Internalizing Behavior Problems Research Articles

Social impacts of inclusive education: On the requirement for an emphasis on girls with emotional and behavioral disorders (EBD) in research on inclusion

While there is an extensive and substantial body of epidemiological research on gender-specific differences regarding the prevalence, persistence, and comorbidity of Emotional and Behavioral Disorders (EBD) in childhood and adolescence, empirical research on inclusive education largely lacks a differentiated and gender-sensitive research approach. However, initial empirical findings indicate that girls with internalizing behavior problems are to be considered a particularly vulnerable group in school regarding their social integration, their self-concept, their well-being in school and their perception and interpretation of social interaction processes. Can girls with internalizing behavior problems thus be referred to as the 'forgotten gender' of empirical research on inclusive education? The following article aims to address the existing tension between gender-specific epidemiological data, school-related practices, and empirical research approaches. In this context, we first (I) summarize the available empirical findings, (II) outline the methodological foundations of an ongoing research project, and (III) discuss the social implications of a predominantly one-sided empirical approach and outline a call to action for practice and research.

Family Stress Processes Underlying COVID‐19–Related Economic Insecurity for Mothers and Fathers and Children's Internalizing Behaviour Problems

ABSTRACTCOVID‐19 and its economic fallout have resulted in unprecedented financial insecurity and material hardship for many American families, with a disproportionately negative impact on children and families from socioeconomically disadvantaged contexts. The current study applied the family stress model to examine the family processes underlying pandemic‐related economic insecurity and children's internalizing behaviours. Online survey data from an economically diverse sample of mothers and fathers, who experienced at least one type of pandemic‐related economic insecurity in the United States (N = 259), were collected across two longitudinal time points in the early weeks of COVID‐19: (1) 14 April and (2) 30 April of 2020. Parental depressive symptoms, negative partner relationship quality and harsh parenting were tested as mediators. Results from the path model showed that pandemic‐related economic insecurity was associated with higher levels of parental depressive symptoms, which were then associated with higher levels of negative partner relationship quality. Negative partner relationship quality was subsequently associated with more harsh parenting, which was then associated with increased child internalizing behaviours. Indirect effects were found for all hypothesized mediators. The family stress model can be applied and extended to the early COVID‐19 period. Child and family social work implications include targeting parents' mental health, relationship quality and parenting behaviours, as well as directly addressing financial and material hardship, to mitigate the adverse effects of pandemic‐related economic insecurity on children's mental health.

Contamination bias in the estimation of child maltreatment causal effects on adolescent internalizing and externalizing behavior problems.

When unaddressed, contamination in child maltreatment research, in which some proportion of children recruited for a nonmaltreated comparison group are exposed to maltreatment, downwardly biases the significance and magnitude of effect size estimates. This study extends previous contamination research by investigating how a dual-measurement strategy of detecting and controlling contamination impacts causal effect size estimates of child behavior problems. This study included 634 children from the LONGSCAN study with 63 cases of confirmed child maltreatment after age 8 and 571 cases without confirmed child maltreatment. Confirmed child maltreatment and internalizing and externalizing behaviors were recorded every 2 years between ages 4 and 16. Contamination in the nonmaltreated comparison group was identified and controlled by either a prospective self-report assessment at ages 12, 14, and 16 or by a one-time retrospective self-report assessment at age 18. Synthetic control methods were used to establish causal effects and quantify the impact of contamination when it was not controlled, when it was controlled for by prospective self-reports, and when it was controlled for by retrospective self-reports. Rates of contamination ranged from 62% to 67%. Without controlling for contamination, causal effect size estimates for internalizing behaviors were not statistically significant. Causal effects only became statistically significant after controlling contamination identified from either prospective or retrospective reports and effect sizes increased by between 17% and 54%. Controlling contamination had a smaller impact on effect size increases for externalizing behaviors but did produce a statistically significant overall effect, relative to the model ignoring contamination, when prospective methods were used. The presence of contamination in a nonmaltreated comparison group can underestimate the magnitude and statistical significance of causal effect size estimates, especially when investigating internalizing behavior problems. Addressing contamination can facilitate the replication of results across studies.

Direct and Indirect Longitudinal Associations of Mother and Father Engagement in Middle Childhood on Adolescent Externalizing and Internalizing Behaviors.

