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

Behavioral problems of school children: impact of social vulnerability, chronic adversity, and... 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. Keywords: Behavior, School children, Adversities, Maternal depression, Social vulnerability Background Heron, Stuart, & Mendelson, 2014; Pizeta, Silva, Cartafina, The behavior of school-aged children is an important indi- &Loureiro, 2013). cator of adaptation in this stage of development; however, When analyzing the potential risk factors for the de- not all children are successful and may present externaliz- velopment of psychopathologies in 252 children and ad- ing or internalizing behavioral problems, expressed within olescents who are victims of domestic violence, the family and/or school contexts (Achenbach, Ivanova, Hildebrand, Celeri, Morcillo, and Zanolli (2015) verified Rescorla, Turner, & Althoff, 2016; Linhares & Martins, that 92.8% of the participants were exposed to at least 2015;Marturano, 2013). one risk factor. The authors also noticed that the associ- Families present structural and internal dynamics that ation of two or more risk factors were present in 53.2% may contribute to either risk or protective outcomes in of the sample, namely family conflicts, mental health terms of child development (Macana & Comim, 2015; problems within the family, gender violence between Walsh, 2016) so that adaptive difficulties associated with parents, family involvement with drug trafficking and behavioral problems are frequent among children (Pizato, criminal behavior, and the abusive consumption of alco- Marturano, & Fontaine, 2014). Considering the relevance hol by parents or legal guardians, among others. of the influence exerted by the family context on school Therefore, among the events listed as conditions that children, various studies have addressed the association of predispose children to behavioral problems, we highlight cumulative adversity present in the family context and the indicators of chronic adversity and mental health condi- outcomes of behavioral problems among children (Dun- tions affecting the parents, especially maternal depres- combe, Havighurst, Holland, & Frankling, 2012;Leis, sion, as risk conditions acknowledged to have a negative impact on children. Additionally, the presence of vari- ables related to social vulnerability is also identified * Correspondence: karinabraguim@usp.br Universidade de São Paulo (USP), Rua Tenente Catão Roxo, 2650, Ribeirão based on conditions or events of life that may interfere Preto, SP CEP: 14051-140, Brazil © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 2 of 11 in the course of developmental outcomes for children, alcohol consumption. The frequency of exposure was at contributing to the maladaptation of children in typical a significant level. Indicators concerning the severity of developmental tasks when experiencing risk conditions. depression and anxiety were examined by Leis et al. Considering social vulnerability in the population in (2014), in a sample of 2891 mother-child pairs, taking general, low socioeconomic status and unemployment into account the perspectives of mothers and teachers. among mothers were identified as predictors of behav- The authors found an association between severe de- ioral problems among children in situations of poverty, pressive symptoms during pregnancy and more frequent according to a study conducted by Bele, Bodhare, Val- behavioral problems at the age of 10 and 11 years old, sangkar, and Saraf (2013) of children in India. In the according to the reports of teachers. Conners-Burrow et Brazilian context, Correia, Saur, and Loureiro (2014) al. (2016), who took into account the assessment of conducted a cohort study and identified an association mothers, determined that early contact with maternal of behavioral problems with low socioeconomic status mild depressive symptoms increased the risk of children for boys and low maternal education and larger families presenting internalizing and externalizing behavioral for girls. In the same direction, Pizato et al. (2014) veri- problems during school-age years. fied association between improved socioeconomic condi- Still considering chronic risk and adversity and their tions with fewer behavioral problems and more social influence on child behavior, we highlight the study by skills in school-aged children; Saur and Loureiro (2015) Wang, Christ, Mills-Koonce, Garrett-Peters, and Cox identified associations between behavioral problems (2013), who found associations between externalizing among 10-year-old children with low maternal educa- problems among 4- to 12-year-old children and the use tional level and low socioeconomic status and families of more rigid control and low maternal educational with more than four members. It is also considered that levels. The study by Bouvette-Turcot et al. (2017) reports the family socioeconomic condition can influence the that exposure to more adversity and low family income cognitive performance of children, being this condition during childhood was associated with the development strongly related to other environmental aspects such as of depressive symptoms in adulthood. maternal depression (Piccolo et al., 2012). When addressing behavioral problems, one issue that In regard to the parents’ mental health, maternal de- arises refers to the source of assessments, considering that pression, especially given its high prevalence and recur- children and adolescents may present problems in a specific rence (World Health Organization [WHO], 2017a, context but not in another, for instance, family versus 2017b), stands out as a form of adversity in different pe- school, indicating a need to obtain assessments from mul- riods of child development, impacting the behavior of tiple informants, especially from parents or legal guardians school-aged children (Bagner, Pettit, Lewinsohn, & Seeley, and teachers (Martoni, Trevisan, Dias, & Seabra, 2016; 2010; Callender, Olson, Choe, & Sameroff, 2012;Edwards Miller, Martinez, Shumka, & Baker, 2014). In this direction, & Hans, 2015; Loosli, Pizeta, & Loureiro, 2016). Such a some studies draw attention to the low to moderate level of psychopathology, however, is associated with other ad- agreement obtained between informants and to the rele- verse contextual conditions, favoring cumulative risk in vance of such information to implementing clinical prac- the family context (Kessler, 2012). Note that the condition tices intended to address specific contexts in which of cumulative risk has been acknowledged in the literature children present problems (De Los Reyes et al., 2015;Mar- as having a greater impact for outcomes among children tel, Markon, & Smith, 2017). Despite disagreement among compared to the presence of a single risk (Evans, Li, & the various informants, different observers provide different Whipple, 2013). Thus, this justifies the relevance of study- perspectives of the same problem (Miller et al., 2014). Each ing potential associations between maternal depression observer, though, can provide potentially valuable data in and behavioral problems, including other variables in the regard to the same patient (De Los Reyes, Thomas, Good- family environment, as proposed in this paper. man, & Kundey, 2013; Clark, Durbin, Hicks, Iacono, & Indicators of social vulnerability and clinical character- McGue, 2017), taking into consideration different contexts. istics of maternal depression have been identified as rele- With school-aged children in mind, mothers and vant factors to understanding risk conditions for child teachers have a privileged opportunity to observe the be- development. Barker, Copeland, Maughan, Jaffee, and havior of children, since the family and school are the Uher (2012) monitored children from their first year of primary contexts of development where competence in life up to the age of 7 and verified that, in comparison to specific tasks inherent to this period is acquired (Achen- children of mothers without depression, children of bach et al., 2008), as previously mentioned. Some studies mothers with depression were more frequently exposed addressing the behavior of children according to the as- to 10 out of the 11 risk factors assessed in the study, sessments of parents and teachers highlight the discrep- among which, low socioeconomic status, single parent, ancy between such assessments. Johnson, Hollis, physical abuse, low maternal education, and drug and Marlow, Simms, and Wolke (2014) used the Strengths Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 3 of 11 and Difficulties Questionnaire (SDQ) to assess 219 chil- techniques from different sources, namely mothers, dren aged 11 years old who were born prematurely. The teachers, and children. The study was approved by the In- authors verified that the parents considered their chil- stitutional Review Board (no. 36415514.5.0000.5407) and dren to present more emotional, attention, and relation- complied with the ethical recommendations proposed by ship problems compared to the assessments provided by the Declaration of Helsinki. teachers. The informants agreed only in regard to the as- sessment of problems related to hyperactivity, which in- dicates the importance of using combined assessments. Participants Kovess et al. (2015) conducted a study with 9084 chil- A total of 85 mother-child pairs and 16 teachers from dren between 6 and 9 years of age, from seven countries a public school located in the state of São Paulo, (Italy, the Netherlands, Germany, Romania, Bulgaria, Brazil, took part in this study. The participants were Lithuania, and Turkey), in which both teachers and par- assigned to three groups, according to the children’s ents were informants. The objective was to identify risks indicators of behavioral problems assessed by their to the mental health of students. They verified that the mothers and teachers, namely G1 = 18 children with teachers found the children to present more externaliz- behavioral problems according to their mothers and ing problems and fewer internalizing problems when teachers, G2 = 39 children with behavioral problems compared to the parents’ assessments. according to their mothers or teachers, and G3 = 28 Even though assessments provided by multiple infor- children without behavioral problems according to mants are considered relevant, the literature still lacks their mothers and teachers. data. This study seeks to fill this gap and is intended to According to the inclusion criteria, mothers were aged produce new data concerning the behavior of school chil- between 25 and 45 years old, 34.5 years old on average dren assessed by mothers and teachers, considering condi- (SD = 5.51), and all were literate. The children were aged tions in which children live with maternal depression and between 7 and 10 years old, 8.8 years old on average other adversities. Therefore, this study is intended to fill (SD = 1.06) and were homogeneously distributed into the gaps pointed out by De Los Reyes et al. (2015)con- three groups. In regard to the children’s sex, 39 were cerning the need for further research using the assess- girls and 46 were boys, making a balanced distribution ments of multiple informants and addressing the specifics according to sex impossible: G1 presented significantly of contexts in which behavioral problems manifest, as a more boys than girls when