The trajectories of child’s internalizing and externalizing problems,social competence and adolescent self-reported problems in a Finnish normal population sample

Abstract

Group-based modeling techniques are increasingly used in developmental studies to explore the patterns and co-occurrence of internalizing and externalizing problems. Social competence has been found to reciprocally influence internalizing and externalizing problems, but studies on its associations with different patterns of these problems are scarce. Using data from a Finnish longitudinal normal population sample, trajectories of internalizing and externalizing problems were formed using the Child Behavior Checklist completed by the mother at the child’s age of 4- to 5-years-old, 8- to 9-years-old, and 16- to 17-years-old (N = 261). The results indicate that adolescent’s self-reported internalizing and externalizing problems based on the Youth Self Report were associated with the trajectories of internalizing and externalizing problems. Social competence both in early childhood and in adolescence was poorer among children with chronic internalizing problems and among those with adolescent-onset externalizing problems. One-third of the children who had a chronically high level of internalizing problems had an initially high but decreasing level of externalizing problems, while 33% of the adolescents with adolescent-onset externalizing problems had a chronically high level of internalizing problems. School psychologists are encouraged to screen for internalizing problems from children with behavioral, academic or social problems.

Keywords

Externalizing problems Finland internalizing problems longitudinal study social competence trajectory analysis

Young children’s ability to express emotions verbally and control their own behavior is limited compared to that of adolescents and adults. As cognitive maturation proceeds and ability in emotion regulation and verbal expression of aggression improve with age, the rates of externalizing problems tend to decrease and those of internalizing problems increase (Crijnen, Achenbach, & Verhulst, 1997; Fanti, Panayiotou, & Fanti, 2012; Rescorla et al., 2007a). In most societies girls tend to score higher on internalizing kinds of problems, especially at ages 12- to 16-years-old and boys on externalizing kinds of problems, especially at ages 6- to 11-years-old (Crijnen et al., 1997; Rescorla et al., 2007a). There are also culture-specific patterns of internalizing and externalizing problems (Savina, Coulacoglou, Sanyal, & Zhang, 2012). In the school environment, externalizing problems are more apparent than internalizing problems. However, studies conducted in the USA indicate that school psychologists find identifying, preventing, and treating internalizing problems important aspects of their work but feel poorly prepared (Miller & Jome, 2008, 2010). Understanding the patterns of individuals’ internalizing and externalizing problems, their interplay and associations with social competence might help in identifying and supporting children with emotional and behavioral problems at school, an integral part of their living environment.

Multilevel modeling techniques are person-centered models to identify different developmental trajectories (Nagin & Odgers, 2010; Nagin & Tremblay, 2001; Tremblay et al., 2004). Studies using these methods have found different patterns of internalizing and externalizing problems. Most children and adolescent have low or moderate level of internalizing and externalizing problems throughout their development. However, trajectories of chronically high and/or increasing internalizing problems from childhood to adolescence are also identified in samples from the USA (Fanti & Henrich, 2010; Leve, Kim, & Pears, 2005; Sterba, Prinstein, & Cox, 2007), Canada (Brendgen, Lamarche, Wanner, & Vitaro, 2010; Brendgen, Wanner, Morin, & Vitaro, 2005), Korea (Lee & Bukowski, 2012), The Netherlands (Dekker et al., 2007) and even among war-affected adolescents in Sierra Leone (Betancourt, McBain, Newnham, & Brennan, 2013). Surprisingly, two studies including Latin origin adolescents indicated decreasing instead of increasing trajectories of internalizing problems among those who had immigrated to the US and also among those living in their home culture (Ramos-Olazagasti, Shrout, Yoshikawa, Canino, & Bird, 2013; Smokowski, Rose, & Bacallao, 2010). These different findings can at least partly be explained by methodological effects.

