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Original Article |

Childhood and Adulthood Psychological Ill Health as Predictors of Midlife Affective and Anxiety Disorders:  The 1958 British Birth Cohort FREE

Charlotte Clark, PhD; Bryan Rodgers, PhD; Tanya Caldwell, PhD; Chris Power, PhD; Stephen Stansfeld, PhD
[+] Author Affiliations

Author Affiliations: Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Queen Mary's School of Medicine and Dentistry, University of London, London, United Kingdom (Drs Clark and Stansfeld); National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia (Drs Rodgers and Caldwell); and Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College Medical School, London, United Kingdom (Dr Power).


Arch Gen Psychiatry. 2007;64(6):668-678. doi:10.1001/archpsyc.64.6.668.
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Context  Affective and anxiety disorders in early adulthood are associated with internalizing and externalizing disorders in childhood. Previous studies have not examined whether the risk associated with childhood psychological ill health persists for midlife psychological health.

Objectives  To examine whether childhood and adulthood psychological health are associated with midlife affective and anxiety disorders and to examine sex differences in these associations.

Design  Data were gathered during a biomedical survey of the 1958 British Birth Cohort, a 45-year longitudinal study of 98% of births in 1 week in 1958.

Setting  General population sample in England, Scotland, and Wales.

Participants  Analyses were based on 9297 participants, 54% of the surviving sample.

Main Outcome Measure  Diagnoses according to the International Statistical Classification of Diseases, 10th Revision (ICD-10) at age 45 years for depressive episode and generalized anxiety disorder.

Results  Internalizing and externalizing disorders at ages 7, 11, and 16 years were associated with a 1.5- to 2-fold increase in risk for midlife anxiety and affective disorder (P<.05), whereas psychological ill health at ages 23, 33, and 42 years was associated with a 2- to 7-fold increase in risk for midlife disorder (P<.05). Early-adulthood associations were significantly stronger for men (P<.05). Type and age at onset of childhood problems did not contribute to variations in the associations with midlife disorder. Risk for midlife disorder increased significantly with the cumulative number of adulthood reports of psychological ill health (P<.001).

Conclusions  Childhood psychological health is an important independent distal factor in adulthood psychological health. Adulthood psychological health shows stronger associations with midlife disorders, indicating a poorer prognosis for adulthood than childhood psychological ill health. Men may be more susceptible than women to the effects of psychological ill health in early adulthood on midlife disorders. Targeting prevention, recognition, and treatment efforts in early adulthood, as well as in childhood and adolescence, may significantly reduce the burden of disease.

For some individuals, psychological disorders begin in early life,1 and there is a broad developmental chronology for the onset of disorder with early childhood being associated with anxiety, middle childhood with externalizing disorders, and adolescence with affective disorders.2 Most individuals with psychological ill health in childhood do not go on to develop ill health in adulthood,25 but for some individuals, psychological ill health recurs or persists into adulthood.

There is increasing evidence that affective and anxiety disorders in early adulthood are associated with both internalizing and externalizing problems in childhood. Homotypic continuity, the same diagnosis at different time points,6 has been demonstrated between internalizing disorders in childhood and early adulthood for both sexes.3,616 Heterotypic continuity, a different diagnosis at different time points,6 has also been demonstrated between externalizing disorders in childhood and affective and anxiety disorders in early adulthood.14,1620 Despite a sex difference in the prevalence of externalizing disorders in childhood, the strength of association between childhood and early adulthood disorders does not differ by sex.4,20

However, age at onset may influence the association between childhood and early adulthood disorder.21 Affective and anxiety disorders in early adulthood are associated with child- and adolescent-onset externalizing disorder14 and adolescent-onset internalizing disorder10,12,17,22 but not with child-onset internalizing disorder.8,11 Whether age at onset in childhood is differentially associated with affective and anxiety disorders in later adulthood remains unknown.

Few studies have examined whether the risk associated with childhood psychological ill health persists into later adulthood, principally because of the lack of prospective data over long periods. Moderate associations between psychological ill health in midlife and internalizing and externalizing problems in childhood have been found,2331 but studies have not examined whether stronger associations exist for homotypic compared with heterotypic disorders. Data are limited on the role of sex, with one study demonstrating an association between externalizing disorder in childhood and adulthood psychological health for men and women26 and another demonstrating an association only for women.27,28

Studies of affective and anxiety disorders in adulthood indicate a high recurrence rate, ranging from 50% to 95%.3235 Given the episodic and, at times, chronic nature of affective disorders in adulthood, midlife disorder is likely to be more strongly associated with psychological ill health in early adulthood than with more distal childhood measures. While previous studies have demonstrated associations between childhood and midlife psychological health, they have not established whether childhood psychological health is independently associated with midlife disorder after taking into account the association between childhood and early adulthood health. Childhood psychological ill health could be an important distal factor in midlife disorder, having an independent direct effect. Early adulthood psychological ill health may also moderate the effect of childhood health on risk for midlife affective and anxiety disorder.

This article examines associations between childhood and early adulthood psychological ill health and diagnoses for affective and anxiety disorder in midlife at age 45 years. Five questions are addressed. Do childhood internalizing disorders show stronger associations with early adulthood psychological ill health and midlife affective and anxiety disorders than childhood externalizing disorders? Does age at onset contribute to variations in the associations between childhood psychological ill health and midlife disorder? Is childhood psychological ill health independently associated with midlife affective and anxiety disorders, after taking into account early adulthood psychological ill health? Does early adulthood psychological ill health moderate the effect of childhood psychological ill health on midlife affective and anxiety disorders? Are there sex differences in these associations? These questions were examined using prospective data from assessments over a 45-year period.

SAMPLE

Data were from the 1958 British Birth Cohort, a study of 98% of births in England, Scotland, and Wales during 1 week in March 1958 (n = 17 416). Information was obtained from parents and schools at ages 7, 11, and 16 years and by participant interviews at ages 7, 11, 16, 23, 33, and 42 years. Analyses are based on 9377 participants who took part in a biomedical survey when aged 45 years (2002-2004)36; the response rate was 78% (invited n = 12 069), representing 54% of the surviving population. Ethical approval for the survey was given by the South East Multi-Centre Research Ethics Committee.