compared to the G2 and G3 way to improve understanding regarding such problems, (p = 0.05; p = 0.02, respectively). In order to assess the focusing on maternal depression. According to Goodman weight of this variable for the presence or absence of be- et al. (2011), there is a need for studies focusing on the havioral problems among children, as assessed by both multiple adversities presented in the family environment, their mothers and their teachers, an ordinal regression taking into account the influence of maternal mental analysis was performed considering the sex of the chil- health when assessing the behavior of children, as indi- dren, which revealed a model that did not present the cated by Leis et al. (2014). minimum criteria regarding slope homogeneity [chi- Therefore, the objective was to identify the behavioral square (1) = 5.285; p = 0.022; D(1) = 5.524; p = 0.019], profile of school children and associations between the that is, it is not a model that fits data under analysis. evaluation of mothers and teachers, identifying the level The inclusion criteria are that the children live with of agreement among the informants. In addition, we their biological mothers, rather than adoptive mothers, aimed to evaluate the predictive effect of indicators con- and have attended at least 1 year of primary school. In- cerning social vulnerability, chronic adversity, and ma- stitutionalized children or those with apparent physical ternal depression on behavioral problems presented by or mental disabilities were excluded. The assessment of school children, according to the perspectives of children was initiated after consent was obtained from mothers and teachers, considering the presence or ab- their mothers, and only one child per family was in- sence of difficulties in both family and school contexts. cluded in the study. In regard to the teachers, only those The hypothesis guiding this study was that social vulner- who had had at least 3 months of contact with the chil- ability, chronic adversity, and maternal depression pre- dren and taught the children whose mothers explicitly dict more frequent behavioral problems among school consented to the assessment of their children at school children in both developmental contexts, family and were included. In accordance with the principles of good school, assessed by mothers and teachers, respectively. research practices, the participation of mothers and teachers was voluntary, without incentive payment Methods mechanisms that stimulated the involvement with the A cross-sectional, correlational, predictive, comparative research. A lecture was offered to the school on the be- design was adopted using data obtained with different havior and learning of school children. Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 4 of 11 Instruments the four behavioral problem scales. Scores are classified Raven’s Colored Progressive Matrices (Raven) as normal, borderline, and abnormal. It was translated to The Raven is an instrument standardized by Angelini, Portuguese and adapted for Brazilian sociocultural char- Alves, Custódio, Duarte, and Duarte (1999), to assess acteristics by Fleitlich, Cortázar, and Goodman (2000), the intellectual level of Brazilian children between 5 and while psychometric data, concerning validity and reli- 11 years old. It is a psychological test of non-verbal ability, were described by Woerner et al. (2004), present- intelligence; the objective of which is to assess one’s ana- ing good indicators. In this study, based on individual logical reasoning as a general factor, composed of three scores and cutoff points established for the Brazilian series: A, AB, and B, each with 12 problems. It presents population, we considered the outcome variable for chil- good psychometric qualities, inferred by construct valid- dren classified as normal or borderline, according to the ity, internal consistency, with item-total correlation be- SDQ, to be “without difficulties,” while those who were tween 0.30 and 0.80 for most items, as well as precision, classified as abnormal to be “with difficulties.” These inter-item coefficient of correlation for the total sample outcomes were grouped with the assessments performed equal to 0.92 (Angelini et al., 1999). Children presenting by the mothers and teachers, according to the distribu- potential cognitive deficits, who presented percentiles tion in the groups. lower than 25, were excluded from the study (Muniz, Gomes, & Pasian, 2016), balancing groups according to Chronic Adversity Scale (CAS) the percentiles obtained by the children. The CAS was proposed by Marturano (1999)and is intended to identify recurrent adverse events that may Patient Health Questionnaire-9 (PHQ-9) have taken place in a child’s life and happened repeated The PHQ-9 is a module directly based on the diagnostic times or lasted 1 year or longer. It is composed of 18 items criteria for major depression disorder from the DSM-IV, addressing issues concerning chronic adversity regarding proposed and validated by Spitzer, Kroenke, and Williams the child’s or the parents’ health, parents’ temperament, (1999) and by Kroenke, Spitzer, and Williams (2001). The and potential family or marital conflicts. The scale is com- questionnaire enables both screening for signs and symp- pleted by the mothers based on a list of adverse conditions toms of current major depression, as well as classifying that may have developed in the lives of children since levels of severity, from mild to moderate or severe; the birth, specifying the duration in years and the child’s greater the score, the more indicators of problems the in- period of life at the time. Each item is scored either 0 (ab- dividual presents. It is composed of nine items assessed by sence of recurrence or chronic nature of the event in the an ordinal scale that measures the frequency of signs and child’s life) or 1 (the event was recurrent or has a chronic symptoms of depression in the last 2 weeks. According to nature); the sum of all 18 items results in the total score, the instrument’s technical instructions, the total score was which is used to identify the existence of chronic events. used so that scores greater than or equal to 10 indicate the presence of depressive symptoms, while scores lower General Questionnaire than 10 indicate an absence of such symptoms. The Bra- This questionnaire addresses sociodemographic data and zilian version used in this study was translated by Pfizer specific information concerning the mothers’ age, mari- (Copyright ©2005 Pfizer Inc., New York, NY), the reliabil- tal status, and educational level; the families’ monthly in- ity of which was verified by Osório, Mendes, Crippa, and come and socioeconomic status; and the age, sex, and Loureiro (2009), presenting satisfactory psychometric education of the children included in the study. The indicators. items from the Brazil Economic Classification Criteria, developed by the Brazilian Association of Survey Com- Strengths and Difficulties Questionnaire (SDQ) panies (2015), were used to assess socioeconomic condi- The SDQ was developed by Goodman (1997) and is tions. Such information was used to characterize the intended to assess the behavior of children and adoles- participants and groups, as well as to identify social vul- cents, aged between 4 and 16 years old, by screening nerability indicators, including low maternal and pater- their behavioral strengths and difficulties. There is a ver- nal education, single-parent families, low socioeconomic sion for children and adolescents between 11 and status, and low family income, as well as being recipients 16 years of age, a version for parents, and another for of governmental financial support. teachers. The SDQ is composed of 25 items subdivided into five subscales: emotional symptoms, conduct prob- Data collection procedures lems, hyperactivity, peer relationship problems, and pro- Preferably, data were collected at school in a private social behavior, with five items each. It provides raw room, or in the families’ homes when requested by the scores and cutoff points for each of the subscales, as well mothers, in which case we sought to preserve the re- as a total score for difficulty that is obtained by totaling spondents’ privacy and convenience. All interviews were Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 5 of 11 held by the first researcher, who is a psychologist and Data treatment and analysis properly trained in the application of instruments. The PHQ-9, Raven, SDQ, and CAS were coded accord- Initially, 427 families received an invitation letter, which ing to the purpose of each instrument. The assessments was delivered to the children in their classrooms. The 260 concerning the behaviors of children performed by the families who responded to the invitation were contacted mothers and teachers using the SDQ were used as dis- by phone with the objective to provide clarification about tinct sources in paired samples, in order to assign the the study’s objectives and schedule an assessment. A total participants to one of the three groups. of 154 families accepted the invitation to cooperate with Coded data were typed in an Excel® spreadsheet and the study, but nine of these were excluded because the checked by independent reviewers. The statistical ana- grandmothers were the primary caregivers of these fam- lyses were performed using IBM SPSS Statistics (v. 23; ilies’ children. Of the 145 mothers scheduled for assess- IBM SPSS, Chicago, IL), and a significance level of 0.05 ment, 43 did not attend the interviews, resulting in 102 was adopted. families. Seventeen of these did not meet the inclusion cri- The reliability of the PHQ-9 was verified for this sam- teria: adolescent mothers or mothers older than 45 years ple using Cronbach’s alpha, which presented good psy- of age, children exclusively living with their fathers, and chometric quality (α = 0.87). The reliability of the SDQ children with characteristics that were not homogeneous (n = 85) for the totality of items regarding difficulties with those presented by the groups. Thus, a total of 85 was based on the mothers’ (α = 0.77) and teachers’ an- mother-child pairs were included and assessed. swers (α = 0.89), as well as items of the pro-social behav- Of the 427 families initially invited to participate in ior scale answered by mothers (α = 0.71) and teachers. this research, 316 refused to collaborate with the survey Normality tests (Kolmogorov-Smirnov, with Lilliefors and 26 were excluded because they did not meet the in- significance correlation, and Shapiro-Wilk) were per- clusion criteria. formed to guide decision-making regarding the statistical The instruments were individually and in-person ap- tests used for each set of variables. plied to mothers in a single section according to the fol- The behavioral profile of children, obtained through lowing order: General Questionnaire, PHQ-9, CAS, and the assessments of mothers and teachers and repre- SDQ, with an average duration of 60 min. The re- sented by the raw scores obtained on the scales address- searcher read the instruments and checked the re- ing problems and pro-social resources and the total sponses while the mothers had a copy of the scale of difficulties in the SDQ, was analyzed using de- instruments to accompany the reading. This procedure scriptive and comparative statistics by means of the Wil- was adopted to deal