In addition to the low and moderate patterns, externalizing problems have been reported to have trajectories of chronically high or decreasing levels from childhood to adolescence in samples from Canada, The Netherlands, New Zealand, and the USA (Brame, Nagin, & Tremblay, 2001; Broidy et al., 2003; Cote, Zoccolillo, Tremblay, Nagin, & Vitaro, 2001; Fanti & Henrich, 2010; Miner & Clarke-Stewart, 2008; Moffitt, 1993; Monahan, Steinberg, Cauffman, & Mulvey, 2009; Odgers et al., 2008; Reef, Diamantopoulou, van Meurs, Verhulst, & van der Ende, 2011; Shaw, Lacourse, & Nagin, 2005; Tremblay et al., 2004; Zhou et al., 2007). Some studies have also reported trajectories of adolescent-onset externalizing problems, especially antisocial behavior (Monahan et al., 2009; Odgers et al., 2008; Reef et al., 2011).

Social competence may be equally important as internalizing and externalizing problems when evaluating child’s strengths and difficulties and assessing prognosis (Achenbach, 1991). The continuity and changes in a child’s emotional and behavioral problems and their associations with social competence have also been considered in the concept of the developmental cascade model (Masten & Cicchetti, 2010). It posits that earlier levels and changes in functioning in one domain (e.g. externalizing behavior) have an impact on later functioning in a different domain (e.g. internalizing problems or poorer social competence). Studies of the cascade model indicate that early externalizing problems may be a risk for poorer social and academic competence at early school age, which leads to an increased risk for internalizing problems later (Burt & Roisman, 2010; Masten et al., 2005; Moilanen, Shaw, & Maxwell, 2010; Obradovic, Burt, & Masten, 2010; van Lier & Koot, 2010). Obradovic and Hipwell (2010) also found a reciprocal influence of internalizing problems and poorer social competence among adolescent girls in the US (Obradovic & Hipwell, 2010). The cascade studies, however, only evaluate the level of internalizing and externalizing problems, lacking the aspect of individuals’ different developmental patterns. A North American study conducted by Kouros, Cumming, and Davies (2010) found that as on average children’s externalizing problems decreased over time, significant individual differences were found in the levels of externalizing problems. In addition, the increasing trajectory of externalizing problems accounted for the longitudinal link between early trajectories of interparental conflict and children’s social problems in preadolescence, supporting the developmental cascade model (Kouros, Cummings, & Davies, 2010). Another US study by Lansford et al. (2006) found that poorer social competence at kindergarten age, along with other risk factors was associated with higher levels of both internalizing and externalizing problems over time (Lansford et al., 2006).

In addition to the different developmental patterns and cascading associations, there is also high co-occurrence between internalizing and externalizing problems (Achenbach, 2001; Chen & Simons-Morton, 2009; Reinke, Eddy, Dishion, & Reid, 2012; Ritakallio et al., 2008; Wiesner & Kim, 2006). The co-occurrence has been explained in various ways. One possibility could be diagnostic overlapping, as internalizing and externalizing behaviors can have similar symptoms, such as irritability. Both internalizing and externalizing problems may also share the same environmental risk factors (e.g. parental psychopathology or hostility) which expose the child to maladjustment (Achenbach, 2001). Internalizing problems, such as depression, may also be a risk factor for externalizing problems such as antisocial behavior or vice versa, as studies of the developmental cascade model mentioned above and other studies (Lee & Bukowski, 2012; Reinke et al., 2012; Ritakallio et al., 2008) have shown. It has also been hypothesized that co-occurrence is a distinct syndrome (Fanti & Henrich, 2010; O’Connor, McGuire, Reiss, Hetherington, & Plomin, 1998). Nevertheless, co-occurrence is found to worsen the prognosis (Fanti & Henrich, 2010; Sourander et al., 2007).