ASSESSMENT
Adulthood Measures of Mental Health

Midlife mental health at age 45 years was assessed using the Revised Clinical Interview Schedule (CIS-R),37 administered by a trained research nurse using computer-assisted personal interviewing as part of a clinical examination in the participant's home. The CIS-R measures affective and anxiety disorders in the past week and enables diagnoses from the International Statistical Classification of Diseases, 10th Revision (ICD-10) for common mental disorders to be derived. The diagnoses examined here are any depressive episode (mild, moderate, severe); generalized anxiety disorder (GAD) only; and any GAD (a diagnosis of GAD or a comorbid diagnosis of GAD and depressive episode, agoraphobia, social phobia, or panic disorder), along with a derived measure comprising any of these diagnoses.

Psychological distress at ages 23, 33, and 42 years was measured using the Malaise Inventory,38 which assesses 24 psychological and somatic symptoms (eg, Do you often feel miserable or depressed? Do you feel tired most of the time?). A score of 7 or higher indicates a high level of distress.39 The validity of the inventory has been demonstrated in this population39: reliability for the scales was high in our sample (age 23 years: Cronbach α = .76, n = 7910; age 33 years: Cronbach α = .79, n = 8150; age 42 years: Cronbach α = .82, n = 8954). A cumulative variable was derived to measure the chronicity of malaise in adulthood (0-3 reports) as, well as a dichotomous variable indicating any malaise in adulthood.

Childhood Measures of Mental Health

Internalizing and externalizing problems at ages 7 and 11 years were measured using the teacher-rated Bristol Social Adjustment Guides, comprising 146 items of behavior assessing 12 separate syndromes.40 Two scales were formed by summing and square-root transforming the syndrome scores for unforthcomingness, withdrawal, depression, and miscellaneous symptoms for internalizing problems and anxiety for acceptance by adults and children, hostility toward adults and children, restlessness, and inconsequential behavior for externalizing problems. Reliable scales were derived for internalizing at age 7 years (Cronbach α = .72, n = 8289), internalizing at age 11 years (Cronbach α = .69, n = 8046), externalizing at age 7 years (Cronbach α = .70, n = 8289), and externalizing at age 11 years (Cronbach α = .73, n = 8047). For each scale, a score in the top 13% defined a case, the lowest 50% were not a case, and the remainder were borderline.41

Internalizing problems and externalizing problems at age 16 years were measured using the teacher version of the Rutter scales.42,43 The scales demonstrate validity, reliability, and sensitivity in large populations.43 Two scales were formed by summing and square-root transforming the items worries, solitary, miserable, fearful, and fussy for internalizing problems (Cronbach α = .66, n = 7225) and destructive, fights, not much liked by other children, irritable, disobedient, lies, steals, resentful/aggressive, and bullies for externalizing problems (Cronbach α = .88, n = 7179). A score in the top 13% defined a case, the lowest 50% were not a case, and the remainder were borderline.41

A cumulative childhood disorder variable was derived from the 6 childhood measures of “caseness” for internalizing and externalizing to determine chronicity of ill health in childhood (0-4 or more reports in childhood). An onset variable was derived, indicating the sweep at which psychological distress was first reported.

Tenure

Housing tenure at age 7 years (owner/occupier, council-rented, or private-rented/other) and at age 45 years (owner/occupier or council-rented/private-rented/other) was used to measure socioeconomic position. The broader classification for childhood reflects the differential social status of council-rented and private-rented in the mid 1960s, which is less well defined today.

SAMPLE ATTRITION

Like most longitudinal studies, the 1958 cohort is affected by loss to follow-up. Follow-up of the original sample in childhood was good with 89% of the original sample participating at age 7 years, 88% at age 11 years, and 84% at age 16 years.36 In adulthood, retention rates fell—largely owing to contact being via home addresses rather than through schools—with 72% participating at age 23 years, 65% at age 33 years, and 66% at age 42 years. Complete CIS-R data were available for 9297 participants at age 45 years; that was 99% of the biomedical sample. To retain 9297 participants in the analyses, the missing data for the predictor variables were included in all analyses: eg, childhood variables were categorized as not a case, borderline, case, or missing data.

At age 45 years, nonparticipation was significantly predicted by internalizing or externalizing problems at age 7, 11, or 16 years and adulthood malaise (at age 23, 33, or 42 years), being male, and having rented tenure at age 7 or 33 years. To take account of sample attrition, we derived inverse probability weights4450 from a logistic regression predicting having complete CIS-R data, adjusting for the preceding variables and all significant interactions. Extreme weights were capped at the value of 4, resulting in 284 participants being given the maximum weight: capping at values up to 10 did not alter the results. All analyses in this article examining the CIS-R outcomes used this weight. Three further weights were derived for analysis of malaise at ages 23, 33, and 42 years as outcomes. The same regression model was used to predict participation at age 45 years, but predictors from the same or subsequent sweeps to the outcome were dropped from the model (eg, in analyses predicting malaise at age 33 years, variables measured at ages 33 and 42 years were dropped from the model).

STATISTICAL ANALYSIS

Initial trends of the prevalence of psychological ill health across the life course and sex were examined using univariate logistic regression analysis. A series of multivariate logistic regression analyses were conducted to examine associations between the individual childhood and adulthood measures of psychological health and the midlife affective and anxiety disorder diagnoses. Analyses were adjusted for household tenure at age 7 years for childhood or at age 45 years for adulthood models; tenure was significantly related to all the childhood and adulthood mental health measures. Interactions between each predictor and sex were included to test differences in the associations; analyses were stratified by sex if the interaction term was significant (P<.05) and adjusted for sex if not. Post hoc Wald tests were used to test whether risk for midlife diagnoses increased cumulatively with the number of childhood or adulthood problems reported. Data were analyzed using Stata version 8 (StataCorp, College Station, Tex).