with potential difficulties or fatigue coxon test. Indicators of the presence and absence of that the reading could produce in the mothers, given behavioral problems among children, assessed by the their level of education or potential depressive symp- mothers and teachers using the SDQ, were compared toms, though the mothers presented a minimum level of using the McNemar test. Inter-observer agreement was literacy that enabled them to understand the questions also verified using the Kappa coefficient, while the criter- posed by the instruments. ion proposed by Landis and Koch (1977) was adopted. The children were assessed at school in individual ses- The sociodemographic data and profiles of social vul- sions that lasted an average of 15 min. After briefly es- nerability and chronic adversity were analyzed using de- tablishing rapport, the Raven’s Colored Progressive scriptive statistics, while the groups were compared Matrices was applied. The three groups were compared using chi-square and Kruskal-Wallis tests. After the uni- according to the percentiles children obtained in order variate analysis, the predictive effect of cumulative ad- to balance the groups in regard to this variable. Note verse conditions on school children’s behavioral that there were no significant statistical differences be- problems was assessed using ordinal regression analysis tween them in regard to the children’s cognitive perfor- (Maroco, 2014), adopting criteria proposed by Field mances (G1: x = 75.1; σ = 19.12; G2: x = 76.0; σ = 13.44; (2013) for the inclusion of predictive variables. G3: x = 66.9; σ = 14.97). The weight of contextual adverse cumulative variables The 16 teachers collectively completed the SDQ, focus- for the children’s behavioral problems was tested using ing on the behavior of 85 children who had been previ- ordinal regression analysis based on the significant vari- ously assessed by their mothers, at the regular time ables identified in the comparison between groups. The scheduled for a meeting concerning collective teaching predictive variables were included in the model (family work. Each teacher was supposed to assess up to five stu- income, mother’s education, and maternal depression dents per meeting, with an average duration of 50 min were included as factors, and the score of chronic adver- and approximately 10 min per child. The teachers filled in sity was included as a covariant), independently tested, the questionnaire, and the researcher remained in the and combined with the sex of children, because the dis- room during the assessment to clarify potential doubts. tribution of children in the groups according to sex was Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 6 of 11 not homogeneous. Additionally, the contextual variables Table 1 Comparisons regarding the behavioral profile of children (SDQ—mothers and teachers) (n = 85) of cumulative risk were jointly tested in a multivariate model. Respondents Mothers Teachers p value* SDQ The analysis of the social vulnerability indicators (in- f (%) f (%) come and maternal education) and maternal depression, Emotional symptoms in one analysis disregarding the sex of children and then With difficulties 52 (61) 05 (06) < 0.001 one considering the sex of children, showed that the Without difficulties 33 (39) 80 (94) models did not fit the data. The analysis of the models Conduct problems that included chronic adversity, as a single variable or With difficulties 31 (37) 16 (19) 0.004 associated with the sex of children, revealed statistically significant models, with very small effect sizes, in which Without difficulties 54 (63) 69 (81) independent variables did not predict the behavioral out- Hyperactivity come among children, thus did not present relevant re- With difficulties 47 (55) 23 (27) < 0.001 sults. Afterwards, the multivariate model including Without difficulties 38 (45) 62 (73) maternal depression, social vulnerability indicators, and Peer relationship problems chronic adversity was tested and presented goodness of With difficulties 22 (26) 08 (09) 0.007 fit and is the model presented here. Without difficulties 63 (74) 77 (91) Results Total difficulties score Based on the objectives proposed, the results are pre- With difficulties 55 (65) 20 (23) < 0.001 sented taking into account the analyses concerning the Without difficulties 30 (35) 65 (77) children’s behavioral profiles according to the assessments Pro-social behavior of mothers and teachers as distinct sources, comparisons With difficulties 06 (07) 06 (07) 1.000 between G1, G2, and G3 regarding profile of social vulner- ability, maternal depression, and chronic adversity, as well Without difficulties 79 (93) 79 (93) as the predictive effect of significant variables on the chil- SDQ Strengths and Difficulties Questionnaire, f frequency, % percentage *p value for McNemar’s test/p ≤ 0.05 dren’s behavioral problems assessed by mothers and pro- fessors, as combined sources of information. score (mothers: x = 17.5; σ = 6.98; teachers: x = 9.33; σ = The children’s behavioral profiles 7.28; p < 0.001) and for the four scales concerning Table 1 presents the behavioral profiles of the children symptoms: emotional symptoms (mothers: x = 3.19; σ = assessed, according to the SDQ, by mothers and teachers 2.52; teachers: x = 2.26; σ = 1.89; p < 0.001), conduct as two different sources, adopting the presence or ab- problems (mothers: x = 3.32; σ = 2.56; teachers: x = 1.59; sence of behavioral problems verified by the SDQ and σ = 2.23; p < 0.001), hyperactivity (mothers: x = 6.79; σ = total difficulties as the outcome of the development of 2.76; teachers: x = 4.04; σ = 3.23; p < 0.001), and peer re- school children. lationships (mothers: x = 2.20; σ = 2.20; teachers: x = 1.42; Significant statistical differences were found when σ = 1.90; p < 0.001). comparing mothers and teachers in regard to the four specific scales of difficulties and total difficulties. Note The profiles of families in terms of vulnerability and risk that the mothers considered their children to present variables more emotional symptoms, conduct problems, hyper- Table 2 presents comparisons concerning social vulner- activity, peer relationship problems, and total difficulties ability, maternal depression, and chronic adversities pre- than the teachers. In regard to pro-social behavior, no sented in the family context of children according to statistically significant differences were found in regard their distribution in the three groups. to the comparisons between mothers and teachers. Statistically significant differences were found between In regard to the level of agreement obtained between G1, G2, and G3 in regard to maternal education, family in- assessments (mothers and teachers), note that reason- come, maternal depression, and chronic adversity. The able agreement levels were found for conduct problems comparison concerning maternal education revealed sig- (kappa = 0.29 p = 0.003) and total behavioral problems nificant differences between G1 and G3 (χ = 5.660, p = (kappa = 0.21; p = 0.007), in addition to minimum in- 0.017) and between G2 and G3 (χ =12.075, p < 0.001). dexes for hyperactivity (kappa = 0.19; p = 0.035). Significant differences were also found in terms of family Similarly, the same differences were found for continu- income between G1 and G2 (χ = 4.349, p < 0.037) and be- ous scores. The means of the mothers were greater than tween G1 and G3 (χ = 5.841, p = 0.016). No differences those presented by the teachers for the total difficulties were found between groups in terms of paternal education, Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 7 of 11 Table 2 Comparisons between the groups regarding social vulnerability, maternal depression, and chronic adversities (n = 85) Groups G1 (n = 18) G2 (n = 39) G3 (n = 28) Test value p value* Social vulnerability f (%) f (%) f (%) Maternal education Up to 8 years 05 (28) 16 (41) 01 (04) 11.961 0.003 More than 8 years 13 (72) 23 (59) 27 (96) Paternal education Up to 8 years 10 (56) 20 (51) 11 (39) 1.429 0.489 More than 8 years 08 (44) 19 (49) 17 (61) Marital status Single-parent family 11 (61) 32 (82) 23 (82) 3.589 0.165 Two-parent family 07 (39) 07 (18) 05 (18) Socioeconomic class C, D, and E 06 (33) 13 (33) 09 (32) 0.012 0.994 A and B 12 (67) 26 (67) 19 (68) Family income Up to 3 minimum wages 13 (72) 24 (62) 10 (36) 7.044 0.030 More than 3 min. wages 05 (28) 15 (38) 18 (64) Government benefit Present 04 (22) 12 (31) 02 (07) 5.465 0.065 Absent 14 (78) 27 (69) 26 (93) Maternal depression Presence 11 (61) 15 (38) 00 (00) 21.376 < 0.001 Absence 07 (39) 24 (62) 28 (100) Chronic adversities M (SD)/Med M (SD)/Med M (SD)/Med Test value p value** 1.50 (0.92) 1.95 (1.61) 1.04 (1.17) 6.651 0.036 2.00 2.00 1.00 Note. G1 = children with behavioral difficulties according to mothers and teachers; G2 = children with behavioral difficulties according to mothers or teachers; G3 = children without behavioral difficulties according to mothers and teachers f frequency, % percentage, M mean, SD standard deviation, Med median *p value for the chi-square test **p value for the Kruskal-Wallis test/p ≤ 0.05 marital status, socioeconomic status, or receiving govern- concerning coefficients and significance of the adjusted mental financial aid. Considering the variable maternal de- ordinal model. pression, however, statistically significant differences were Data suggest that the adjusted model is significantly 2 2 found between G1 and G2 (χ = 13.876, p < 0.000) and be- better than the null model [G (4) = 24,792, p < 0.001). tween G1 and G3 (χ =22.489, p <0.001). G1 was the Additionally, the multivariate model was statistically sig- group in which mothers more frequently presented nificant [chi-square (58) = 50,367, p = 0.752; D(58) = current symptoms of depression in comparison to the 57,402, p = 0.497] and showed moderate effect size 2 2 2 other two groups, while no differences were found be- (R MF = 0.253; R N = 0.288; R CS = 0.139). According to tween G2 and G3. the model, children are more likely to present behavioral Comparisons concerning chronic adversities revealed problems when their mothers present indicators of de- significant differences between G2 and G3 (F = 363.000, pression, according to the assessments of both mothers p = 0.016), but no differences were found between G1 and teachers (b = 1.955, p = 0.001). and G2 or between G1 and G3. Discussion The predictive effect of adverse cumulative variables on This study was intended to verify associations between child behavior indicators of social vulnerability, chronic adversity, and Table 3 presents the weight of adverse cumulative con- maternal depression, and the weight of such associa- textual variables on child behavior, including data tions, with behavioral problems among school children, Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 8 of 11 Table 3 Multiple ordinal regression with contextual variables for behavioral problems (n = 85) Parameters Behavioral problems (SDQ—mothers and teachers) Estimate SE Wald df p value CI 95% Limit Behavior problems =.00 2.590 0.676 14.960 1 < 0.001 − 3.915;− 1.266 Behavior problems = 1.00 0.039 0.579 0.005 1 0.946 − 1.097;1.175 Location Maternal depression = 1.00 − 1.955 0.572 11.683 1 < 0.001 − 3.077;− 0.834 Mother schooling = 1.00 − 0.340 0.527 0.417 1 0.518 − 1.374;0.693 Monthly income = 1.00 − 0.513 0.458 1.254 1 0.263 − 1.410;0.384 Chronic adversity − 