To conclude, trajectory analyses are a fairly new statistical method to explore the different patterns of development in longitudinal samples. The trajectories of internalizing problems, although less studied, are more consistent, while the identified trajectories of externalizing problems are more variable. On the other hand, there are fewer studies considering externalizing problems as a broad spectrum than those focusing on narrower aspects or subgroups. A scant number of studies have explored the associations between the trajectories of internalizing and externalizing problems (e.g. Chen & Simons-Morton, 2009; Reinke et al., 2012; Wiesner & Kim, 2006) but only one has used general internalizing and externalizing problem scales (Fanti & Henrich, 2010). All of these studies are based on samples from the US. We know of no studies that have explored the associations between the trajectories of internalizing and externalizing problems and social competence measured at the same multiple time-points as the internalizing and externalizing problems on which the trajectories are based.

The aims of this study were: (1) To explore trajectories of the internalizing and externalizing problems of children based on maternal reports in a longitudinal sample from early childhood to adolescence; and (2) the associations of those trajectories with the adolescent outcome based on self-reported internalizing and externalizing problems. We also wanted to study (3) how social competence in middle childhood as reported by mothers and in adolescence according to the mothers’ reports and adolescents’ self-reports is associated with the trajectories of internalizing and externalizing problems. In addition, we aimed (4) to explore the associations between the trajectories of internalizing and externalizing problems. Our first hypothesis was that both internalizing and externalizing problem trajectories would show both high-stable and low-stable trajectories, but also alteration in such a way that trajectories of decreasing externalizing problems and increasing internalizing problems from childhood to adolescence would be detected. We did not construct hypotheses regarding the adolescent-onset trajectory of externalizing problems as prior findings are contradictory. Our second hypothesis was that trajectories based on maternal reports of internalizing and externalizing problems from childhood to adolescence would be associated with self-reported internalizing and externalizing problems at adolescence. The third hypothesis was that a higher level of internalizing and externalizing problems would show associations with poorer social competence in middle childhood and adolescence. The fourth hypothesis was that the levels of internalizing and externalizing problem trajectories would be associated with each other in such a way that high or increasing levels of one problem type would be associated with high or increasing levels of the other type.

Method

Sample

This study is part of a longitudinal study which started in Tampere, Finland in 1989. The original sample was collected from Tampere maternity centers in 1989–1990. The sample consisted of 349 consecutively selected normal population first-time mothers during the third trimester of the pregnancy. Fewer than 10% refused to participate. Due to drop-outs and schedule issues the number of those included at later study stages varies. The study stages and the sample flow are described in Figure 1 provided in Supplemental Materials retrievable from the Journal website. In this study we used data from study stages T5 (child’s age of 4- to 5-years-old), T6 (8- to 9-years-old), and T7 (16- to 17-years-old). At T5 questionnaires were sent to 200 mothers of the original sample and were completed by 158 recipients (79%). At T6 questionnaires were sent to 270 mothers of the original sample and were completed by 188 (70%) mothers of 189 children (one pair of twins) (Luoma et al., 2001). At T7 the questionnaires were sent to 327 mothers—the total sample of 349 mothers except those 22 mothers and children who were excluded because of the death or serious illness of mother or child or explicit refusal of participation. The questionnaires were returned by 191 (59%) mothers and 192 adolescents (59%) (Korhonen, Luoma, Salmelin, & Tamminen, 2012). The characteristics of the study are shown in Table 1.

Table 1.

Characteristics of the sample and means of internalizing and externalizing problem scores and social competence scores at different data collection points.