Parent engagement is an important aspect of parenting during childhood. However, little is known about the unique longitudinal associations of mother and father engagement with adolescents' externalizing and internalizing problem behaviors. This study uses Future of Families and Child Wellbeing Study data to examine the potential direct and indirect associations of parent engagement at age 9 on adolescent externalizing and internalizing behaviors at age 15. The analytic sample size is 1349, and at age 9, the mean age of children was 9.40 years (SD = 0.37). Forty-eight percent of children were female and 68% of them were from the married families. The results show that while controlling for mother engagement, higher father engagement at age 9 was directly associated with fewer adolescent internalizing behaviors, only among adolescent boys and in married families. In addition, among adolescent boys, father engagement had an indirect association with externalizing behaviors through father-child closeness. Mother engagement, however, is only found to have an indirect association with adolescents' externalizing and internalizing behaviors through maternal hostility (while controlling for father engagement). The results for mother engagement held for boys and in married families only. The findings indicate that both mother and father engagement during childhood is important and helpful to prevent adolescent problem behaviors directly or indirectly via parent-child relationship.

Emotion regulation and internal behavior problems in young autistic children-preliminary study

Emotion regulation and internal behavior problems in young autistic children-preliminary study

어머니의 사회경제적 배경에 따른 양육 특성이 유아의 문제행동에 미치는 영향

Objectives The purpose of this study is to investigate the discrimination of mothers' parenting characteristics according to socioeconomic background and analyze the effects of parenting characteristics on the young children's problem behaviors.
 Methods It was analyzed the socioeconomic background, parenting characteristics, and problem behavior of 2,150 mothers with 5-year-old children, using the 7th panel data of the Panel Study on Korean Children. Using the program SPSS 21.0, the mean differences in parenting characteristics according to the mother's socioeconomic background were analyzed using t-test and one-way ANOVA. In addition, after analyzing the correlation between the mother's parenting characteristics and the young children's problem behavior, hierarchical multiple regression analysis was conducted to analyze the influence of the mother's parenting characteristics on the young children's problem behavior.
 Results Mothers' parenting characteristics differed depending on the mother's age, education level, and household income level, and the correlation between parenting characteristics and young children's problem behavior was low. As a result of analyzing the factors affecting children's internalizing problem behavior, the higher the income in the socioeconomic background, the less internalizing problem behavior, and among parenting characteristics, the higher the parenting stress and the less parent-child interaction, the more internalizing problem behavior increased. As a result of the analysis of externalizing problem behavior, it was found that for male young children, the greater the parenting stress, and the less paternalistic parenting behavior and parent-child interaction, the more the infant's externalizing problem behavior increased.
 Conclusions System establishment and policy support are required to minimize the interdependence and connection between socioeconomic background, parenting characteristics, and problem behavior. Additionally, because mothers' parenting stress has the greatest impact on their children's problem behavior, mothers should seek ways to reduce stress themselves. Additionally, a consensus on co-parenting must be formed at the community and government levels, breaking away from the framework that childrearing is the mother's responsibility.

Caregiver Distress and Child Behavior Problems in Children with Developmental Delay from Predominantly Minoritized Backgrounds

ABSTRACT Importance Child behavior problems have been shown to contribute to caregiver distress and vice versa among youth with developmental delay (DD). However, studies have not examined these associations among children and caregivers from underrepresented ethnic/racial backgrounds. Furthermore, research has not explored how associations function differently following internet-delivered treatment or based on the level of acculturation and enculturation. Objective We examined bidirectional associations between caregiver distress (i.e. symptoms of depression, anxiety, and stress) and externalizing and internalizing behavior problems in 3- to 5-year-old children with DD from underrepresented ethnic/racial backgrounds. We also examined the impact of internet-delivered Parent–Child Interaction Therapy (iPCIT) and the moderating role of acculturation and enculturation on these bidirectional associations. Method Children aging out of early intervention services (n = 150) and their primary caregiver were randomized to receive iPCIT or referrals as usual (RAU) in the community. Results Findings provide support for bidirectional associations between child internalizing behavior problems and caregiver depressive symptoms, although there were fewer significant associations among families randomized to iPCIT compared to RAU. Weaker associations were observed among families with higher levels of enculturation, whereas stronger associations were observed among families with higher levels of acculturation. Conclusions Results highlight a sensitive period from age 3.5 to 4 years old for bidirectional associations between caregiver distress and child behavior problems and highlight the importance of addressing family cultural values during treatment. Findings also suggest the utility of internet-delivered behavioral parenting interventions in weakening the effect of child behavior problems on caregiver distress and vice versa.