0.086 0.157 0.301 1 0.583 − 0.222;0.394 p ≤ 0.05 Note. SDQ Strengths and Difficulties Questionnaire, SE standard error, df degrees of freedom, CI (95%) confidence interval 95% as assessed by their mothers and teachers. In this study, due to the large range of daily situations, which are not al- mothers and teachers were considered distinct sources ways structured (Leis et al., 2014). In the case of the of information, and the information they provided on mothers, the parameter is one specific child. In the class- the children’s behaviors was combined considering the room, in contrast, teachers have more structured situations presence or absence of difficulties manifested in the two to assess children and the teachers’ references include com- developmental contexts of family and school. The hy- paring the behavior of a set of children with similar demo- pothesis guiding this study that social vulnerabilities, graphic parameters. In this sense, when the assessments of chronic adversity, and maternal depression impact be- mothers and teachers were combined, we accessed a larger havioral problems among school children was partially set of information concerning the behavior of children, fo- confirmed, as data analysis revealed peculiarities regard- cusing on aspects of contextual comparisons and individual ing such variables, which deserve to be highlighted. and collective parameters, as proposed by Miller et al. The assessments of the children’s behavior from the (2014) and De Los Reyes et al. (2015). perspectives of mothers and teachers in general showed The literature has recognized the relevance of assess- that mothers identified more behavioral problems in ments performed by teachers; however, few studies ad- children than did the teachers. This finding is in agree- dress behavioral difficulties of children using multiple ment with those reported in the studies conducted by informants and combined data as a strategy to identify De Los Reyes et al. (2015) and Martel et al. (2017), the presence of problems in more than one context of which indicate low to moderate agreement among infor- life. The predominance of the mother as the only in- mants. In this same direction, Clark et al. (2017) con- formant may compromise the results of assessments, es- sider that agreement between assessments of parents, pecially when a mother presents a psychopathological teachers, and children is rarely high, however, emphasiz- disorder (Leis et al., 2014), such as depression. Such a ing that varied information enriches the understanding disorder may influence the individual’s perception of of the associations between academic conditions, per- child behavior, and avoiding this influence justifies the sonality, psychosocial functioning, behavioral aspects, use of distinct and combined sources of information. mental health, and social adjustment of school children. Therefore, we note that one of the contributions of this According to the mothers’ assessments, a larger number study, in addition to including multiple informants, is of children experienced difficulties concerning emotional the combined analysis of children’s behavioral outcomes, symptoms, while the teachers identified a larger number which enabled verifying problems in two contexts, family of children with externalizing problems expressed and school, to estimate how many children face these through conduct problems and hyperactivity. Such re- sorts of difficulties, information that is relevant for prac- sults are similar to those reported by Kovess et al. tices in the mental health field. (2015), who note that externalizing problems are more Another aspect to be analyzed involves social vulner- visible to teachers than internalizing problems. ability, which was assessed considering different social Analysis of this discrepancy between assessments should and economic factors, among which are low maternal take into account that the interaction of mothers and educational level and income. These are relevant social teachers with children occurs in contexts that exhibit differ- determinants associated with the presence of behavioral ent demands, in addition to the fact that observers are problems among children, according to the assessments guided by different criteria. In the family context, mothers by mothers and/or children, indicating aspects to be have a more detailed picture of their children’sbehavior considered when planning preventive practices. Note Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 9 of 11 that these findings are consistent with those reported by depression, and chronic adversity, characterizes a group Correia et al. (2014), who identified association between that requires greater attention, as it is exposed to multiple child behavioral problems and low socioeconomic status risks. This information highlights the relevance of investi- and low maternal educational level, indicating a potential gating the presence of cumulative risk in the family context profile of cumulative vulnerability favoring behavioral prob- to understand developmental outcomes among children lems among children. Families with low socioeconomic sta- (Evans et al., 2013; Goodman et al., 2011). tus generally have high rates of divorce, unemployment, In regard to the identification of the predictive effect and a larger number of members, while parents with a high of cumulative risk variables and vulnerability, as poten- socioeconomic level have a higher educational level and in- tial predictors of behavioral problems among children, vest more in their children’s education (Carneiro, Meghir, only maternal depression appears as an explanatory vari- &Parey, 2013; Piccolo et al., 2012). able for the presence of behavioral problems among The associations between mental health conditions children in the context of multiple adverse conditions. and vulnerability indicators have been widely recognized These findings are in agreement with Bagner et al. by the World Health Organization (WHO, 2017a, (2010), who stress that living with maternal depression 2017b), which highlights low schooling, lower income, increases a child’s likelihood of presenting externalizing worse material and economic conditions, and less social and internalizing behavioral problems up to the age of support, as possible determinants that negatively influ- 12 years old. Therefore, maternal depression was the ence health mental health of adults and children, favor- only adverse condition with the power to predict the be- ing the accumulation of vulnerability and risk havioral problem outcome, confirming the relevance of conditions. This developmental scenario focuses on the considering such a variable when addressing child be- relevance of the present study, which encompasses di- havior, especially considering the high prevalence of de- verse and competing contextual variables that influence pression among women of childbearing age (World children’s developmental outcomes in the perception of Health Organization [WHO], 2017a, 2017b). different informants. As the positive aspects of this study, we highlight the The presence of current depressive symptoms among presence of multiple informants, the methodological the mothers was associated with behavioral problems care adopted in the systematic assessment of the partici- among the children, as indicated by the mothers and/or pants, and the use of validated instruments, in addition teachers, characterizing problems in two contexts, family to the inclusion of diverse variables to identify, in the and school. Such an association was also verified by Leis same sample, vulnerability indicators that potentially im- et al. (2014) and Conners-Burrow et al. (2016), who pact the behavior of school children. It is highlighted as noted an increase in behavioral problems among chil- the main strength of the study the inclusion of children dren who had early experience with maternal depression. in the groups considering the presence or absence of be- In this sense, when we considered the behavior of chil- havioral problems in the two main development con- dren from the perspectives of mothers and teachers to- texts for the school period, namely, family and school, gether, we verified that, regardless of the informant, thus highlighting relevant variables associated with vul- children living with maternal depression more frequently nerability and to developmental resources in both con- experienced behavioral problems, including in the school texts, which may favor preventive care and target groups context, characterizing the need for specific mental with potential risks. health practices directed to this group, which was identi- This study’s limitations include the sample size, lack of fied as the most vulnerable. a homogeneous distribution between groups in regard to The presence of chronic adversities was also verified the sex of children, and the identification of depressive to identify variables with a potential negative impact on symptoms using a screening instrument, which limit the school-aged children. This study reveals that children fa- generalization of results. Further studies adopting longi- cing behavioral difficulties, according to the combined tudinal designs, considering the influence of contextual assessments of mothers and teachers, lived in family en- risks over the course of a child’s development, including vironments that presented more chronic adversities, in- other sources of information, in addition to the reports dicating cumulative and recurrent adversity in these of mothers, are needed, as well as observational mea- children’s contexts of life. These findings corroborate the sures. The relevance of inclusion in new studies of par- study conducted by Hildebrand et al. (2015), who identi- ents’/stepfathers’ evaluations, as well as studies that fied an association of two or more risk factors for more address the characteristics of the various family configu- than half of the sample under study. rations in which children are inserted as conditions that The identification of differences among groups, especially can influence the behavior of the school-aged children, for children facing problems in the family and school con- is also highlighted. Another relevant point to be consid- texts (G1) in regard to social vulnerability, current maternal ered in new studies is the inclusion of variables that may Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 10 of 11 function as protective factors, which in a cumulative way Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in to vulnerability and risk conditions may favor a more published maps and institutional affiliations. complete and complex analysis of the mechanisms that favor or hinder children’s behavioral problems. Received: 20 July 2017 Accepted: 2 March 2018 Conclusions References In this study, low maternal educational level, low family Achenbach, T. M., Becker, A., Döpfner, M., Heiervang, E., Roessner, V., Steinhausen, income, the presence of more chronic adversity, and liv- H.-C., & Rothenberger, A. (2008). Multicultural assessment of child and adolescent psychopathology with ASEBA and SDQ instruments: Research ing with current maternal depression are factors associ- findings, applications, and future directions. 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Behavioral problems of school children: impact of social vulnerability, chronic adversity, and maternal depression