CHILDHOOD AND ADULTHOOD HISTORY OF PSYCHOLOGICAL HEALTH

Of the 9297 participants, 50% were female, 78% were homeowners, 84% were employed, and 71% were married/remarried. Table 1 shows that in childhood, 41% of the sample had a report of internalizing or externalizing problems at least once: men were significantly more likely to have externalizing problems at age 7, 11, or 16 years and internalizing problems at age 7 or 11 years than women. At age 45 years, 6.5% of the sample had a diagnosis for affective or anxiety disorder. The most prevalent diagnosis was any GAD, and women had a significantly higher prevalence and risk for all of the diagnoses with the exception of GAD only. Just under half of the sample had no history of psychological ill health by age 45 years; this did not differ for men and women. Few respondents had a first report of psychological ill health at age 33 years or older (8.4%), indicating that childhood and early adulthood onset was most frequent with 41% of the sample having a report of psychological ill health by age 16 years, 45% by age 23 years, and 47% by age 33 years. Childhood onset was significantly higher for men than women at ages 7 and 11 years but not at age 16 years. Adulthood onset was significantly higher for women at ages 23, 33, and 42 years but not at age 45 years.

Table Graphic Jump LocationTable 1. Prevalence, Odds Ratios, and 95% Confidence Intervals for Sex Differences in Childhood and Adulthood Psychological Health Measures and Onset of Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003
ASSOCIATIONS BETWEEN CHILDHOOD AND ADULTHOOD PSYCHOLOGICAL HEALTH

Most respondents with psychological ill health in childhood or adulthood did not have a psychiatric diagnosis at age 45 years (Table 1 and Table 2): only 8% (295/3652) with childhood ill health and 17% (337/2025) with adulthood ill health had a psychiatric diagnosis at age 45 years. However, compared with respondents with no diagnosis at age 45 years, a greater proportion of respondents with a diagnosis had earlier diagnoses for all of the childhood and adulthood measures: 56% experienced ill health in childhood and 56% in adulthood.

Table Graphic Jump LocationTable 2. Prevalence, Odds Ratios, and 95% Confidence Intervals for Psychological Ill Health Across the Life Course by CIS-R Diagnosis: the 1958 British Birth Cohort Biomedical Survey, 2002-2003

Table 3 indicates that internalizing and externalizing problems at ages 7, 11, and 16 years were associated with 1.5 to 2 times the risk for adulthood psychological ill health; the strength of the association did not differ for early adulthood (age 23 years) compared with later adulthood (ages 33 and 42 years). Borderline reports of internalizing and externalizing problems were significantly associated with a 1.3- to 1.5-fold increase in risk for adulthood ill health. There were sex differences in the associations: internalizing problems at age 7 years and borderline internalizing problems at ages 7 and 11 years showed stronger associations with psychological ill health at age 23 years for women than men. No sex differences were observed between externalizing at ages 7, 11, and 16 years or internalizing at age 16 years and adulthood psychological health. Finally, having 1, 2, or 3 or more problems in childhood was associated with increased risk of adulthood ill health compared with having no childhood problems; however, post hoc Wald tests indicated that the risk for distress did not increase significantly with each increase in the number of childhood problems with the exception of malaise at age 23 years for women.

Table Graphic Jump LocationTable 3. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of Malaise in Adulthood for Childhood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey*

Table 4 indicates that childhood psychological ill health was independently associated with midlife affective and anxiety disorders after taking into account early adulthood psychological ill health. After adjustment for malaise at age 23 years (model B), internalizing problems at ages 7, 11, and 16 years were associated with 1.5 to 2 times the risk for depressive episode, any GAD, only GAD, and any diagnosis at age 45 years. Externalizing problems at ages 7, 11, and 16 years were associated with 1.5 times the risk for any GAD: a similar association was observed between externalizing at ages 11 and 16 years and only GAD. Risk for any diagnosis was significantly greater for individuals reporting internalizing problems at age 16 years and malaise at 23 years (odds ratio, 2.21, 95% confidence interval, 1.05-4.65, P<.05): no other interactions between childhood problems and malaise at age 23 years were observed. No significant sex differences were observed.

Table Graphic Jump LocationTable 4. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of CIS-R Diagnoses in Midlife for Childhood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003

Early-onset disorder was not indicative of greater risk for midlife affective disorder. Internalizing and externalizing problems at age 7 years were not differentially associated with midlife affective and anxiety disorder in comparison with the measures at ages 11 years and 16 years. One exception was that externalizing problems at ages 11 and 16 years were associated with only GAD while externalizing at age 7 years was not. The number of childhood problems reported was associated with increased risk for the midlife diagnoses, but risk did not increase significantly with each increase in the number of childhood problems reported.

ASSOCIATIONS BETWEEN ADULTHOOD MEASURES OF PSYCHOLOGICAL HEALTH

Table 5 indicates that adulthood psychological ill health at ages 23, 33, and 42 years was associated with a 2- to 7-fold increase in risk for midlife affective and anxiety disorder with stronger relationships being observed for the more proximal measures. These associations were only moderately attenuated by adjusting for childhood disorder, suggesting stronger associations for adulthood psychological ill health than for childhood psychological ill health. Associations between malaise at age 23 years and any GAD, only GAD, and any diagnosis were significantly stronger for men than women; malaise at age 23 years was associated with a 5- to 6-fold increase in risk for midlife disorder for men compared with a 2- to 3-fold increase for women.

Table Graphic Jump LocationTable 5. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of CIS-R Diagnoses in Midlife for Adulthood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003

Risk for all diagnoses increased significantly with each increase in the number of adulthood reports of psychological ill health (P<.001): having 2 or more reports of adulthood psychological ill health was associated with an 8- to 9-fold increase in risk for disorder. For any diagnosis, risk was significantly higher for men than women, although both men and women were greatly affected by experiencing malaise 2 or more times in adulthood.

This study used prospective data over a 45-year period to examine the associations between childhood and early adulthood psychological ill health and affective and anxiety disorders in midlife. As expected, the majority of individuals who had psychological ill health in childhood or early adulthood did not have a diagnosis at age 45 years, which confirms previous studies.25 However, psychological ill health across the life course was associated with an increased risk of disorder at age 45 years.

ATTRITION

One considerable limitation for longitudinal studies is attrition, and it is likely that the most severely psychologically distressed cohort members have been lost from the study along with those with lower social position, who are more likely to suffer poor psychological health.51 Loss to follow-up may mean that the associations between psychological health demonstrated in this study are weaker than those that would be observed in the general population. The analyses presented have been weighted by measures of psychological health and social disadvantage across the life course, which should partially compensate for the attrition; however, the associations may still be conservative and should be thought of as indicative rather than definitive. In addition, the associations may be specific to this cohort.