The double jeopardy of low family income and negative emotionality: The family stress model revisited.

The family stress model has, for decades, guided empirical work linking poverty with increased risk of child social-emotional dysfunction. The present study extends this line of work by examining whether child negative emotionality moderates associations between family income, family stress (maternal distress, parental locus of control, and relationship dissatisfaction), and later externalizing and internalizing behavior problems. In a longitudinal population-based sample (n ~ 80,000) of Norwegian children followed from birth through age five (The Norwegian Mother, Father, and Child Cohort Study; MoBa), we examined whether high (vs. moderate or low) negative emotionality families would display: (a) compounding stress (i.e., particularly strong associations between low family income and family stress), (b) diathesis-stress (i.e., particularly strong associations between family stress and behavior problems), or (c) double jeopardy (i.e., both compounding stress and diathesis-stress moderating effects). Negative emotionality significantly moderated the association between family income and behavior problems in a manner most consistent with double jeopardy. As a result, compared with children with moderate/low negative emotionality, the family income-behavior problems association was two to three times larger for those with higher negative emotionality. These findings underscore the active role children may play in family processes that link low family income with behavior problems.

Finding the balance: The influence of movement behaviours on childhood behaviour problems

Background and aimsThe Canadian 24-h movement guidelines have led to an increased focus on movement behaviours (sleep, screen, sedentary, and physical activity) throughout the day. MethodsWe examined the cross-sectional and longitudinal associations between 24-h movement behaviours and parent-reported levels of internalizing, externalizing, and total behaviour problems in a subset of the CHILD birth cohort study at ages 3 (N Age 3 = 541, 48.1% girls) through 5 (N Age 5 = 575, 49.6% girls). Physical activity, sedentary time, and sleep were measured using an accelerometer worn on the non-dominant wrist for seven days following a 24-h protocol. Screen time was measured via parent-report and date-matched to daily accelerometer recordings. Compositional isotemporal substitution models predicted change in behaviour problems with reallocating time between movement behaviours. ResultsCross-sectional analysis indicated that screen time relative to other movement behaviours was associated with greater externalizing behaviours at age 3 and greater internalizing and total problem behaviours at ages 3 and 5. This was supported in the longitudinal analysis, where increased screen time at 3 was associated with increased internalizing, externalizing, and total problem behaviours at 5. Cross-sectional reallocation from screen to non-screen sedentary time was associated with reductions in internalizing and total behaviour problems at 3 and 5 years and reductions in externalizing at 3. Contrary to previous findings, cross-sectional proportional increases in moderate-to-vigorous-intensity physical activity were associated with increased externalizing and total problem behaviours at 5. ConclusionsClinicians should prioritize supporting families to find a balanced approach rather than promoting specific movement behaviours.

Effectiveness of Mental Health and Wellbeing Interventions for Children and Young People in Foster, Kinship, and Residential Care: Systematic Review and Meta-Analysis.

The mental health and wellbeing of children and young people who have been in care, primarily foster care, kinship care or residential care, remains a public health priority. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) synthesized evidence for the effectiveness of interventions targeting: subjective wellbeing; mental, behavioral and neurodevelopmental disorders; and suicide-related outcomes. Searches were conducted in 16 bibliographic databases and 22 websites between 1990 and 2022. This was supplemented by citation tracking, screening of relevant systematic reviews, and expert recommendation. We identified 35 interventions, with 44 evaluations via randomized controlled trials. Through meta-analyses, we found that interventions have a small beneficial impact on a variety of mental health outcomes in the short term (0-6 months). Interventions improved total social, emotional, and behavioral problems (d = -0.15, 95% CI [-0.28, -0.02]), social-emotional functioning difficulties (d = -0.18, 95% CI [-0.31, -0.05]), externalizing problem behaviors (d = -0.30, 95% CI [-0.53, -0.08]), internalizing problem behaviors (d = -0.35, 95% CI [-0.61, -0.08]); and depression and anxiety (d = -0.26, 95% CI [-0.40, -0.13]). Interventions did not demonstrate any effectiveness for outcomes assessed in the longer term (>6 months). Certainty of effectiveness was limited by risk of bias and imprecision. There was limited available evidence for interventions targeting subjective wellbeing and suicide-related outcomes. Future intervention design and delivery must ensure that programs are sufficient to activate causal mechanisms and facilitate change. Evaluation research should use a robust methodology.PROSPERO Registration: CRD42020177478.