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Psychology; Psychology Research; Psychological Methods/Evaluation; Health Psychology; Developmental Psychology; Biological Psychology; Psychometrics
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Abstract

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. Keywords: Behavior, School children, Adversities, Maternal depression, Social vulnerability Background Heron, Stuart, & Mendelson, 2014; Pizeta, Silva, Cartafina, The behavior of school-aged children is an important indi- &Loureiro, 2013). cator of adaptation in this stage of development; however, When analyzing the potential risk factors for the de- not all children are successful and may present externaliz- velopment of psychopathologies in 252 children and ad- ing or internalizing behavioral problems, expressed within olescents who are victims of domestic violence, the family and/or school contexts (Achenbach, Ivanova, Hildebrand, Celeri, Morcillo, and Zanolli (2015) verified Rescorla, Turner, & Althoff, 2016; Linhares & Martins, that 92.8% of the participants were exposed to at least 2015;Marturano, 2013). one risk factor. The authors also noticed that the associ- Families present structural and internal dynamics that ation of two or more risk factors were present in 53.2% may contribute to either risk or protective outcomes in of the sample, namely family conflicts, mental health terms of child development (Macana & Comim, 2015; problems within the family, gender violence between Walsh, 2016) so that adaptive difficulties associated with parents, family involvement with drug trafficking and behavioral problems are frequent among children (Pizato, criminal behavior, and the abusive consumption of alco- Marturano, & Fontaine, 2014). Considering the relevance hol by parents or legal guardians, among others. of the influence exerted by the family context on school Therefore, among the events listed as conditions that children, various studies have addressed the association of predispose children to behavioral problems, we highlight cumulative adversity present in the family context and the indicators of chronic adversity and mental health condi- outcomes of behavioral problems among children (Dun- tions affecting the parents, especially maternal depres- combe, Havighurst, Holland, & Frankling, 2012;Leis, sion, as risk conditions acknowledged to have a negative impact on children. Additionally, the presence of vari- ables related to social vulnerability is also identified * Correspondence: karinabraguim@usp.br Universidade de São Paulo (USP), Rua Tenente Catão Roxo, 2650, Ribeirão based on conditions or events of life that may interfere Preto, SP CEP: 14051-140, Brazil © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 2 of 11 in the course of developmental outcomes for children, alcohol consumption. The frequency of exposure was at contributing to the maladaptation of children in typical a significant level. Indicators concerning the severity of developmental tasks when experiencing risk conditions. depression and anxiety were examined by Leis et al. Considering social vulnerability in the population in (2014), in a sample of 2891 mother-child pairs, taking general, low socioeconomic status and unemployment into account the perspectives of mothers and teachers. among mothers were identified as predictors of behav- The authors found an association between severe de- ioral problems among children in situations of poverty, pressive symptoms during pregnancy and more frequent according to a study conducted by Bele, Bodhare, Val- behavioral problems at the age of 10 and 11 years old, sangkar, and Saraf (2013) of children in India. In the according to the reports of teachers. Conners-Burrow et Brazilian context, Correia, Saur, and Loureiro (2014) al. (2016), who took into account the assessment of conducted a cohort study and identified an association mothers, determined that early contact with maternal of behavioral problems with low socioeconomic status mild depressive symptoms increased the risk of children for boys and low maternal education and larger families presenting internalizing and externalizing behavioral for girls. In the same direction, Pizato et al. (2014) veri- problems during school-age years. fied association between improved socioeconomic condi- Still considering chronic risk and adversity and their tions with fewer behavioral problems and more social influence on child behavior, we highlight the study by skills in school-aged children; Saur and Loureiro (2015) Wang, Christ, Mills-Koonce, Garrett-Peters, and Cox identified associations between behavioral problems (2013), who found associations between externalizing among 10-year-old children with low maternal educa- problems among 4- to 12-year-old children and the use tional level and low socioeconomic status and families of more rigid control and low maternal educational with more than four members. It is also considered that levels. The study by Bouvette-Turcot et al. (2017) reports the family socioeconomic condition can influence the that exposure to more adversity and low family income cognitive performance of children, being this condition during childhood was associated with the development strongly related to other environmental aspects such as of depressive symptoms in adulthood. maternal depression (Piccolo et al., 2012). When addressing behavioral problems, one issue that In regard to the parents’ mental health, maternal de- arises refers to the source of assessments, considering that pression, especially given its high prevalence and recur- children and adolescents may present problems in a specific rence (World Health Organization [WHO], 2017a, context but not in another, for instance, family versus 2017b), stands out as a form of adversity in different pe- school, indicating a need to obtain assessments from mul- riods of child development, impacting the behavior of tiple informants, especially from parents or legal guardians school-aged children (Bagner, Pettit, Lewinsohn, & Seeley, and teachers (Martoni, Trevisan, Dias, & Seabra, 2016; 2010; Callender, Olson, Choe, & Sameroff, 2012;Edwards Miller, Martinez, Shumka, & Baker, 2014). In this direction, & Hans, 2015; Loosli, Pizeta, & Loureiro, 2016). Such a some studies draw attention to the low to moderate level of psychopathology, however, is associated with other ad- agreement obtained between informants and to the rele- verse contextual conditions, favoring cumulative risk in vance of such information to implementing clinical prac- the family context (Kessler, 2012). Note that the condition tices intended to address specific contexts in which of cumulative risk has been acknowledged in the literature children present problems (De Los Reyes et al., 2015;Mar- as having a greater impact for outcomes among children tel, Markon, & Smith, 2017). Despite disagreement among compared to the presence of a single risk (Evans, Li, & the various informants, different observers provide different Whipple, 2013). Thus, this justifies the relevance of study- perspectives of the same problem (Miller et al., 2014). Each ing potential associations between maternal depression observer, though, can provide potentially valuable data in and behavioral problems, including other variables in the regard to the same patient (De Los Reyes, Thomas, Good- family environment, as proposed in this paper. man, & Kundey, 2013; Clark, Durbin, Hicks, Iacono, & Indicators of social vulnerability and clinical character- McGue, 2017), taking into consideration different contexts. istics of maternal depression have been identified as rele- With school-aged children in mind, mothers and vant factors to understanding risk conditions for child teachers have a privileged opportunity to observe the be- development. Barker, Copeland, Maughan, Jaffee, and havior of children, since the family and school are the Uher (2012) monitored children from their first year of primary contexts of development where competence in life up to the age of 7 and verified that, in comparison to specific tasks inherent to this period is acquired (Achen- children of mothers without depression, children of bach et al., 2008), as previously mentioned. Some studies mothers with depression were more frequently exposed addressing the behavior of children according to the as- to 10 out of the 11 risk factors assessed in the study, sessments of parents and teachers highlight the discrep- among which, low socioeconomic status, single parent, ancy between such assessments. Johnson, Hollis, physical abuse, low maternal education, and drug and Marlow, Simms, and Wolke (2014) used the Strengths Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 3 of 11 and Difficulties Questionnaire (SDQ) to assess 219 chil- techniques from different sources, namely mothers, dren aged 11 years old who were born prematurely. The teachers, and children. The study was approved by the In- authors verified that the parents considered their chil- stitutional Review Board (no. 36415514.5.0000.5407) and dren to present more emotional, attention, and relation- complied with the ethical recommendations proposed by ship problems compared to the assessments provided by the Declaration of Helsinki. teachers. The informants agreed only in regard to the as- sessment of problems related to hyperactivity, which in- dicates the importance of using combined assessments. Participants Kovess et al. (2015) conducted a study with 9084 chil- A total of 85 mother-child pairs and 16 teachers from dren between 6 and 9 years of age, from seven countries a public school located in the state of São Paulo, (Italy, the Netherlands, Germany, Romania, Bulgaria, Brazil, took part in this study. The participants were Lithuania, and Turkey), in which both teachers and par- assigned to three groups, according to the children’s ents were informants. The objective was to identify risks indicators of behavioral problems assessed by their to the mental health of students. They verified that the mothers and teachers, namely G1 = 18 children with teachers found the children to present more externaliz- behavioral problems according to their mothers and ing problems and fewer internalizing problems when teachers, G2 = 39 children with behavioral problems compared to the parents’ assessments. according to their mothers or teachers, and G3 = 28 Even though assessments provided by multiple infor- children without behavioral problems according to mants are considered relevant, the literature still lacks their mothers and teachers. data. This study seeks to fill this gap and is intended to According to the inclusion criteria, mothers were aged produce new data concerning the behavior of school chil- between 25 and 45 years old, 34.5 years old on average dren assessed by mothers and teachers, considering condi- (SD = 5.51), and all were literate. The children were aged tions in which children live with maternal depression and between 7 and 10 years old, 8.8 years old on average other adversities. Therefore, this study is intended to fill (SD = 1.06) and were homogeneously distributed into the gaps pointed out by De Los Reyes et al. (2015)con- three groups. In regard to the children’s sex, 39 were cerning the need for further research using the assess- girls and 46 were boys, making a balanced distribution ments of multiple informants and addressing the specifics according to sex impossible: G1 presented significantly of contexts in which behavioral problems manifest, as a more boys than girls when compared to the G2 and G3 way to improve understanding regarding such problems, (p = 0.05; p = 0.02, respectively). In order to assess the focusing on maternal depression. According to Goodman weight of this variable for the presence or absence of be- et al. (2011), there is a need for studies focusing on the havioral problems among children, as assessed by both multiple adversities presented in the family environment, their mothers and their teachers, an ordinal regression taking into account the influence of maternal mental analysis was performed considering the sex of the chil- health when assessing the behavior of children, as indi- dren, which revealed a model that did not present the cated by Leis et al. (2014). minimum criteria regarding slope homogeneity [chi- Therefore, the objective was to identify the behavioral square (1) = 5.285; p = 0.022; D(1) = 5.524; p = 0.019], profile of school children and associations between the that is, it is not a model that fits data under analysis. evaluation of mothers and teachers, identifying the level The inclusion criteria are that the children live with of agreement among the informants. In addition, we their biological mothers, rather than adoptive mothers, aimed to evaluate the predictive effect of indicators con- and have attended at least 1 year of primary school. In- cerning social vulnerability, chronic adversity, and ma- stitutionalized children or those with apparent physical ternal depression on behavioral problems presented by or mental disabilities were excluded. The assessment of school children, according to the perspectives of children was initiated after consent was obtained from mothers and teachers, considering the presence or ab- their mothers, and only one child per family was in- sence of difficulties in both family and school contexts. cluded in the study. In regard to the teachers, only those The hypothesis guiding this study was that social vulner- who had had at least 3 months of contact with the chil- ability, chronic adversity, and maternal depression pre- dren and taught the children whose mothers explicitly dict more frequent behavioral problems among school consented to the assessment of their children at school children in both developmental contexts, family and were included. In accordance with the principles of good school, assessed by mothers and teachers, respectively. research practices, the participation of mothers and teachers was voluntary, without incentive payment Methods mechanisms that stimulated the involvement with the A cross-sectional, correlational, predictive, comparative research. A lecture was offered to the school on the be- design was adopted using data obtained with different havior and learning of school children. Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 4 of 11 Instruments the four behavioral problem scales. Scores are classified Raven’s Colored Progressive Matrices (Raven) as normal, borderline, and abnormal. It was translated to The Raven is an instrument standardized by Angelini, Portuguese and adapted for Brazilian sociocultural char- Alves, Custódio, Duarte, and Duarte (1999), to assess acteristics by Fleitlich, Cortázar, and Goodman (2000), the intellectual level of Brazilian children between 5 and while psychometric data, concerning validity and reli- 11 years old. It is a psychological test of non-verbal ability, were described by Woerner et al. (2004), present- intelligence; the objective of which is to assess one’s ana- ing good indicators. In this study, based on individual logical reasoning as a general factor, composed of three scores and cutoff points established for the Brazilian series: A, AB, and B, each with 12 problems. It presents population, we considered the outcome variable for chil- good psychometric qualities, inferred by construct valid- dren classified as normal or borderline, according to the ity, internal consistency, with item-total correlation be- SDQ, to be “without difficulties,” while those who were tween 0.30 and 0.80 for most items, as well as precision, classified as abnormal to be “with difficulties.” These inter-item coefficient of correlation for the total sample outcomes were grouped with the assessments performed equal to 0.92 (Angelini et al., 1999). Children presenting by the mothers and teachers, according to the distribu- potential cognitive deficits, who presented percentiles tion in the groups. lower than 25, were excluded from the study (Muniz, Gomes, & Pasian, 2016), balancing groups according to Chronic Adversity Scale (CAS) the percentiles obtained by the children. The CAS was proposed by Marturano (1999)and is intended to identify recurrent adverse events that may Patient Health Questionnaire-9 (PHQ-9) have taken place in a child’s life and happened repeated The PHQ-9 is a module directly based on the diagnostic times or lasted 1 year or longer. It is composed of 18 items criteria for major depression disorder from the DSM-IV, addressing issues concerning chronic adversity regarding proposed and validated by Spitzer, Kroenke, and Williams the child’s or the parents’ health, parents’ temperament, (1999) and by Kroenke, Spitzer, and Williams (2001). The and potential family or marital conflicts. The scale is com- questionnaire enables both screening for signs and symp- pleted by the mothers based on a list of adverse conditions toms of current major depression, as well as classifying that may have developed in the lives of children since levels of severity, from mild to moderate or severe; the birth, specifying the duration in years and the child’s greater the score, the more indicators of problems the in- period of life at the time. Each item is scored either 0 (ab- dividual presents. It is composed of nine items assessed by sence of recurrence or chronic nature of the event in the an ordinal scale that measures the frequency of signs and child’s life) or 1 (the event was recurrent or has a chronic symptoms of depression in the last 2 weeks. According to nature); the sum of all 18 items results in the total score, the instrument’s technical instructions, the total score was which is used to identify the existence of chronic events. used so that scores greater than or equal to 10 indicate the presence of depressive symptoms, while scores lower General Questionnaire than 10 indicate an absence of such symptoms. The Bra- This questionnaire addresses sociodemographic data and zilian version used in this study was translated by Pfizer specific information concerning the mothers’ age, mari- (Copyright ©2005 Pfizer Inc., New York, NY), the reliabil- tal status, and educational level; the families’ monthly in- ity of which was verified by Osório, Mendes, Crippa, and come and socioeconomic status; and the age, sex, and Loureiro (2009), presenting satisfactory psychometric education of the children included in the study. The indicators. items from the Brazil Economic Classification Criteria, developed by the Brazilian Association of Survey Com- Strengths and Difficulties Questionnaire (SDQ) panies (2015), were used to assess socioeconomic condi- The SDQ was developed by Goodman (1997) and is tions. Such information was used to characterize the intended to assess the behavior of children and adoles- participants and groups, as well as to identify social vul- cents, aged between 4 and 16 years old, by screening nerability indicators, including low maternal and pater- their behavioral strengths and difficulties. There is a ver- nal education, single-parent families, low socioeconomic sion for children and adolescents between 11 and status, and low family income, as well as being recipients 16 years of age, a version for parents, and another for of governmental financial support. teachers. The SDQ is composed of 25 items subdivided into five subscales: emotional symptoms, conduct prob- Data collection procedures lems, hyperactivity, peer relationship problems, and pro- Preferably, data were collected at school in a private social behavior, with five items each. It provides raw room, or in the families’ homes when requested by the scores and cutoff points for each of the subscales, as well mothers, in which case we sought to preserve the re- as a total score for difficulty that is obtained by totaling spondents’ privacy and convenience. All interviews were Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 5 of 11 held by the first researcher, who is a psychologist and Data treatment and analysis properly trained in the application of instruments. The PHQ-9, Raven, SDQ, and CAS were coded accord- Initially, 427 families received an invitation letter, which ing to the purpose of each instrument. The assessments was delivered to the children in their classrooms. The 260 concerning the behaviors of children performed by the families who responded to the invitation were contacted mothers and teachers using the SDQ were used as dis- by phone with the objective to provide clarification about tinct sources in paired samples, in order to assign the the study’s objectives and schedule an assessment. A total participants to one of the three groups. of 154 families accepted the invitation to cooperate with Coded data were typed in an Excel® spreadsheet and the study, but nine of these were excluded because the checked by independent reviewers. The statistical ana- grandmothers were the primary caregivers of these fam- lyses were performed using IBM SPSS Statistics (v. 23; ilies’ children. Of the 145 mothers scheduled for assess- IBM SPSS, Chicago, IL), and a significance level of 0.05 ment, 43 did not attend the interviews, resulting in 102 was adopted. families. Seventeen of these did not meet the inclusion cri- The reliability of the PHQ-9 was verified for this sam- teria: adolescent mothers or mothers older than 45 years ple using Cronbach’s alpha, which presented good psy- of age, children exclusively living with their fathers, and chometric quality (α = 0.87). The reliability of the SDQ children with characteristics that were not homogeneous (n = 85) for the totality of items regarding difficulties with those presented by the groups. Thus, a total of 85 was based on the mothers’ (α = 0.77) and teachers’ an- mother-child pairs were included and assessed. swers (α = 0.89), as well as items of the pro-social behav- Of the 427 families initially invited to participate in ior scale answered by mothers (α = 0.71) and teachers. this research, 316 refused to collaborate with the survey Normality tests (Kolmogorov-Smirnov, with Lilliefors and 26 were excluded because they did not meet the in- significance correlation, and Shapiro-Wilk) were per- clusion criteria. formed to guide decision-making regarding the statistical The instruments were individually and in-person ap- tests used for each set of variables. plied to mothers in a single section according to the fol- The behavioral profile of children, obtained through lowing order: General Questionnaire, PHQ-9, CAS, and the assessments of mothers and teachers and repre- SDQ, with an average duration of 60 min. The re- sented by the raw scores obtained on the scales address- searcher read the instruments and checked the re- ing problems and pro-social resources and the total sponses while the mothers had a copy of the scale of difficulties in the SDQ, was analyzed using de- instruments to accompany