4–5 years (T5)			8–9 years (T6)			16–17 years (T7)
%	Mean	SD	%	Mean	SD	%	Mean	SD
Child’s gender
Female	53	56	52
Male	47	44	48
Mother’s marital status
Married or cohabiting	92	86	82
Single	8	14	18
Mother’s education
Elementary, vocational school	37	24	37
College	46	60	47
Academic	17	16	16
No. of mother’s biological children
One	28	17	13
Two	62	52	52
Three or more	10	31	35
Mother’s age (years)	31.4	4.1	35.5	4.2	44.0	4.2
Child’s age (years)	4.4	0.1	8.5	0.3	16.6	0.2
Internalizing problems (CBCL)	48.1	9.2	51.3	9.4	50.9	9.8
Externalizing problems (CBCL)	53.6	8.5	49.3	8.6	49.0	9.1
Social competence (CBCL)	49.7	8.5	46.7	9.6
Internalizing problems (YSR)	50.4	11.2
Externalizing problems (YSR)	52.1	8.9
Social competence (YSR)	45.8	10.2

At the first four study stages (T1–T4, i.e. from pregnancy to six months of child’s age), permission for the study was granted by the Ethics Committee of the City of Tampere. Study stages T5–T7 were approved by the Ethics Committee of Pirkanmaa Hospital District. At each study stage a written informed consent was obtained from the mothers and at the last study stage also from the adolescents (T7; ref number R05174).

During the longitudinal process the group size varies at different time-points due to the varying selection of those included and to drop-outs. The drop-out analysis between study stages T5–T6 and T6–T7 showed no statistically significant differences as regards mother’s age, level of education, marital status, family SES, or mean of child’s internalizing and externalizing problem score between the mothers included in the analysis and those who dropped out. However, there were more mother-son-dyads in the drop-out group at both study stages T6 (p = 0.002) and T7 (p = 0.019).

Procedures

To evaluate child’s psychosocial functioning and emotional and behavioral problems the Finnish translation of the Child Behavior Checklist (CBCL) (Achenbach, 1991) was used at study stages T5–T7. The CBCL is a valid questionnaire and there are different forms for children under school age (4- to 6-years-old) and of school age (6- to 18-years-old). The CBCL contains questions on child’s emotional and behavioral problems for the parent to record. The CBCL for school-aged children also contains questions on the child’s social competence. The internalizing problems score is a sum score including the items withdrawal, somatic complaints, and anxiety/depression. The externalizing problems score is a sum score of the items social problems, rule-breaking behavior, and aggressive behavior. The social competence sum score includes scores from activities, social skills and relationships, and school performance subscales. The CBCL internalizing and externalizing raw problem scores and social competence score were converted into normalized T-scores and used as continuous variables. In clinical use scoring between 60–62 is considered the subclinical level and ≥63 the clinical level.

At T7 the adolescents also completed the Youth Self Report (YSR) for ages 11- to 18-years-old (Achenbach & Edelbrock, 1991). It contains questions on emotional and behavioral problems and social competence similar to those of the CBCL for the adolescent to report. The YSR internalizing and externalizing problem scores and social competence score were also converted into normalized T-scores and used as continuous variables. Socio-demographic data were collected by questionnaires designed for this study phase.

Statistical analysis

Group-based trajectory modeling (Nagin & Odgers, 2010) was used to explore the number and type of potential clusters (trajectory groups) of internalizing and externalizing problems. The square function of time was used for modeling the scores. The trajectory analyses were based on 261 children (49% male) whose mothers completed the CBCL during at least one of the three assessment points. The Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) formed an empirical basis for determining the number and shapes of the latent trajectories. The best fits according to AIC and BIC were contradictory, resulting in a two-cluster model based on BIC and a three- or five-cluster model based on AIC. Thus, due to these discrepancies, the theoretical framework and the findings of earlier studies, the model with four groups was selected to best fit and characterize the trajectories of both internalizing and externalizing problems (See Figure 2, Supplemental Materials). Trajectory models were fitted using flexmix package in statistical program R, version 2.13.0. Other statistical analyses were conducted using cross-tabulations for categorical variables. ANOVA was used in the analysis of categorical and normally distributed continuous variables. Bonferroni corrected p-values were calculated for the subsequent multiple pairwise analyses. SPSS 15.0 was used for these analyses.

Results

Means and standard deviations of CBCL and YSR internalizing and externalizing problem and social competence T-scores at different data collection points are presented in Table 1.