Between- and within-child level associations between externalizing and internalizing behavior problems in a nationally representative sample of US elementary school children.

Both transactional and common etiological models have been proposed as explanations of why externalizing behavior problems (EBP) and internalizing behavior problems (IBP) co-occur in children. Yet little research has empirically evaluated these competing theoretical explanations. We examined whether EBP and IBP are transactionally related at the within-child level while also identifying antecedents commonly associated with between-child differences in underlying stability of both EBP and IBP across elementary school. We analyzed a nationally representative and longitudinal sample of US schoolchildren (N = 7,326; 51% male) using random-intercept cross-lagged panel modeling (RI-CLPM). We used teacher ratings of EBP and IBP as annually assessed from the spring of kindergarten (Mage = 6.12 years) through the spring of 5th grade (Mage = 11.09 years). Early childhood antecedents included child internal (i.e. inhibitory control, cognitive flexibility, working memory, and language/literacy) and external factors (i.e. parental warmth, harsh parenting, parenting stress, and maternal depressive symptoms). We found little evidence for within-child, transactional relations between EBP and IBP. Both types of behavior problems instead were substantially associated at the between-child level. Inhibitory control was the strongest common antecedent that explained this longitudinal overlap. Cognitive flexibility, working memory, language/literacy skills, and maternal depression contributed specifically to the stability of IBP. Measures of parenting were specific to the stability of EBP. Common etiological factors rather than transactional relations better explain the co-occurrence of EBP and IBP during elementary school. Inhibitory control is a promising target of early intervention efforts for schoolchildren at risk of displaying both EBP and IBP.

Role of Pubertal Timing and Perceived Parental Attachment in Internalizing Problem Behaviours Among Adolescents.

Adolescents need supportive social institutions to help them deal effectively with the demands of pubertal changes accompanied by new social roles, reducing their susceptibility to problem behaviors. Considering this, it will be investigated how internalizing problem behaviors in teenagers is affected by the interaction between pubertal timing and perceived parental attachment. For this, cross-sectional data from 772 adolescents with ages ranging from 11 to 15years old was used. Regression analyses showed early maturing adolescents with insecure perceived parental attachments had higher levels of depression and anxiety than their early, on-time, and late maturing counterparts with secure perceived parental attachments. This finding supports the contextual amplification model, as the detrimental consequences of early maturation are impacted by difficult parent-adolescent relationships.

Disrupted Maturation of White Matter Microstructure After Concussion Is Associated With Internalizing Behavior Scores in Female Children

BackgroundSome children who experience concussions, particularly females, develop long-lasting emotional and behavioral problems. Establishing the potential contribution of preexisting behavioral problems and disrupted white matter maturation has been challenging due to a lack of preinjury data. MethodsFrom the Adolescent Brain Cognitive Development cohort, 239 (90 female) children age 12.1 ± 0.6 years who experienced a concussion after study entry at 10.0 ± 0.6 years were compared to 6438 (3245 female) children without head injuries who were age 9.9 ± 0.6 years at baseline and 12.0 ± 0.6 years at follow-up. The Child Behavior Checklist was used to assess internalizing and externalizing behavior at study entry and follow-up. In the children with magnetic resonance imaging data available (concussion n = 134, comparison n = 3520), deep and superficial white matter was characterized by neurite density from restriction spectrum image modeling of diffusion magnetic resonance imaging. Longitudinal ComBat harmonization removed scanner effects. Linear regressions modeled 1) behavior problems at follow-up controlling for baseline behavior, 2) impact of concussion on white matter maturation, and 3) contribution of deviations in white matter maturation to postconcussion behavior problems. ResultsOnly female children with concussion had higher internalizing behavior problem scores. The youngest children with concussion showed less change in superficial white matter neurite density over 2 years than children with no concussion. In females with concussion, less change in superficial white matter neurite density was correlated with increased internalizing behavior problem scores. ConclusionsConcussions in female children are associated with emotional problems beyond preinjury levels. Injury to superficial white matter may contribute to persistent internalizing behavior problems in females.