INFLUENCE OF CHILDHOOD VS ADULTHOOD PSYCHOLOGICAL ILL HEALTH ON MIDLIFE DISORDERS

Childhood psychological ill health was associated with 1.5 to 2 times the risk of poor psychological health in early adulthood and midlife. The independent association of childhood psychological ill health with midlife affective and anxiety disorder, after adjustment for early adulthood psychological health, suggests a direct role for childhood problems in the etiology of midlife disorders. Stronger associations were observed between adulthood psychological ill health and midlife affective and anxiety disorders with ill health being associated with a 2- to 7-fold increase in risk for midlife disorder: as expected, stronger associations were observed for the more proximal measures at ages 33 and 42 years.

Our study is one of only a few that have been able to examine prospectively whether the risk associated with psychological ill health in childhood persists into midlife. This study confirmed that early adulthood psychological health was associated with both internalizing and externalizing disorders in childhood6,14,17,18 and extends knowledge by demonstrating that associations of a similar magnitude are observed for psychological ill health in later adulthood. The independent association of childhood problems with midlife disorders supports previous studies that have demonstrated associations between externalizing disorders in adolescence and midlife psychological health.26,27,30 We found no sex difference in these associations, failing to replicate analyses of the 1946 British Birth Cohort, which found associations only for women.27,30 The current study has a larger sample and therefore greater power to detect associations, but the variation could reflect genuine differences between the cohorts.

Early adulthood psychological ill health did not moderate the effect of childhood ill health on risk for midlife disorder: experiencing psychological ill health in both childhood and early adulthood did not increase risk for midlife disorder. One exception was that risk for any disorder at age 45 years was significantly greater for individuals reporting both internalizing problems at age 16 years and malaise at age 23 years. These results suggest that persistent internalizing problems in late adolescence and early adulthood are important in the etiology of midlife affective and anxiety disorder and that internalizing problems at age 16 years have a direct effect on midlife disorder, as well as an additional effect moderated by early adulthood psychological ill health. This may reflect the start of a recurrent cycle of internalizing problems for those with life-course susceptibility for affective disorders or the subsequent consequences of poor psychological ill health on education and employment chances in early adulthood.

The difference in magnitude of associations between childhood and adulthood psychological ill health may partly reflect the temporal distance between the measures; however, it may also be indicative of the greater impact of psychological ill health in adulthood on risk for midlife disorder. This may reflect a poorer prognosis for psychological ill health in adulthood whereby disorders may be more likely to persist and recur, causing greater impairment and accumulation of negative consequences, which in turn may increase the risk of later adverse outcomes. There may also be a greater impact of individual, family, social, and environmental factors on continuities in psychological health in adulthood and greater continuity of adversity across adulthood. Psychological ill health in childhood may partly reflect a transient developmental stage rather than life-course susceptibility for psychological ill health. Alternatively, the transition from childhood to adulthood may allow for an escape from chronic stressors that is less possible within adult life.

CONTINUITY AND SPECIFICITY OF DISORDERS

Overall, internalizing problems in childhood did not show stronger associations than externalizing problems with early adulthood psychological ill health or midlife affective and anxiety disorders. There was homotypic continuity between internalizing disorders in childhood and midlife affective and anxiety disorders, which corroborates previous demonstrations of continuity between internalizing disorders in childhood and early adulthood.6,8,1215 This could reflect genetic susceptibility for these disorders, as well as continuity in environmental influences. There was heterotypic continuity between externalizing disorders and midlife anxiety disorders. Externalizing disorders, conduct disorder in particular, have been found to have a strong association with affective and anxiety disorders in early adulthood.14,17,19 Previous studies have only examined the associations in early adulthood; externalizing in childhood may differentially relate to depressive disorders across the life course while associations with anxiety and antisocial behavior may be more consistent.

ONSET, RECURRENCE, AND CHRONICITY

Onset of psychological ill health was not evenly distributed across the life course and occurred in childhood and early adulthood. This suggests that priorities for prevention and recognition should be targeted not only in childhood but into early adulthood as well. Sex differences in onset suggest that there may be sex-specific pathways for the development of psychological ill health. The higher childhood rates for men may reflect a greater susceptibility to influences on psychological health such as low socioeconomic position.52 While adulthood onset may be partly determined by the persistence of childhood problems,12,53 it is also strongly influenced by life events and chronic stressors to which women may be more exposed in adulthood. Women are more vulnerable to the effects of life events on mental health,28 which may reflect sex differences in social roles that enable men to distance themselves from life events54 and differences in hormonal exposures and susceptibility to stress.55

Age at onset of disorder does not contribute to variations in associations between childhood psychological health and midlife disorder: the strength of the associations for measures at ages 7, 11, and 16 years were similar. These findings contradict those of previous studies, suggesting that early-adulthood affective and anxiety disorders are associated with adolescent-onset but not child-onset internalizing problems.8,10,17,22 It is possible that by midlife, age at onset becomes less influential: poor psychological ill health is predominantly recurrent and it becomes less important whether the first incidence was in childhood or early adulthood. However, some caution is needed in interpreting our results as while at age 7 years we have incidence data reflecting early onset problems, the measures used at ages 11 and 16 years report prevalence and do not take into account previous psychological ill health. This limitation could account for our findings.