the reading. This procedure scriptive and comparative statistics by means of the Wil- was adopted to deal with potential difficulties or fatigue coxon test. Indicators of the presence and absence of that the reading could produce in the mothers, given behavioral problems among children, assessed by the their level of education or potential depressive symp- mothers and teachers using the SDQ, were compared toms, though the mothers presented a minimum level of using the McNemar test. Inter-observer agreement was literacy that enabled them to understand the questions also verified using the Kappa coefficient, while the criter- posed by the instruments. ion proposed by Landis and Koch (1977) was adopted. The children were assessed at school in individual ses- The sociodemographic data and profiles of social vul- sions that lasted an average of 15 min. After briefly es- nerability and chronic adversity were analyzed using de- tablishing rapport, the Raven’s Colored Progressive scriptive statistics, while the groups were compared Matrices was applied. The three groups were compared using chi-square and Kruskal-Wallis tests. After the uni- according to the percentiles children obtained in order variate analysis, the predictive effect of cumulative ad- to balance the groups in regard to this variable. Note verse conditions on school children’s behavioral that there were no significant statistical differences be- problems was assessed using ordinal regression analysis tween them in regard to the children’s cognitive perfor- (Maroco, 2014), adopting criteria proposed by Field mances (G1: x = 75.1; σ = 19.12; G2: x = 76.0; σ = 13.44; (2013) for the inclusion of predictive variables. G3: x = 66.9; σ = 14.97). The weight of contextual adverse cumulative variables The 16 teachers collectively completed the SDQ, focus- for the children’s behavioral problems was tested using ing on the behavior of 85 children who had been previ- ordinal regression analysis based on the significant vari- ously assessed by their mothers, at the regular time ables identified in the comparison between groups. The scheduled for a meeting concerning collective teaching predictive variables were included in the model (family work. Each teacher was supposed to assess up to five stu- income, mother’s education, and maternal depression dents per meeting, with an average duration of 50 min were included as factors, and the score of chronic adver- and approximately 10 min per child. The teachers filled in sity was included as a covariant), independently tested, the questionnaire, and the researcher remained in the and combined with the sex of children, because the dis- room during the assessment to clarify potential doubts. tribution of children in the groups according to sex was Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 6 of 11 not homogeneous. Additionally, the contextual variables Table 1 Comparisons regarding the behavioral profile of children (SDQ—mothers and teachers) (n = 85) of cumulative risk were jointly tested in a multivariate model. Respondents Mothers Teachers p value* SDQ The analysis of the social vulnerability indicators (in- f (%) f (%) come and maternal education) and maternal depression, Emotional symptoms in one analysis disregarding the sex of children and then With difficulties 52 (61) 05 (06) < 0.001 one considering the sex of children, showed that the Without difficulties 33 (39) 80 (94) models did not fit the data. The analysis of the models Conduct problems that included chronic adversity, as a single variable or With difficulties 31 (37) 16 (19) 0.004 associated with the sex of children, revealed statistically significant models, with very small effect sizes, in which Without difficulties 54 (63) 69 (81) independent variables did not predict the behavioral out- Hyperactivity come among children, thus did not present relevant re- With difficulties 47 (55) 23 (27) < 0.001 sults. Afterwards, the multivariate model including Without difficulties 38 (45) 62 (73) maternal depression, social vulnerability indicators, and Peer relationship problems chronic adversity was tested and presented goodness of With difficulties 22 (26) 08 (09) 0.007 fit and is the model presented here. Without difficulties 63 (74) 77 (91) Results Total difficulties score Based on the objectives proposed, the results are pre- With difficulties 55 (65) 20 (23) < 0.001 sented taking into account the analyses concerning the Without difficulties 30 (35) 65 (77) children’s behavioral profiles according to the assessments Pro-social behavior of mothers and teachers as distinct sources, comparisons With difficulties 06 (07) 06 (07) 1.000 between G1, G2, and G3 regarding profile of social vulner- ability, maternal depression, and chronic adversity, as well Without difficulties 79 (93) 79 (93) as the predictive effect of significant variables on the chil- SDQ Strengths and Difficulties Questionnaire, f frequency, % percentage *p value for McNemar’s test/p ≤ 0.05 dren’s behavioral problems assessed by mothers and pro- fessors, as combined sources of information. score (mothers: x = 17.5; σ = 6.98; teachers: x = 9.33; σ = The children’s behavioral profiles 7.28; p < 0.001) and for the four scales concerning Table 1 presents the behavioral profiles of the children symptoms: emotional symptoms (mothers: x = 3.19; σ = assessed, according to the SDQ, by mothers and teachers 2.52; teachers: x = 2.26; σ = 1.89; p < 0.001), conduct as two different sources, adopting the presence or ab- problems (mothers: x = 3.32; σ = 2.56; teachers: x = 1.59; sence of behavioral problems verified by the SDQ and σ = 2.23; p < 0.001), hyperactivity (mothers: x = 6.79; σ = total difficulties as the outcome of the development of 2.76; teachers: x = 4.04; σ = 3.23; p < 0.001), and peer re- school children. lationships (mothers: x = 2.20; σ = 2.20; teachers: x = 1.42; Significant statistical differences were found when σ = 1.90; p < 0.001). comparing mothers and teachers in regard to the four specific scales of difficulties and total difficulties. Note The profiles of families in terms of vulnerability and risk that the mothers considered their children to present variables more emotional symptoms, conduct problems, hyper- Table 2 presents comparisons concerning social vulner- activity, peer relationship problems, and total difficulties ability, maternal depression, and chronic adversities pre- than the teachers. In regard to pro-social behavior, no sented in the family context of children according to statistically significant differences were found in regard their distribution in the three groups. to the comparisons between mothers and teachers. Statistically significant differences were found between In regard to the level of agreement obtained between G1, G2, and G3 in regard to maternal education, family in- assessments (mothers and teachers), note that reason- come, maternal depression, and chronic adversity. The able agreement levels were found for conduct problems comparison concerning maternal education revealed sig- (kappa = 0.29 p = 0.003) and total behavioral problems nificant differences between G1 and G3 (χ = 5.660, p = (kappa = 0.21; p = 0.007), in addition to minimum in- 0.017) and between G2 and G3 (χ =12.075, p < 0.001). dexes for hyperactivity (kappa = 0.19; p = 0.035). Significant differences were also found in terms of family Similarly, the same differences were found for continu- income between G1 and G2 (χ = 4.349, p < 0.037) and be- ous scores. The means of the mothers were greater than tween G1 and G3 (χ = 5.841, p = 0.016). No differences those presented by the teachers for the total difficulties were found between groups in terms of paternal education, Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 7 of 11 Table 2 Comparisons between the groups regarding social vulnerability, maternal depression, and chronic adversities (n = 85) Groups G1 (n = 18) G2 (n = 39) G3 (n = 28) Test value p value* Social vulnerability f (%) f (%) f (%) Maternal education Up to 8 years 05 (28) 16 (41) 01 (04) 11.961 0.003 More than 8 years 13 (72) 23 (59) 27 (96) Paternal education Up to 8 years 10 (56) 20 (51) 11 (39) 1.429 0.489 More than 8 years 08 (44) 19 (49) 17 (61) Marital status Single-parent family 11 (61) 32 (82) 23 (82) 3.589 0.165 Two-parent family 07 (39) 07 (18) 05 (18) Socioeconomic class C, D, and E 06 (33) 13 (33) 09 (32) 0.012 0.994 A and B 12 (67) 26 (67) 19 (68) Family income Up to 3 minimum wages 13 (72) 24 (62) 10 (36) 7.044 0.030 More than 3 min. wages 05 (28) 15 (38) 18 (64) Government benefit Present 04 (22) 12 (31) 02 (07) 5.465 0.065 Absent 14 (78) 27 (69) 26 (93) Maternal depression Presence 11 (61) 15 (38) 00 (00) 21.376 < 0.001 Absence 07 (39) 24 (62) 28 (100) Chronic adversities M (SD)/Med M (SD)/Med M (SD)/Med Test value p value** 1.50 (0.92) 1.95 (1.61) 1.04 (1.17) 6.651 0.036 2.00 2.00 1.00 Note. G1 = children with behavioral difficulties according to mothers and teachers; G2 = children with behavioral difficulties according to mothers or teachers; G3 = children without behavioral difficulties according to mothers and teachers f frequency, % percentage, M mean, SD standard deviation, Med median *p value for the chi-square test **p value for the Kruskal-Wallis test/p ≤ 0.05 marital status, socioeconomic status, or receiving govern- concerning coefficients and significance of the adjusted mental financial aid. Considering the variable maternal de- ordinal model. pression, however, statistically significant differences were Data suggest that the adjusted model is significantly 2 2 found between G1 and G2 (χ = 13.876, p < 0.000) and be- better than the null model [G (4) = 24,792, p < 0.001). tween G1 and G3 (χ =22.489, p <0.001). G1 was the Additionally, the multivariate model was statistically sig- group in which mothers more frequently presented nificant [chi-square (58) = 50,367, p = 0.752; D(58) = current symptoms of depression in comparison to the 57,402, p = 0.497] and showed moderate effect size 2 2 2 other two groups, while no differences were found be- (R MF = 0.253; R N = 0.288; R CS = 0.139). According to tween G2 and G3. the model, children are more likely to present behavioral Comparisons concerning chronic adversities revealed problems when their mothers present indicators of de- significant differences between G2 and G3 (F = 363.000, pression, according to the assessments of both mothers p = 0.016), but no differences were found between G1 and teachers (b = 1.955, p = 0.001). and G2 or between G1 and G3. Discussion The predictive effect of adverse cumulative variables on This study was intended to verify associations between child behavior indicators of social vulnerability, chronic adversity, and Table 3 presents the weight of adverse cumulative con- maternal depression, and the weight of such associa- textual variables on child behavior, including data tions, with behavioral problems among school children, Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 8 of 11 Table 3 Multiple ordinal regression with contextual variables for behavioral problems (n = 85) Parameters Behavioral problems (SDQ—mothers and teachers) Estimate SE Wald df p value CI 95% Limit Behavior problems =.00 2.590 0.676 14.960 1 < 0.001 − 3.915;− 1.266 Behavior problems = 1.00 0.039 0.579 0.005 1 0.946 − 1.097;1.175 Location Maternal depression = 1.00 − 1.955 0.572 11.683 1 < 0.001 − 3.077;− 0.834 Mother schooling = 1.00 − 0.340 0.527 0.417 1 