Trajectories of internalizing and externalizing problems

The trajectories of the four-group model of internalizing problems are illustrated in Figure 2a, Supplemental Materials. The three lowest trajectories remained at a low or moderate level of the CBCL internalizing problems score throughout the study (low-stable, N = 73, 28%; moderate-decreasing, N = 53, 20%; moderate-increasing, N = 107, 41%). The highest trajectory (high-stable, N = 28, 11%) was above the subclinical/clinical level of internalizing problems throughout the study.

The trajectories of the four-group model of externalizing problems are illustrated in Figure 2b, Supplemental Materials. The two lowest trajectories remained at low or moderate level throughout the study (low-stable N = 53, 20% and moderate-decreasing N = 151, 58%). The third trajectory (high-decreasing N = 45, 17%) was above the subclinical/clinical level in childhood but below the cut-point in adolescence. The fourth trajectory (moderate-to-high N = 12, 5%) was below even the subclinical level in childhood but significantly above the clinical level in adolescence.

There were no statistically significant gender differences in either the internalizing or the externalizing problem trajectories. Nor were there any statistically significant associations between the trajectories of internalizing and externalizing problems and the age, marital status, or education level of the mother or the number of siblings of the index child at T7.

Trajectories of internalizing and externalizing problems and adolescent self-reported internalizing and externalizing problems

The trajectory of internalizing problems the adolescent belonged to was statistically significantly associated with the adolescent self-reports of internalizing problems at T7 (p < 0.001; Figure 3a, Supplemental Materials). The mean was highest among the children in the high-stable trajectory group and lowest among those in the low-stable trajectory group. The means, CIs, and p-values, overall and between the different the trajectory groups, are presented in Figure 3a, Supplemental Materials.

The association between the trajectory of internalizing problems and the adolescent-reported externalizing problems scores at T7 was also statistically significant (p = 0.007; Figure 3a, Supplemental Materials). The mean was highest among the children in the moderate-increasing trajectory group and lowest among those in the low-stable trajectory group.

The externalizing problems trajectory and externalizing problems scores in the adolescent self-reports were statistically significantly associated (p < 0.001). The mean was highest among the children in the moderate-to-high trajectory group and lowest among those in the low-stable group (means, CIs and p-values; see Figure 3b, Supplemental Materials).

The externalizing problem trajectory and adolescent-reported internalizing problems score were also associated (p = 0.034; Figure 3b, Supplemental Materials). The mean was highest among the children in the moderate-to-high trajectory group and lowest among those in the low-stable trajectory.

Trajectories of internalizing and externalizing problems and social competence in middle childhood and adolescence

Maternal report of the child’s social competence in middle childhood (T6) was statistically significantly associated with the trajectory of internalizing problems (p = 0.021; Figure 4a, Supplemental Materials). The mean social competence score was lowest among the children in the high-stable trajectory group and highest among those in the low-stable trajectory group.

Maternal report of child’s social competence in adolescence (T7) was statistically significantly associated with the trajectory of internalizing problems (p < 0.001; Figure 4a, Supplemental Materials). The mean social competence score was lowest among the children in the high-stable trajectory group and highest among those in the moderate-decreasing trajectory group. The means, CIs, and p-values (overall and between the different the trajectory groups) are presented in Figure 4a, Supplemental Materials.

Self-reported social competence in adolescence (T7) was statistically significantly associated with the trajectory of internalizing problems (p < 0.001). The mean was lowest among the children in the high-stable trajectory group and highest among those in the moderate-decreasing trajectory group (for means, CIs and p-values see Figure 4a).

The social competence variable at T7, but not at T6 reported by the mother was statistically significantly associated with the externalizing problems trajectory (p < 0.001; Figure 4b, Supplemental Materials). The lowest social competence score at T7 was among the children in the moderate-to-high trajectory group and highest among those in the low-stable group. Adolescent self-reported social competence at T7 was also statistically significantly associated with the trajectory of externalizing problems (p < 0.001). The mean social competence score was lowest among the children in the moderate-to-high trajectory group and highest among those in the moderate-decreasing trajectory group (for means, CIs, and p-values see Figure 4b, Supplemental Materials).