There was a dose-response relationship between cumulative psychological ill health in adulthood and risk for midlife diagnosis, which was not observed for childhood psychological ill health. Experiencing psychological distress 2 or 3 times in adulthood was associated with an 8- to 9-fold increase in risk for these disorders in midlife, indicating the powerful effect that recurring, chronic psychological ill health has on risk for affective and anxiety disorders in midlife. These findings confirm a poorer prognosis for individuals with recurrent psychological ill health problems in adulthood.12,33

SEX DIFFERENCES IN PSYCHOLOGICAL HEALTH ACROSS THE LIFE COURSE

Evidence for sex associations between internalizing and externalizing disorders in childhood and adulthood psychological health is equivocal.17,18,20,28,30,56,57 The current study, the largest to date, found no sex differences between childhood psychological health and the midlife diagnoses. However, internalizing problems at age 7 years showed stronger associations with poor psychological health at age 23 years for women than men, suggesting that women may be more susceptible to the effects of early-onset internalizing problems in early adulthood than men. In contrast, men may be more susceptible to the effects of poor psychological health in early adulthood as significantly stronger associations were observed between malaise at age 23 years and the midlife diagnoses for men. This increased risk may reflect the consequences of poor psychological health in early adulthood, such as unemployment, reduced educational opportunities, and poorer personal relationships, which may have a greater impact on subsequent mental health for men than women58: reduced life chances associated with psychological ill health in early adulthood may place men on a pathway for persistent or recurrent psychological ill health. This finding has important clinical implications as men, who are more vulnerable to poor psychological health in early adulthood, are less likely to seek treatment for psychological disorders than women.59,60 Interventions targeting treatment for this group could reduce burden of disease both in early and later adulthood. Interestingly, there were no sex differences in the associations of psychological ill health at ages 33 and 42 years with midlife disorder, suggesting that early adulthood may be a critical period for psychological health for men. To our knowledge, this is the first study to illustrate a greater effect of poor psychological health in early adulthood on midlife psychological health for men.

STRENGTHS AND LIMITATIONS

Prospective studies of this nature offer the best opportunity to understand the links between psychological health outcomes across the life course. This study is one of only a few that are able to examine associations from childhood to midlife, and it is the first to examine psychiatric diagnoses in midlife. As well as attrition, further limitations of the study include an increased risk of type I errors as many nonindependent analyses have been conducted; a lack of data about the recurrence, persistence, and chronicity of psychological ill health; and a lack of information about psychological health problems that emerge between assessments and the consequent incomplete data about the onset of psychological health problems. Both of these latter factors could influence the strength of the associations between psychological health across the life course.

A final limitation is the comparability of assessments of psychological health across the life course. Psychological symptoms were measured using different scales in childhood and adulthood, and different measures of internalizing and externalizing problems were available at ages 7 and 11 years compared with age 16 years. Differences in the associations for childhood and adulthood ill health could be because of measurement variance between developmental periods. The stronger associations for adulthood psychological health could reflect the greater number of items measured in adulthood compared with the childhood measures. Associations between symptoms and later diagnoses may also differ from those between diagnoses across the life course. Furthermore, the study underestimates life-course psychological ill health as no measures of externalizing behavior in midlife were available: this may be particularly significant for men. While the 1958 British Birth cohort gives a unique opportunity to explore psychological health from early childhood to midlife, the findings need to be replicated by other prospective studies.

In conclusion, childhood psychological health is an important independent distal factor for midlife affective and anxiety disorder. Adulthood psychological health shows stronger associations with midlife disorders, indicating a poorer prognosis for adulthood than childhood psychological ill health. Men may be more susceptible to the effects of psychological ill health in early adulthood on midlife disorders than women. Age at onset and type of childhood problems do not contribute to variations in associations between childhood and midlife affective and anxiety disorder. The findings suggest that along with targeting primary prevention efforts in childhood and adolescence,12 targeting prevention, recognition, and treatment efforts in early adulthood, particularly for men, may also significantly reduce the subsequent burden of disease.

Correspondence: Charlotte Clark, PhD, Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Queen Mary's School of Medicine and Dentistry, University of London, Charterhouse Square, London EC1M 6BQ, United Kingdom (c.clark@qmul.ac.uk).

Submitted for Publication: March 10, 2006; final revision received October 11, 2006; accepted October 12, 2006.

Financial Disclosure: None reported.

Funding/Support: Dr Clark receives support from an Engineering and Physical Sciences Research Council Fellowship. Research at the Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust benefits from research and development funding received from the NHS Executive. Drs Caldwell and Rodgers receive support from a National Health and Medical Research Council (NHMRC) program grant, and Dr Rodgers receives support from a NHMRC research fellowship. The survey and statistical analysis were funded by grant G0000934 under the Health of the Public initiative of the Medical Research Council.

Acknowledgment: We are grateful to the study participants in the 2002-2004 biomedical follow-up and to the Medical Research Council. We also thank Glyn Lewis for his advice about the scoring of the Revised Clinical Interview Schedule, Barbara Maughan and Stephan Collishaw for advice about scoring the childhood measures, Ian White for advice about weighting the data, and Verity Morgan for helping prepare the manuscript.

