater in Atlanta, where Roberts was raised. A bitter, arrogant striver, Walter encouraged his son to act, only to savagely criticize him when he did so, which confused and angered his son.

Roberts’ father was a small-time grifter and once tried to enlist him to rob a pharmacy for much-needed cash. At night, Roberts’ mother frequently beat him with a dowel. Blessed relief from the lash of the dowel came when Roberts’ parents split. Walter was awarded custody of Roberts; sisters Julia and Lisa went to live with their mother. Walter continued to whittle his son down to size. “My father taught me a lot about the process of being a professional actor, but he would denigrate me at every turn,” says Roberts. “As a kid it was very difficult. How do you deal with a father like that? It was hard to process.”

Even when Roberts somehow scraped up the money to move to New York, his father continued to hound him with an endless stream of letters in which he would alternately browbeat him as an underachieving mediocrity, praise his talent, ask for money and accuse him of abandonment. “I was still getting thousands of letters,” says Roberts. “I still have them. It was insane, dude! Eventually, I realized you have to love people for who they are, but you can’t let them walk all over you. Even when it was sincere and loving, it felt misplaced and mean.”

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Despite this epistolary “mind control,” Roberts soldiered on, landing his first TV gig in 1977 on the soap opera “Another World.” Roberts’ smoldering, high-beam intensity caught the attention of Joe Papp, a panjandrum of New York theater who cast Roberts in a Public Theater production of the Civil War drama “Rebel Women.” Roberts earned his Actors’ Equity card, then scored his first film role as Dave Stepanowicz, the scion of a New York crime family, in 1978’s “King of the Gypsies.”

Yet even as Roberts was endearing himself to a wider audience, he was enraging directors with his insistence on staying in character 24/7. “I would yell at people for no reason, lock myself in the trailer and violently kick the door from the inside,” Roberts writes about “Star 80.” “I began manifesting [Snider] to the point that it was imperiling the entire production and infuriating Fosse.”

After that, it was hard to shake the “problem actor” label, especially given the hair-trigger eccentrics he was manifesting so convincingly on film. Roberts’ drug addiction did little to help his cause. “Blow was everywhere,” he says. “I mean, you go to the prop truck on a set and they would have a big bowl of cocaine for everyone. How could I get any work done?”

Roberts’ private and public lives converged, as if he were using Stanislavski’s sense memory in reverse, conjuring up weird scenes from his films as material for his personal use. His stepson Keaton, whom Eric helped raise, moved out as a teenager, unnerved by Roberts’ erratic and often violent behavior. In 1995, Roberts was arrested for shoving his wife Eliza against a wall.

Suffice to say, he didn’t walk into rehab; a court order got him there, for 18 months.

When he emerged, somewhat purged of his own self-hate, Eliza was waiting for him. She pulled him up, brushed him off and transitioned him into a life where he would sublimate his addictive impulses into steady work. She is Roberts’ manager and consigliere, and the pairing has paid off nicely. This year alone, Roberts has acted in 73 productions — a western miniseries, a few low-budget sci-fi films and something called “My Redneck Neighbor: Chapter 1 — The Rednecks Are Coming.” He’s also a contestant on the new season of “Dancing With the Stars,” premiering Tuesday.

And Keaton came back. A singer-songwriter and TV and film composer, he has subsequently worked with Roberts. As for Emma, Roberts’ daughter with former partner Kelly Cunningham, Roberts says, considering that they haven’t been involved in each other’s lives and don’t communicate with each other that much, their relationship is “cordial and supportive, but not close.”

Given how many times Roberts has tried to sabotage his life and his career, he is well aware that it could have gone the other way. “I’m not sure how all this worked out for me, honestly,” he says. “If it weren’t for my wife, I might have been dead by now. I know that sounds dramatic, but it’s a fact.”

Eric Roberts will be signing copies of his memoir, “Runaway Train,” at 7 p.m. Sept. 25 at Barnes & Noble at the Grove in L.A.

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