Associations between the internalizing and externalizing problem trajectories

The internalizing and externalizing problem trajectories were statistically significantly associated with each other (p < 0.001). The distributions of adolescents in each trajectory group can be seen in Figures 1a and 1b.

Figure 1.

Distribution of a) adolescents in each of the internalizing problems trajectory groups into the externalizing problems trajectory groups and b) adolescents in each of the externalizing problems trajectory groups into the internalizing problems trajectory groups.

Discussion

The resulting trajectory model of child’s internalizing problems supported the hypothesis and the findings of earlier studies (Brendgen et al., 2005, 2010; Dekker et al., 2007; Fanti & Henrich, 2010; Leve et al., 2005). In general, internalizing problems were found to increase towards adolescence and both chronically high and permanently low trajectories were identified. The biggest proportion of the adolescents belonged to the moderate-increasing group. The mean internalizing problem T-score in that group was highest in adolescence yet remained below the subclinical level. The mean in the chronically high (high-stable) trajectory was at the subclinical/clinical level from early childhood to adolescence.

As hypothesized, the mean social competence score was lowest among the children in the chronically high trajectory group regarding internalizing problems both in middle childhood and adolescence. Being assigned to the increasing trajectory group regarding internalizing problems was also associated with poorer social competence in adolescence. The findings thus confirm our hypothesis and the findings of earlier studies of the reciprocal influences of internalizing problems and social competence (Lansford et al., 2006; Obradovic & Hipwell, 2010).

Another notable finding is that the level of internalizing problems in the moderate-decreasing and moderate-increasing groups was equal in middle childhood and separated into different directions between middle childhood and adolescence. Developmental studies have found both environmental and child-related risk factors to explain the increasing trajectory of internalizing problems (BoothLaForce & Oxford, 2008; Brendgen et al., 2005; Feng, Shaw, & Silk, 2008; Leve et al., 2005). Although the level of internalizing problems in the increasing trajectory group in this study was below subclinical level and may rather indicate ‘normal adolescent internalization’, a longer follow-up might have revealed a subgroup of adolescents who reach the subclinical/clinical level later in adolescence or adulthood, as found in a study by Dekker et al. (2007). In addition, even a moderate level of affective problems has been found to be related to poorer outcome in young adulthood (Dekker et al., 2007).

The trajectories of externalizing problems also supported the hypothesis and the results of earlier studies. While most of the children were assigned to the moderate-decreasing trajectory of externalizing problems, high-decreasing and adolescent-onset (moderate-to-high) trajectories were also identified. As noted earlier, some studies have identified an adolescent-onset pattern of externalizing problems (Moffitt & Caspi, 2001; Monahan et al., 2009; Odgers et al., 2008; Reef et al., 2011), while others have not (Brame et al., 2001; Broidy et al., 2003; Cote et al., 2001; Fanti & Henrich, 2010; Shaw et al., 2005; Zhou et al., 2007). This could be due to the fact that studies of externalizing problems trajectories have, in fact, considered only some aspects of it (e.g. conduct problems, physical aggression, or antisocial behavior). However, the developmental trajectories of different kinds of externalizing problems may differ from each other, as found in a study by Reef et al. (2011). The age range also differs; most studies end at preadolescence, while the adolescent-onset trajectory has been found to increase later. However, to the best of our knowledge this is the first study to have identified an adolescent-onset trajectory group of general externalizing problems.

