Children with chronically elevated externalizing symptoms, such as behavioral problems, or internalizing symptoms, such as mental health concerns, have an increased risk for poor economic and social outcomes in adulthood, data from a new study suggest.
Children with comorbid externalizing and internalizing symptoms were especially vulnerable to long-term economic and social exclusion.
"Research has mostly studied the outcomes of children with either behavioral problems or depression–anxiety problems. However, comorbidity is the rule rather than the exception in clinical practice," senior author Massimilliano Orri, PhD, an assistant professor of psychiatry at McGill University in Montreal, Canada, and clinical psychologist with the Douglas Mental Health University Institute, told Medscape Medical News.
"Our findings are important, as they show that comorbidity between externalizing and internalizing problems is associated with real-life outcomes that profoundly influence a youth's chances to participate in society later in life," he said.
The study was published January 9 in JAMA Network Open.
Orri and colleagues analyzed data for 3017 children in the Quebec Longitudinal Study of Kindergarten Children, a population-based birth cohort that enrolled participants in 1986-1987 and 1987-1988 while they were attending kindergarten. The sample included 2000 children selected at random and 1017 children who scored at or above the 80th percentile for disruptive behavior problems.
The research team looked at the association between childhood behavioral profiles and economic and social outcomes for ages 19-37 years, including employment earnings, receipt of welfare, intimate partnerships, and having children living in the household. They obtained the outcome data from participants' tax returns for 1998-2017.
During enrollment in the study, the children's teachers assessed behavioral symptoms annually for ages 6-12 years using the Social Behavior Questionnaire. Based on the assessments, the research team categorized the students as having no or low symptoms, high externalizing symptoms only (such as hyperactivity, impulsivity, aggression, and rule violation), high internalizing symptoms only (such as anxiety, depression, worry, and social withdrawal), or comorbid symptoms. They looked at other variables as well, including the child's sex, the parents' age at the birth of their first child, the parents' years of education, family structure, and the parents' household income.
Among the 3017 participants, 45.4% of children had no or low symptoms, 29.2% had high externalizing symptoms, 11.7% had high internalizing symptoms, and 13.7% had comorbid symptoms. About 53% were boys, and 47% were girls.
In general, boys were more likely to exhibit high externalizing symptoms, and girls were more likely to exhibit high internalizing symptoms. In the comorbid group, about 82% were boys, and they were more likely to have younger mothers, come from households with lower earnings when they were ages 3-5 years, and have a nonintact family at age 6 years.
The average age at follow-up was 37 years. Participants earned an average of $32,800 per year at ages 33-37 years (between 2013 and 2017). During the 20 years of follow-up, participants received welfare support for about 1.5 years, had an intimate partner for 7.4 years, and had children living in the household for 11 years.
Overall, participants in the high externalizing and high internalizing symptom profiles — and especially those in the comorbid profile — had lower earnings and a higher incidence of annual welfare receipt across early adulthood, compared with participants with low or no symptoms. They were also less likely to have an intimate partner or have children living in the household. Participants with a comorbid symptom profile earned $15,031 less per year and had a 3.79-times higher incidence of annual welfare receipt.
Across the sample, men were more likely to have higher earnings and less likely to receive welfare each year, but they also were less likely to have an intimate partner or have children in the household. Among those with the high externalizing profile, men were significantly less likely to receive welfare. Among the comorbid profile, men were less likely to have children in the household.
Compared with the no-symptom or low-symptom profile, those in the high externalizing profile earned $5904 less per year and had a two-times-higher incidence of welfare receipt. Those in the high internalizing profile earned $8473 less per year, had a 2.07-times higher incidence of welfare receipt, and had a lower incidence of intimate partnership.
Compared with the high externalizing profile, those in the comorbid profile earned $9126 less per year, had a higher incidence of annual welfare receipt, had a lower incidence of intimate partnership, and were less likely to have children in the household. Similarly, compared with the high internalizing profile, those in the comorbid profile earned $6558 less per year and were more likely to exhibit the other poor long-term outcomes. Participants in the high internalizing profile earned $2568 less per year than those in the high externalizing profile.
During a 40-year working career, the estimated lost personal employment earnings were $140,515 for the high externalizing profile, $201,657 for the high internalizing profile, and $357,737 for the comorbid profile, compared with those in the no-symptom or low-symptom profile.
"We know that children with externalizing and internalizing symptoms can have many problems in the short term — like social difficulties and lower education attainment — but it's important to also understand the potential long-term outcomes," study author Francis Vergunst, DPhil/PhD, an associate professor of child psychosocial difficulties at the University of Oslo, told Medscape.
"For example, when people have insufficient income, are forced to seek welfare support, or lack the social support structure that comes from an intimate partnership, it can have profound consequences for their mental health and well-being — and for society as a whole," he said. "Understanding this helps to build the case for early prevention programs that can reduce childhood externalizing and internalizing problems and improve long-term outcomes."
Several mechanisms could explain the associations found across the childhood symptom profiles, the study authors wrote. For instance, children with early behavior problems may be more likely to engage in risky adolescent activities, such as substance use, delinquent peer affiliations, and academic underachievement, which affects their transition to adulthood and accumulation of social and economic capital throughout life. Those with comorbid symptoms likely experience a compounded effect.
Future studies should investigate how to intervene effectively to support children, particularly those with comorbid externalizing and internalizing symptoms, the study authors write.
"Currently, most published studies focus on children with either externalizing or internalizing problems (and these programs can be effective, especially for externalizing problems), but we know very little about how to improve long-term outcomes for children with comorbid symptoms," Vergunst said. "Given the large costs of these problems for individuals and society, this is a critical area for further research."
Commenting on the findings for Medscape, Ian Colman, PhD, a professor of epidemiology and public health and director of the Applied Psychiatric Epidemiology Across the Life course (APEAL) lab at the University of Ottawa, said, "Research like this provides solid evidence that if we do not provide appropriate supports for children who are struggling with their mental health or related behaviors, then these children are more likely to face a life of social and economic exclusion."
Colman, who wasn't involved with this study, has researched long-term psychosocial outcomes among adolescents with depression, as well as those with externalizing behaviors. He and colleagues have found poorer outcomes among those who exhibit mild or severe difficulties during childhood.
"Studying the long-term outcomes associated with child and adolescent mental and behavioral disorders gives us an idea of how concerned we should be about their future," he said.
Vergunst was funded by the Canadian Institute of Health Research and Fonds de Recherche du Quebec Santé postdoctoral fellowships. Orri and Colman report no relevant financial relationships.
JAMA Netw Open. Published January 9, 2023. Full text
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.
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Cite this: Childhood Behavioral, Emotional Problems Linked to Poor Economic and Social Outcomes in Adulthood - Medscape - Jan 23, 2023.