0.518 − 1.374;0.693 Monthly income = 1.00 − 0.513 0.458 1.254 1 0.263 − 1.410;0.384 Chronic adversity − 0.086 0.157 0.301 1 0.583 − 0.222;0.394 p ≤ 0.05 Note. SDQ Strengths and Difficulties Questionnaire, SE standard error, df degrees of freedom, CI (95%) confidence interval 95% as assessed by their mothers and teachers. In this study, due to the large range of daily situations, which are not al- mothers and teachers were considered distinct sources ways structured (Leis et al., 2014). In the case of the of information, and the information they provided on mothers, the parameter is one specific child. In the class- the children’s behaviors was combined considering the room, in contrast, teachers have more structured situations presence or absence of difficulties manifested in the two to assess children and the teachers’ references include com- developmental contexts of family and school. The hy- paring the behavior of a set of children with similar demo- pothesis guiding this study that social vulnerabilities, graphic parameters. In this sense, when the assessments of chronic adversity, and maternal depression impact be- mothers and teachers were combined, we accessed a larger havioral problems among school children was partially set of information concerning the behavior of children, fo- confirmed, as data analysis revealed peculiarities regard- cusing on aspects of contextual comparisons and individual ing such variables, which deserve to be highlighted. and collective parameters, as proposed by Miller et al. The assessments of the children’s behavior from the (2014) and De Los Reyes et al. (2015). perspectives of mothers and teachers in general showed The literature has recognized the relevance of assess- that mothers identified more behavioral problems in ments performed by teachers; however, few studies ad- children than did the teachers. This finding is in agree- dress behavioral difficulties of children using multiple ment with those reported in the studies conducted by informants and combined data as a strategy to identify De Los Reyes et al. (2015) and Martel et al. (2017), the presence of problems in more than one context of which indicate low to moderate agreement among infor- life. The predominance of the mother as the only in- mants. In this same direction, Clark et al. (2017) con- formant may compromise the results of assessments, es- sider that agreement between assessments of parents, pecially when a mother presents a psychopathological teachers, and children is rarely high, however, emphasiz- disorder (Leis et al., 2014), such as depression. Such a ing that varied information enriches the understanding disorder may influence the individual’s perception of of the associations between academic conditions, per- child behavior, and avoiding this influence justifies the sonality, psychosocial functioning, behavioral aspects, use of distinct and combined sources of information. mental health, and social adjustment of school children. Therefore, we note that one of the contributions of this According to the mothers’ assessments, a larger number study, in addition to including multiple informants, is of children experienced difficulties concerning emotional the combined analysis of children’s behavioral outcomes, symptoms, while the teachers identified a larger number which enabled verifying problems in two contexts, family of children with externalizing problems expressed and school, to estimate how many children face these through conduct problems and hyperactivity. Such re- sorts of difficulties, information that is relevant for prac- sults are similar to those reported by Kovess et al. tices in the mental health field. (2015), who note that externalizing problems are more Another aspect to be analyzed involves social vulner- visible to teachers than internalizing problems. ability, which was assessed considering different social Analysis of this discrepancy between assessments should and economic factors, among which are low maternal take into account that the interaction of mothers and educational level and income. These are relevant social teachers with children occurs in contexts that exhibit differ- determinants associated with the presence of behavioral ent demands, in addition to the fact that observers are problems among children, according to the assessments guided by different criteria. In the family context, mothers by mothers and/or children, indicating aspects to be have a more detailed picture of their children’sbehavior considered when planning preventive practices. Note Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 9 of 11 that these findings are consistent with those reported by depression, and chronic adversity, characterizes a group Correia et al. (2014), who identified association between that requires greater attention, as it is exposed to multiple child behavioral problems and low socioeconomic status risks. This information highlights the relevance of investi- and low maternal educational level, indicating a potential gating the presence of cumulative risk in the family context profile of cumulative vulnerability favoring behavioral prob- to understand developmental outcomes among children lems among children. Families with low socioeconomic sta- (Evans et al., 2013; Goodman et al., 2011). tus generally have high rates of divorce, unemployment, In regard to the identification of the predictive effect and a larger number of members, while parents with a high of cumulative risk variables and vulnerability, as poten- socioeconomic level have a higher educational level and in- tial predictors of behavioral problems among children, vest more in their children’s education (Carneiro, Meghir, only maternal depression appears as an explanatory vari- &Parey, 2013; Piccolo et al., 2012). able for the presence of behavioral problems among The associations between mental health conditions children in the context of multiple adverse conditions. and vulnerability indicators have been widely recognized These findings are in agreement with Bagner et al. by the World Health Organization (WHO, 2017a, (2010), who stress that living with maternal depression 2017b), which highlights low schooling, lower income, increases a child’s likelihood of presenting externalizing worse material and economic conditions, and less social and internalizing behavioral problems up to the age of support, as possible determinants that negatively influ- 12 years old. Therefore, maternal depression was the ence health mental health of adults and children, favor- only adverse condition with the power to predict the be- ing the accumulation of vulnerability and risk havioral problem outcome, confirming the relevance of conditions. This developmental scenario focuses on the considering such a variable when addressing child be- relevance of the present study, which encompasses di- havior, especially considering the high prevalence of de- verse and competing contextual variables that influence pression among women of childbearing age (World children’s developmental outcomes in the perception of Health Organization [WHO], 2017a, 2017b). different informants. As the positive aspects of this study, we highlight the The presence of current depressive symptoms among presence of multiple informants, the methodological the mothers was associated with behavioral problems care adopted in the systematic assessment of the partici- among the children, as indicated by the mothers and/or pants, and the use of validated instruments, in addition teachers, characterizing problems in two contexts, family to the inclusion of diverse variables to identify, in the and school. Such an association was also verified by Leis same sample, vulnerability indicators that potentially im- et al. (2014) and Conners-Burrow et al. (2016), who pact the behavior of school children. It is highlighted as noted an increase in behavioral problems among chil- the main strength of the study the inclusion of children dren who had early experience with maternal depression. in the groups considering the presence or absence of be- In this sense, when we considered the behavior of chil- havioral problems in the two main development con- dren from the perspectives of mothers and teachers to- texts for the school period, namely, family and school, gether, we verified that, regardless of the informant, thus highlighting relevant variables associated with vul- children living with maternal depression more frequently nerability and to developmental resources in both con- experienced behavioral problems, including in the school texts, which may favor preventive care and target groups context, characterizing the need for specific mental with potential risks. health practices directed to this group, which was identi- This study’s limitations include the sample size, lack of fied as the most vulnerable. a homogeneous distribution between groups in regard to The presence of chronic adversities was also verified the sex of children, and the identification of depressive to identify variables with a potential negative impact on symptoms using a screening instrument, which limit the school-aged children. This study reveals that children fa- generalization of results. Further studies adopting longi- cing behavioral difficulties, according to the combined tudinal designs, considering the influence of contextual assessments of mothers and teachers, lived in family en- risks over the course of a child’s development, including vironments that presented more chronic adversities, in- other sources of information, in addition to the reports dicating cumulative and recurrent adversity in these of mothers, are needed, as well as observational mea- children’s contexts of life. These findings corroborate the sures. The relevance of inclusion in new studies of par- study conducted by Hildebrand et al. (2015), who identi- ents’/stepfathers’ evaluations, as well as studies that fied an association of two or more risk factors for more address the characteristics of the various family configu- than half of the sample under study. rations in which children are inserted as conditions that The identification of differences among groups, especially can influence the behavior of the school-aged children, for children facing problems in the family and school con- is also highlighted. Another relevant point to be consid- texts (G1) in regard to social vulnerability, current maternal ered in new studies is the inclusion of variables that may Martineli et al. Psicologia: Reflexão e Crítica (2018) 31:11 Page 10 of 11 function as protective factors, which in a cumulative way Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in to vulnerability and risk conditions may favor a more published maps and institutional affiliations. complete and complex analysis of the mechanisms that favor or hinder children’s behavioral problems. Received: 20 July 2017 Accepted: 2 March 2018 Conclusions References In this study, low maternal educational level, low family Achenbach, T. M., Becker, A., Döpfner, M., Heiervang, E., Roessner, V., Steinhausen, income, the presence of more chronic adversity, and liv- H.-C., & Rothenberger, A. (2008). Multicultural assessment of child and adolescent psychopathology with ASEBA and SDQ instruments: Research ing with current maternal depression are factors associ- findings, applications, and future directions. 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