Studies have found that compared to childhood-onset antisocial problems, adolescents with adolescent-onset problems lack the social, familial, and neurodevelopmental risk factors from childhood (Moffitt & Caspi, 2001; Odgers et al., 2008). The theory of adolescent-limited antisocial behavior suggests that the contemporary gap between biological and social maturity encourages teens to mimic antisocial behavior in ways that might be normative and adaptive rather than pathological (Moffitt, 1993). However, longitudinal studies from childhood to adulthood indicate that all types of antisocial behavior and aggression in childhood or adolescence, including the adolescent-onset and childhood-limited types, are associated with various adulthood difficulties (Odgers et al., 2008; Reef et al., 2011), the individuals with childhood-limited externalizing problems having only low to moderate levels of internalizing problems, though (Odgers et al., 2008).

This study indicates that children with adolescent-onset externalizing problems had poorer social competence in adolescence, but not in middle childhood. On the other hand, the children assigned to the high-decreasing trajectory group who had clinical/subclinical level of externalizing problems in childhood had equally good social competence both in middle childhood and adolescence as the children assigned to the low or decreasing trajectory groups with externalizing problems. Thus, the findings only partially supported our hypothesis and the findings of earlier studies (Burt & Roisman, 2010; Kouros et al., 2010; Lansford et al., 2006; Masten et al., 2005; Obradovic et al., 2010; van Lier & Koot, 2010). The current findings also suggest that a high level of externalizing problems is perhaps not a risk for poorer social competence but rapidly increasing externalizing problems might instead be accompanied by poor social competence.

The hypothesis and earlier findings (Achenbach, 2001; Chen & Simons-Morton, 2009; Reinke et al., 2012; Ritakallio et al., 2008; Wiesner & Kim, 2006) of the co-occurrence of internalizing and externalizing problems was also supported. Adolescents belonging to the increasing internalizing problem trajectory group, according to mothers’ reports, reported themselves to have significantly more externalizing problems than did those from other trajectory groups. Adolescents with the adolescent-onset externalizing problems, according to mothers’ reports, also reported significantly more internalizing problems in adolescent self-reports than did those from other trajectory groups.

The associations between the trajectories of internalizing and externalizing problems also indicate that 32% of the children who had chronically high levels of internalizing problems throughout the study also had high (although decreasing) levels of externalizing problems. Furthermore, 56% of the children with high levels of externalizing problems in childhood had increasing level of internalizing problems and 20% had chronically high level of internalizing problems from childhood onwards. In addition to co-occurrence, these findings imply that high level of externalizing problems in childhood may be a risk-indicator for an increasing level of internalizing problems in adolescence. The associations between the internalizing and externalizing problem trajectories also indicate that among over one-half of the adolescents with adolescent-onset externalizing problems the level of internalizing problems also increased towards adolescence (the moderate-increasing trajectory of internalizing problems). Further, 20% of the adolescents who had adolescent-onset externalizing problems had a chronically high level of internalizing problems from early childhood onwards (high-stable). This finding has two important implications; first, chronically high level of internalizing problems may be a risk for adolescent-onset externalizing problems, and second, adolescent-onset of externalizing problems may be accompanied by an increasing level of internalizing problems.

This study also found high cross-informant consistency between the internalizing and externalizing problem trajectories according to maternal reports and adolescent self-reported internalizing and externalizing problems and social competence.

Limitations and future directions

Despite strengths and noteworthy findings, there are also limitations to be considered. Partly because of the long follow-up time, the number of drop-outs is relatively high. Thus, cumulative attrition increases the amount of incomplete data. The sample remained moderate in size but still restricted the analyses. Contrary to earlier trajectory studies, we could not identify a high-stable group of children with externalizing problems. Finnish parents and adolescents have in general been found to report fewer problems than respondents in other countries (Rescorla et al., 2007a, 2007b). There may also be more children with high levels of externalizing problems in the drop-out group between study stages T4 and T5, prior to the first evaluation of the internalizing and externalizing problems of the child.

Finland is a Western society with a rather homogenous population. This can be considered as a limitation or as a strength. Although several studies have found rather similar trajectories of internalizing problems in different cultures, there are few studies considering especially the trajectories of externalizing problems among children living in non-Western cultures—thus, further research is needed in those settings.