Prospective Associations Between Family-Based Social Capital, Wellbeing, and Emotional and Behavioral Problems Amongst People with Mild Intellectual Disabilities: A Two-Wave Study

ABSTRACT Introduction Family members are often the main provider of informal support to people with mild intellectual disabilities. In the current study, we explored whether their family-based social capital is prospectively associated with their wellbeing and emotional and behavioral problems. Methods Sixty-nine participants with mild intellectual disabilities and key (proxy reporting) staff members participated in two waves of data collection (T1, T2). Data were collected about family-based social capital (FNM-ID), subjective wellbeing (PWI-ID), and emotional and behavioral problems (ABCL, BPI-01). Results People who reported less support provision to family members and more reciprocal family support relationships at T1 experienced higher levels of internalizing behavior problems at T2, after accounting for T1 levels of internalizing behavior problems. No other associations were found between earlier family-based social capital dimensions and psychological outcomes at T2. Conclusion Our study provides initial insights regarding the prospective associations between the family-based social capital of people with mild intellectual disabilities and their wellbeing and emotional and behavioral problems. Future studies should include larger samples to investigate if our preliminary results are replicated.

From environment to genes… and back to the environment

ABSTRACT This overview paper summarizes the results of studies that were conducted in the framework of two interdisciplinary, longitudinal projects of which Luc Goossens was a principal investigator: Studying the Transition to Adolescence: Testing Genes, Interactions, and Environments (STRATEGIES), and Methylation and Internalizing Problem Behaviors in Adolescence: Examining Associations Across Multiple Levels of Analysis (MIND). The main aim of these projects was to investigate to which extent genes as personal characteristics, in interaction with different environments (family, teachers and peers), can affect developmental outcomes in adolescents, such as internalizing and externalizing behaviours, loneliness, and school engagement. Different approaches were used to include genetic information, such as single nucleotide polymorphisms, polygenic scores, and methylation, and specific statistical methods were applied to combine genetic information. Although no strong conclusions could be made about GxE interactions, there is evidence for the contribution of parents, teachers and peers (in the development) of adolescent behaviours and emotions, but genes also appear to play a role.

Longitudinal Associations from Maternal and Paternal Internalizing Symptoms to Preschooler's Problem Behavior and Social Competence in China: The Mediating Role of Executive Function.

By using a two-year longitudinal design, the current study recruited 199 preschoolers and their parents in Beijing to examine the effects of parental internalizing symptoms (T1) on children's internalizing and externalizing problem behavior and social competence (T3), and further explore whether executive function (EF, T2) may act as the mediator. The results showed that maternal internalizing symptoms and paternal internalizing symptoms at T1 separately had significant direct predictive effect on children's internalizing and externalizing problem behavior but not on social competence at T3 after controlling family socioeconomic status. Further analysis indicated that children's inhibitory self-control at T2 mediated the association between maternal and paternal internalizing symptoms at T1 and children's externalizing problem behavior at T3, and metacognition at T2 could mediate the influence of maternal internalizing symptoms at T1 on children's internalizing problem behavior, externalizing problem behavior and social competence at T3. These findings to some extent highlight the importance of including both parents and exploring mother-father differences in effective interventions aiming to promoting child development. Metacognition and self-control skill training would be helpful to reduce children's problem behavior or to improve their social competence.

Associations between Family Routines, Family Relationships, and Children’s Behavior