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PubMed Link to Article
Fergusson  DMWoodward  LJ Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry 2002;59225- 231
PubMed Link to Article
Kim-Cohen  JCaspi  AMoffitt  TEHarrington  HMilne  BJPoulton  R Prior juvenile diagnoses in adults with mental disorder. Arch Gen Psychiatry 2003;60709- 717
PubMed Link to Article
Reinhertz  HZParadis  ADGiaconia  RMStashwick  CFitzmaurice  G Childhood and adolescent predictors of major depression in the transition to adulthood. Am J Psychiatry 2003;1602141- 2147
PubMed Link to Article
Roza  SJHofstra  MBvan der Ende  JVerhulst  FC Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14 year follow-up during childhood, adolescence and young adulthood. Am J Psychiatry 2003;1602116- 2121
PubMed Link to Article
Pine  DSCohen  PGurley  DBrook  JMa  Y The risk for early adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998;5556- 64
PubMed Link to Article
Hofstra  MBvan der Ende  JVerhulst  FC Child and adolescent problems predict DSM-IV disorders in adulthood: a 14 year follow-up of a Dutch epidemiological sample. J Am Acad Child Adolesc Psychiatry 2002;41182- 189
PubMed Link to Article
Mason  WAKosterman  RHawkins  DHerrenkohl  TILengua  LJMcCauley  E Predicting depression, social phobia and violence in early adulthood from childhood behavior problems. J Am Acad Child Adolesc Psychiatry 2004;43307- 315
PubMed Link to Article
Fergusson  DMHorwood  LJRidder  EM Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. J Child Psychol Psychiatry 2005;46837- 849
PubMed Link to Article
Rutter  MKim-Cohen  JMaughan  B Continuities and discontinuities in psychopathology between childhood and adult life. J Child Psychol Psychiatry 2006;47276- 295
PubMed Link to Article
Rao  URyan  NBirmaher  BDahl  RWilliamson  DEKaufman  JRao  RNelson  B Unipolar depression in adolescents: clinical outcome in adulthood. J Am Acad Child Adolesc Psychiatry 1995;34566- 578
PubMed Link to Article
Robins  LN Deviant Children Grown Up: A Sociological and Psychiatric Study of Sociopathic Personality.  Baltimore, Md Williams & Wilkins1966;
Robins  LN Sturdy childhood predictors of adult antisocial behaviour: replications from longitudinal studies. Psychol Med 1978;8611- 622
PubMed Link to Article
Vaillant  GESchnurr  P What is a case? Arch Gen Psychiatry 1988;45313- 319
PubMed Link to Article
Robins  LNPrice  RK Adult disorders predicted by childhood conduct problems: results from the NIHM epidemiologic catchment area project. Psychiatry 1991;54116- 132
PubMed
Rodgers  B Models of stress, vulnerability and affective disorder. J Affect Disord 1991;211- 13
PubMed Link to Article
van Os  JJones  PLewis  GWadsworth  MMurray  R Developmental precursors of affective illness in a general population birth cohort. Arch Gen Psychiatry 1997;54625- 631
PubMed Link to Article
Van Os  JJones  PB Early risk factors and adult person-environment relationships in affective disorder. Psychol Med 1999;291055- 1067
PubMed Link to Article
Kuh  DHardy  RRodgers  BWadsworth  M Lifetime risk factors for women's psychological distress in midlife. Soc Sci Med 2002;551957- 1973
PubMed Link to Article
Merikangas  KRZhang  HAvenevoli  SAcharyya  SNeuenschwander  MAngst  J Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003;60993- 1000
PubMed
Murphy  JMOlivier  DCSobol  AMMonson  RRLeighton  AH Diagnosis and outcome: depression and anxiety in a general population. Psychol Med 1986;16117- 126
PubMed Link to Article
Mueller  TILeon  ACKeller  MBSolomon  DAEndicott  JCoryell  WWarshaw  MMaser  JD Recurrence and recovery from major depressive disorder during 15 years of observational follow-up. Am J Psychiatry 1999;1561000- 1006
PubMed
Paykel  ESHayhurst  HAbbott  RWadsworth  M Stability and change in milder psychiatric disorder over 7 years in a birth cohort. Psychol Med 2001;311373- 1384
PubMed
Kennedy  NAbbot  RPaykel  ES Remission and recurrence of depression in the maintenance era: long-term outcome in a Cambridge cohort. Psychol Med 2003;33827- 838
PubMed Link to Article
Power  CElliot  J Cohort profile: 1958 British birth cohort (National Child Development Study). Int J Epidemiol 2006;3534- 41
PubMed Link to Article
Lewis  GPelosi  AJAraya  RDunn  G Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychol Med 1992;22465- 486
PubMed Link to Article
Rutter  ML Psycho-social disorders in childhood, and their outcome in adult life. J R Coll Physicians Lond 1970;4211- 218
PubMed
Rodgers  BPickles  APower  CCollishaw  SMaughan  B Validity of the Malaise Inventory in general population samples. Soc Psychiatry Psychiatr Epidemiol 1999;34333- 341
PubMed Link to Article
Stott  DH The Social Adjustment of Children. 3rd ed London, England University of London Press1969;
Ghodsian  M Measuring behaviour in the school and home. Fogelman  KedGrowing Up in Britain. London, England The Macmillan Press Ltd1983;329- 338
Rutter  M A children's behaviour questionnaire for completion by teachers. J Child Psychol Psychiatry 1967;81- 11
PubMed Link to Article
Elander  JRutter  M Use and development of the Rutter parents' and teachers' scales. Int J Methods Psychr Res 1996;663- 78
Link to Article
Bethlehem  JG Weighting nonresponse adjustments based on auxiliary information. Groves  RMDillman  DAEltinge  JLLittle  RJAedsSurvey Nonresponse. New York, NY John Wiley & Sons Inc2002;275- 288
Robins  JMRotnitzky  AZhao  LP Analysis of semiparametric regression models for repeated outcomes in the presence of missing data. J Am Stat Assoc 1995;90106- 129
Link to Article
Robins  JMRotnitzky  A Semiparametric efficiency in multivariate regression models with missing data. J Am Stat Assoc 1995;90122- 129
Link to Article
Hogan  JWRoy  JKorkontzelou  C Handling drop-out in longitudinal studies. Stat Med 2004;231455- 1497
PubMed Link to Article
Jones  AMKoolman  XRice  N Health related non-response in the British Household Panel Survey and European Community Household Panel: using inverse-probability-weighted estimators in non-linear models. J R Stat Soc Ser A Stat Soc 2006;169543- 569
Link to Article
Alati  RMamun  AAWilliam  GMO’Callaghan  MNajman  JMBor  W In utero alcohol exposure and prediction of alcohol disorders in early adulthood: a birth cohort study. Arch Gen Psychiatry 2006;631009- 1016
PubMed Link to Article
Maughan  BTaylor  A Adolescent psychological problems, partnership transitions and adult mental health: an investigation of selection effects. Psychol Med 2001;31291- 305
PubMed Link to Article
Hawkes  DPlewis  I Modelling non-response in the National Child Development Study. J R Stat Soc Ser A Stat Soc 2006;169479- 491
Link to Article
Lorant  VDeliege  DEaton  WRobert  APhilippot  PAnsseau  M Socioeconomic inequalities in depression: a meta analysis. Am J Epidemiol 2003;15798- 112
PubMed Link to Article
Moffitt  TECaspi  AHarrington  HMilne  BJ Males on the life-course-persistent and adolescence-limited antisocial pathways: follow-up at age 26 years. Dev Psychopathol 2002;14179- 207
PubMed Link to Article
Nazroo  JYEdwards  ACBrown  GW Gender differences in the onset of depression following a shared life event: a study of couples. Psychol Med 1997;279- 19
PubMed Link to Article
Bebbington  PE Sex and depression. Psychol Med 1998;281- 8
PubMed Link to Article
Robins  LN The consequences of conduct disorder in girls. Olweus  DBlock  JRadke-Yarrow  MedsDevelopment of Antisocial and Prosocial Behavior: Research, Theories and Issues. Orlando, Fla Academic Press1986;385- 414
Rodgers  B Behaviour and personality in childhood as predictors of adult psychiatric disorder. J Child Psychol Psychiatry 1990;31393- 414
PubMed Link to Article
Power  CStansfeld  SAMatthews  SManor  OHope  S Childhood and adulthood risk factors for socio-economic differentials in psychological distress: evidence from the 1958 British birth cohort. Soc Sci Med 2002;551989- 2004
PubMed Link to Article
Wang  PSBerglund  POlfson  MPincus  HAWells  KBKessler  RC Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62603- 613
PubMed Link to Article
Jorm  AFKelly  CMWright  AParslow  RAHarris  MGMcGorry  PD Belief in dealing with depression alone: results from community surveys of adolescents and adults. J Affect Disord 2006;9659- 65
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Prevalence, Odds Ratios, and 95% Confidence Intervals for Sex Differences in Childhood and Adulthood Psychological Health Measures and Onset of Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003
Table Graphic Jump LocationTable 2. Prevalence, Odds Ratios, and 95% Confidence Intervals for Psychological Ill Health Across the Life Course by CIS-R Diagnosis: the 1958 British Birth Cohort Biomedical Survey, 2002-2003
Table Graphic Jump LocationTable 3. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of Malaise in Adulthood for Childhood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey*
Table Graphic Jump LocationTable 4. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of CIS-R Diagnoses in Midlife for Childhood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003
Table Graphic Jump LocationTable 5. Adjusted Odd Ratios and 95% Confidence Intervals of the Occurrence of CIS-R Diagnoses in Midlife for Adulthood Psychological Ill Health: the 1958 British Birth Cohort Biomedical Survey, 2002-2003