Although other studies have identified different kinds of trajectories for girls and boys, especially in internalizing problems (Dekker et al., 2007; Leve et al., 2005; Sterba et al., 2007) but also in their co-occurrence (Wiesner & Kim, 2006), we were unable to identify differences between the genders. This could be due to the rather small number of cases. The CBCL-T scores are also based on separate normative samples for each sex within each age range (Achenbach, 1991). Thus, separate trajectories for genders should be scrutinized in order to study differences between the genders, as other studies have also recommended (Dekker et al., 2007). Future studies should also further explore the risk and protective factors associated with different patterns of child’s emotional and behavioral problems.

Implications for practice

Child development should be seen as a pathway which is influenced by different child related and environmental risk and protective factors. Understanding the different patterns of emotional and behavioral problems enables us to identify risk groups and to plan interventions. Both chronic and increasing internalizing problems as well as adolescent-onset externalizing problems were associated with poorer social competence. Thus, social or academic problems might be seen as reflections of emotional distress or adjustment problems. Supporting children in their social contacts and academic achievements in schools might also be beneficial in relieving the effects of problems. While this is out of the scope of this article it deserves to be studied further.

In addition, this study indicates that there is not only a rather high co-occurrence between the emotional and behavioral problems but one problem type also magnifies the risk-power for the other type. When treating children and adolescents with behavioral or academic problems, emotional problems should also be screened.

Footnotes

Acknowledgements

We kindly thank Mrs Virginia Mattila for checking the language. We also thank Professor Tapio Nummi, PhD, for contributing his expertise to the statistical analysis.

Funding

This study was supported by grants from the Medical Research Fund of Tampere University Hospital, the Academy of Finland, the Odd Fellows and the University of Tampere. The funding sources had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The authors report no disclosures of interests.

Author biographies

Marie Korhonen, MD, is a Doctoral Student at the University of Tampere, Department of Child Psychiatry, Finland. Her research explores the longitudinal associations between maternal depressive symptoms and child’s psychosocial functioning and emotional and behavioral problems.

Ilona Luoma, MD, PhD, is Postdoctoral Researcher at the University of Tampere, School of Medicine and Deputy Chief Physician in the Department of Child Psychiatry, Tampere University Hospital, Finland. Her research topics are children in family context, developmental psychopathology and particularly the links between parental depressive symptoms and child adjustment during development.

Raili K. Salmelin, MSc, PhD, is a Postdoctoral Researcher at the University of Tampere, School of Health Sciences and a part-time Researcher at the Tampere University Hospital, Department of Child Psychiatry, Finland. As a member of the Child Psychiatric Research Team she is responsible for the statistical analysis of their studies, and also offers statistical consultation to researchers of other subject areas.

Mika Helminen, MSc, is a Biostatistician working at Science Centre, Pirkanmaa Hospital District and School of Health Sciences, University of Tampere, Finland. He offers statistical consultation to all researchers working in Pirkanmaa Hospital District and thus acts as a data analyst, statistical advisor, and co-author in various studies concerning health science.

Riittakerttu Kaltiala-Heino, MD, PhD is Professor of Adolescent Psychiatry in the School of Medicine at the University of Tampere, and Director of the Department of Adolescent Psychiatry in Tampere University Hospital, Finland. Her research focuses on epidemiology of psychiatric disorders in adolescence and adolescent psychiatric health services research. Special topics include pubertal development and mental health, and school bullying and mental health.

Tuula Tamminen, MD, PhD is Professor of Child Psychiatry in School of Medicine at the University of Tampere, Finland, and part-time Chief Medical Officer at the Department of Child Psychiatry in Tampere Universital Hospital, Finland. She acts as the Chair of Health Research Council in the Academy of Finland. Her main research interests focus on infant psychiatry, childhood emotional development and disorders.

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