Consistent daily routines are associated with children’s well-being. Family routines provide both a predictable structure to guide behavior and an emotional environment that supports development. Enforcing family routines, improving family relationships, and creating a healthy home environment are necessary to maintain children’s psychosocial health. This study examined the associations between family routines, family relationships, and elementary school children’s behavior. Parents of 1515 third-grade students (8–9 years old) completed a self-administered questionnaire in Japan in 2017. We conducted a path analysis to examine the associations between the predictor variable of family routines, the mediating variable of family relationships, and the criterion variable of children’s behavior. A total of 717 valid responses were included in the analysis. The results showed that family routines were significantly related to children’s behavior (internalizing problem behaviors, externalizing problem behaviors, and prosocial behaviors) through family relationships (cohesiveness, expressiveness, and conflict). Family routines were positively associated with cohesiveness and expressiveness, and negatively associated with conflict. Cohesiveness was negatively associated with externalizing problem behaviors. While expressiveness was negatively associated with internalizing and externalizing problem behaviors, it was positively associated with prosocial behaviors. Conversely, conflict was positively associated with internalizing and externalizing problem behaviors, and negatively associated with prosocial behaviors. Our findings indicate that family routines may protect children’s mental health from the stressors of daily life and foster interpersonal and social competence. Moreover, family routines may stabilize family relationships, reduce children’s problem behaviors, and improve social competence.

Trajectories of cognitive flexibility through kindergarten and first grade: Implications for externalizing and internalizing behavior problems in the second grade.

Developmental delays in cognitive flexibility early in elementary school can potentially increase vulnerability for subsequent externalizing and internalizing psychopathology. The first goal of the current study was to identify latent subgroups of children characterized by different developmental trajectories of cognitive flexibility throughout kindergarten and first grade using data from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 dataset. The second goal was to examine whether identified longitudinal developmental trajectories of cognitive flexibility could be associated with internalizing and externalizing behaviors in the second grade, while accounting for background child (age, gender, and Spanish-speaking) and family (family income and mother's education) covariates. The analytic sample consisted of 15,827 kindergarteners (51.20% male; 48.50% White, 13.5% Black/African American, 24.3% Hispanic/Latino, 7.60% Asian, and 6.1% other), who were approximately 5.62 years old (SD = 4.48 months) at the study's outset. Most children lived in households with medium family income of approximately $50,000-$55,000. Using a growth mixture modeling approach, our analyses identified normative (91.05%; 50.4% male) and delayed (8.95%; 59.4% male) cognitive flexibility groups and demonstrated that delayed developers have higher levels of externalizing and internalizing behaviors in the second grade, even after adjusting for background covariates. Our findings, in conjunction with research on cognitive flexibility training, suggest that caregivers may lower the risk for externalizing and internalizing behaviors in delayed developers by correcting inflexible thinking, encouraging alternative solutions, and providing emotional support when children face challenging problems. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Class size and teacher effects on non-cognitive outcomes in grades K-3: a fixed effects analysis of ECLS-K:2011 data

This study examines the association between class size, teacher characteristics and five non-cognitive student outcomes (i.e., self-control, interpersonal skills, approaches to learning, externalizing and internalizing problem behaviors) in grades K-3. Individual fixed-effects, that control for observed and unobserved time-invariant factors, including student and school time-constant variables, are employed to analyze national data from the Early Childhood Longitudinal Study, Kindergarten Class of 2010–11 (ECLS-K:2011). Results suggest a significant linear association between reducing class size and interpersonal skills. Teacher experience is saliently, positively and significantly related with student self-control, interpersonal skills, and approaches to learning, and negatively associated with externalizing problem behaviors. Teacher education and certification were not associated with any of the five non-cognitive outcomes. Changing schools had a negative effect on student’s self-control.

The Relationship between Paternal Alexithymia and Children's Internalizing and Externalizing Behavioral Problems during Early Childhood.

The literature has long recognized that parental emotional competence, that is, the ability to express, understand, and regulate emotions, plays a key role in children's development from early childhood. Nevertheless, the effect of parental alexithymia, which can be understood as a deficit in emotional competence, has not been thoroughly studied. In particular, the association between paternal alexithymia and behavioral problems in young children is still a neglected area of research. This study aims to investigate the association between paternal alexithymia and children's internalizing and externalizing problems during the first three years of life, including whether overreactive parenting practices mediate the effect of alexithymia on children's behavioral problems. A sample of 203 fathers of children aged 18-36 months were administered the TAS-20, the Overreactivity subscale of the Parenting Scale, and the Child Behavior Checklist (CBCL)/1½-5. The data indicate that paternal alexithymia is a predictor of children's internalizing and externalizing behavioral problems and that paternal overreactivity mediates the effect of alexithymia. These results highlight the importance of preventing parental alexithymia and involving fathers in parenting support programs aimed at ensuring children's mental health and adjustment.