References

Insel  TRFenton  WS Psychiatric epidemiology: it's not just about counting anymore. Arch Gen Psychiatry 2005;62590- 592
PubMed Link to Article
Kovacs  MDevlin  B Internalizing disorders in childhood. J Child Psychol Psychiatry 1998;3947- 63
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Ferdinand  RFVerhulst  FC Psychopathology from adolescence into young adulthood: an 8-year follow-up study. Am J Psychiatry 1995;1521586- 1594
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Maughan  BRutter  M Antisocial children grown up. Hill  JMaughan  Beds Conduct Disorders in Childhood and Adolescence.  Cambridge, England Cambridge University Press2001;507- 552
Wals  MVerhulst  F Child and adolescent antecedents of mood disorders. Curr Opin Psychiatry 2005;1815- 19
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Costello  EJMustillo  SErkanli  AKeeler  GAngold  A Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60837- 844
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Kandel  DBDavies  M Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry 1986;43255- 262
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Harrington  RFudge  HRutter  MPickles  AHill  J Adult outcomes of childhood and adolescent depression. Arch Gen Psychiatry 1990;47465- 473
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Verhulst  FCvan der Ende  J Six year developmental course of internalizing and externalizing problem behaviors. J Am Acad Child Adolesc Psychiatry 1992;31924- 931
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Bardone  AMMoffitt  TECaspi  ADickson  NStanton  WRSilva  PA Adult physical health outcomes of adolescent girls with conduct disorder, depression and anxiety. J Am Acad Child Adolesc Psychiatry 1998;37594- 601
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Weissman  MMWolk  SWickramaratne  PGoldstein  RBAdams  PGreenwald  SRyan  NDDahl  RESteinberg  D Children with prepubertal-onset major depressive disorder and anxiety grown up. Arch Gen Psychiatry 1999;56794- 801
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Lewinsohn  PMRohde  PSeely  JRKlein  DNGotlib  IH Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. Am J Psychiatry 2000;1571584- 1591
PubMed Link to Article
Fergusson  DMWoodward  LJ Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry 2002;59225- 231
PubMed Link to Article
Kim-Cohen  JCaspi  AMoffitt  TEHarrington  HMilne  BJPoulton  R Prior juvenile diagnoses in adults with mental disorder. Arch Gen Psychiatry 2003;60709- 717
PubMed Link to Article
Reinhertz  HZParadis  ADGiaconia  RMStashwick  CFitzmaurice  G Childhood and adolescent predictors of major depression in the transition to adulthood. Am J Psychiatry 2003;1602141- 2147
PubMed Link to Article
Roza  SJHofstra  MBvan der Ende  JVerhulst  FC Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14 year follow-up during childhood, adolescence and young adulthood. Am J Psychiatry 2003;1602116- 2121
PubMed Link to Article
Pine  DSCohen  PGurley  DBrook  JMa  Y The risk for early adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998;5556- 64
PubMed Link to Article
Hofstra  MBvan der Ende  JVerhulst  FC Child and adolescent problems predict DSM-IV disorders in adulthood: a 14 year follow-up of a Dutch epidemiological sample. J Am Acad Child Adolesc Psychiatry 2002;41182- 189
PubMed Link to Article
Mason  WAKosterman  RHawkins  DHerrenkohl  TILengua  LJMcCauley  E Predicting depression, social phobia and violence in early adulthood from childhood behavior problems. J Am Acad Child Adolesc Psychiatry 2004;43307- 315
PubMed Link to Article
Fergusson  DMHorwood  LJRidder  EM Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. J Child Psychol Psychiatry 2005;46837- 849
PubMed Link to Article
Rutter  MKim-Cohen  JMaughan  B Continuities and discontinuities in psychopathology between childhood and adult life. J Child Psychol Psychiatry 2006;47276- 295
PubMed Link to Article
Rao  URyan  NBirmaher  BDahl  RWilliamson  DEKaufman  JRao  RNelson  B Unipolar depression in adolescents: clinical outcome in adulthood. J Am Acad Child Adolesc Psychiatry 1995;34566- 578
PubMed Link to Article
Robins  LN Deviant Children Grown Up: A Sociological and Psychiatric Study of Sociopathic Personality.  Baltimore, Md Williams & Wilkins1966;
Robins  LN Sturdy childhood predictors of adult antisocial behaviour: replications from longitudinal studies. Psychol Med 1978;8611- 622
PubMed Link to Article
Vaillant  GESchnurr  P What is a case? Arch Gen Psychiatry 1988;45313- 319
PubMed Link to Article
Robins  LNPrice  RK Adult disorders predicted by childhood conduct problems: results from the NIHM epidemiologic catchment area project. Psychiatry 1991;54116- 132
PubMed
Rodgers  B Models of stress, vulnerability and affective disorder. J Affect Disord 1991;211- 13
PubMed Link to Article
van Os  JJones  PLewis  GWadsworth  MMurray  R Developmental precursors of affective illness in a general population birth cohort. Arch Gen Psychiatry 1997;54625- 631
PubMed Link to Article
Van Os  JJones  PB Early risk factors and adult person-environment relationships in affective disorder. Psychol Med 1999;291055- 1067
PubMed Link to Article
Kuh  DHardy  RRodgers  BWadsworth  M Lifetime risk factors for women's psychological distress in midlife. Soc Sci Med 2002;551957- 1973
PubMed Link to Article
Merikangas  KRZhang  HAvenevoli  SAcharyya  SNeuenschwander  MAngst  J Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003;60993- 1000
PubMed
Murphy  JMOlivier  DCSobol  AMMonson  RRLeighton  AH Diagnosis and outcome: depression and anxiety in a general population. Psychol Med 1986;16117- 126
PubMed Link to Article
Mueller  TILeon  ACKeller  MBSolomon  DAEndicott  JCoryell  WWarshaw  MMaser  JD Recurrence and recovery from major depressive disorder during 15 years of observational follow-up. Am J Psychiatry 1999;1561000- 1006
PubMed
Paykel  ESHayhurst  HAbbott  RWadsworth  M Stability and change in milder psychiatric disorder over 7 years in a birth cohort. Psychol Med 2001;311373- 1384
PubMed
Kennedy  NAbbot  RPaykel  ES Remission and recurrence of depression in the maintenance era: long-term outcome in a Cambridge cohort. Psychol Med 2003;33827- 838
PubMed Link to Article
Power  CElliot  J Cohort profile: 1958 British birth cohort (National Child Development Study). Int J Epidemiol 2006;3534- 41
PubMed Link to Article
Lewis  GPelosi  AJAraya  RDunn  G Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychol Med 1992;22465- 486
PubMed Link to Article
Rutter  ML Psycho-social disorders in childhood, and their outcome in adult life. J R Coll Physicians Lond 1970;4211- 218
PubMed
Rodgers  BPickles  APower  CCollishaw  SMaughan  B Validity of the Malaise Inventory in general population samples. Soc Psychiatry Psychiatr Epidemiol 1999;34333- 341
PubMed Link to Article
Stott  DH The Social Adjustment of Children. 3rd ed London, England University of London Press1969;
Ghodsian  M Measuring behaviour in the school and home. Fogelman  KedGrowing Up in Britain. London, England The Macmillan Press Ltd1983;329- 338
Rutter  M A children's behaviour questionnaire for completion by teachers. J Child Psychol Psychiatry 1967;81- 11
PubMed Link to Article
Elander  JRutter  M Use and development of the Rutter parents' and teachers' scales. Int J Methods Psychr Res 1996;663- 78
Link to Article
Bethlehem  JG Weighting nonresponse adjustments based on auxiliary information. Groves  RMDillman  DAEltinge  JLLittle  RJAedsSurvey Nonresponse. New York, NY John Wiley & Sons Inc2002;275- 288
Robins  JMRotnitzky  AZhao  LP Analysis of semiparametric regression models for repeated outcomes in the presence of missing data. J Am Stat Assoc 1995;90106- 129
Link to Article
Robins  JMRotnitzky  A Semiparametric efficiency in multivariate regression models with missing data. J Am Stat Assoc 1995;90122- 129
Link to Article
Hogan  JWRoy  JKorkontzelou  C Handling drop-out in longitudinal studies. Stat Med 2004;231455- 1497
PubMed Link to Article
Jones  AMKoolman  XRice  N Health related non-response in the British Household Panel Survey and European Community Household Panel: using inverse-probability-weighted estimators in non-linear models. J R Stat Soc Ser A Stat Soc 2006;169543- 569
Link to Article
Alati  RMamun  AAWilliam  GMO’Callaghan  MNajman  JMBor  W In utero alcohol exposure and prediction of alcohol disorders in early adulthood: a birth cohort study. Arch Gen Psychiatry 2006;631009- 1016
PubMed Link to Article
Maughan  BTaylor  A Adolescent psychological problems, partnership transitions and adult mental health: an investigation of selection effects. Psychol Med 2001;31291- 305
PubMed Link to Article
Hawkes  DPlewis  I Modelling non-response in the National Child Development Study. J R Stat Soc Ser A Stat Soc 2006;169479- 491
Link to Article
Lorant  VDeliege  DEaton  WRobert  APhilippot  PAnsseau  M Socioeconomic inequalities in depression: a meta analysis. Am J Epidemiol 2003;15798- 112
PubMed Link to Article
Moffitt  TECaspi  AHarrington  HMilne  BJ Males on the life-course-persistent and adolescence-limited antisocial pathways: follow-up at age 26 years. Dev Psychopathol 2002;14179- 207
PubMed Link to Article
Nazroo  JYEdwards  ACBrown  GW Gender differences in the onset of depression following a shared life event: a study of couples. Psychol Med 1997;279- 19
PubMed Link to Article
Bebbington  PE Sex and depression. Psychol Med 1998;281- 8
PubMed Link to Article
Robins  LN The consequences of conduct disorder in girls. Olweus  DBlock  JRadke-Yarrow  MedsDevelopment of Antisocial and Prosocial Behavior: Research, Theories and Issues. Orlando, Fla Academic Press1986;385- 414
Rodgers  B Behaviour and personality in childhood as predictors of adult psychiatric disorder. J Child Psychol Psychiatry 1990;31393- 414
PubMed Link to Article
Power  CStansfeld  SAMatthews  SManor  OHope  S Childhood and adulthood risk factors for socio-economic differentials in psychological distress: evidence from the 1958 British birth cohort. Soc Sci Med 2002;551989- 2004
PubMed Link to Article
Wang  PSBerglund  POlfson  MPincus  HAWells  KBKessler  RC Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62603- 613
PubMed Link to Article
Jorm  AFKelly  CMWright  AParslow  RAHarris  MGMcGorry  PD Belief in dealing with depression alone: results from community surveys of adolescents and adults. J Affect Disord 2006;9659- 65
PubMed Link to Article

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