Running head: QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 1 A Comparison of Quantitative and Qualitative Methods in the Assessment of Internalizing Behaviors in Preschool-Aged Children from Mexican Farmworker Families Rogelio Gonzalez California State University San Marcos QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 2 Abstract Evidence suggests that internalizing behaviors (e.g., anxiety, irritability, sadness) emerge early in childhood. However, very few researchers have investigated these behaviors in vulnerable preschool-aged (3-6-year-old) children from Mexican/Mexican American farmworker families. This population may be at an increased risk for poor mental health due to chronic exposure to risk factors associated with farmwork. In addition, the utility of standard measures of child psychopathology in such samples is unclear. Evidence suggests there may be cultural differences in the description and expression of internalizing behaviors in young children. The current study aimed to examine mental health in preschool-aged children from Mexican/Mexican-American farmworker families. Mothers (N = 100) completed measures of child internalizing behavior (affective [i.e., mood] and anxiety problems; Child Behavior Checklist; CBCL) and impairment (Impairment Rating Scale; IRS). In addition, a culturally sensitive semi-structured qualitative interview was used to assess parent-reported behaviors of child internalizing behaviors. CBCL mood and anxiety problems were found to be associated with child impairment. When examining the association between quantitative and qualitative data, CBCL mood problems were associated with qualitative interview mood scores, whereas CBCL anxiety problems were not associated with interview anxiety scores. In addition, the number of years the mother has spent in the U.S. did not moderate the relationship between CBCL and interview scores. Qualitative analyses showed that CBCL mood items and qualitative themes derived from the interviews overlap in some mother-reported behaviors (e.g., crying, decreased energy levels). However, other behaviors such as social withdrawal and somatic symptoms were endorsed by mothers as depressive symptoms on the interview but were not mood items on the CBCL. Qualitative analyses also showed that CBCL anxiety items generally did not align with themes endorsed by QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 3 mothers in the interviews. Thus the CBCL anxiety scale may not be culturally appropriate for this particular community of preschool-aged children of Mexican farmworker families. By identifying culturally relevant emotional problems in this group as well as highlighting methodological and thematic overlap with and differences between standard and qualitative measures, this study can provide important information to drive culturally competent health care, policies, prevention, and interventions for children from farmworker families. QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 4 A Comparison of Quantitative and Qualitative Methods in the Assessment of Internalizing Behaviors in Preschool-Aged Children from Mexican Farmworker Families Evidence suggests that symptoms of internalizing problems (including, for example, anxiety, irritability, sadness) often emerge early in childhood (Bufferd, Dougherty, Carlson, & Klein, 2011; Bufferd, Dyson, Hernandez, & Wakschlag, 2016; Dougherty et al., 2013, 2015; Hudson & Dodd, 2012; Luby, Belden, Pautsch, Si, Spitznagel, 2009; Mian, Godoy, Briggs- Gowan, & Carter, 2012). However, most research has focused on school-aged children (i.e., 6-12 years old) and adolescents; relatively fewer studies have assessed these behaviors in preschool- aged children aged 3-6 years old (Luby, Si, Belden, Tandan, & Spitznagel, 2009; Mesman, Bongers, & Koot, 2001; Sterba, Prinstein, & Cox, 2007). In addition, much of the work has been dedicated to externalizing behaviors (e.g., Reef, Diamantopoulou, van Meurs, Verhulst, & van der Ende, 2011; Wakschlag et al., 2012, 2014), whereas internalizing behaviors during the preschool age have often been overlooked (Mesman et al., 2001). Some researchers posit that the lack of investigation in this age group stems from a belief that young children simply “grow out” of emotional problems (Lavigne, LeBailly, Hopkins, Gouze, & Binns, 2009), a fear of “labeling” young children early in their lifespan (Egger & Angold, 2006), or the perception that is too difficult to reliably measure internalizing behaviors during a period of rapid development (Sterba et al., 2007). These issues may help explain why many preschoolers who may benefit from mental health services are never referred for treatment (Egger & Angold, 2006). However, in the limited work that has investigated internalizing problems in young children, it appears that some children do show symptoms of impairing internalizing behaviors as early as the preschool period that persist over time (Birmaher et al., QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 5 2009; Bufferd, et al., 2011; Bufferd, Dougherty, Carlson, Rose, & Klein, 2012; Franz et al., 2013; Luby et al., 2009a, 2009b; Mesman et al., 2001). Despite this growing knowledge base on the impairing and persistent nature of early- emerging emotional difficulties, researchers have not yet considered cultural expressions and interpretations of internalizing problems in ethnic minority preschool-aged children. One group that has been relatively absent from the literature is Mexican/Mexican-American children from farmworker families. This group is particularly vulnerable to mental health difficulties given the economic, health, and cultural hardships these families encounter (Evans, 2004; Evans & English, 2002; Koruk et al., 2010; Raikes & Thompson, 2005; Scararmella, Neppl, Ontai, & Conger, 2008) This study sought to examine the level of emotional difficulties in Mexican/Mexican- American preschool-aged children from farmworker families and identify the similarities and/or differences between standard assessment of these difficulties and culturally sensitive assessment. To do so, I conducted a quantitative assessment using standardized measures of internalizing behavior and impairment in young children to document the rate of internalizing behavior in this population and compared this method to a culturally-sensitive qualitative assessment in which descriptive themes were extrapolated from semi-structured interviews to examine whether these methods revealed similar information. Internalizing behaviors Internalizing behaviors are over-controlled and inner-directed behaviors related to anxiety and depression such as shyness, fear, sadness, and irritability and are often associated with social isolation and withdrawal (Achenbach & Rescorla, 2000; de Leon Siantz, Coronado, & Dovydaitis, 2010; Lecompte, Moss, Cyr, & Pascuzzo, 2014; Madigan, Atkinson, Laurin, & QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 6 Benoit, 2013). More specifically, anxiety is marked by intense fear or worry and is associated with avoidant behaviors in situations that cause anxiety (American Psychiatric Association [APA], 2000). Depression can include moods such as irritability and feelings of sadness, as well as symptoms such as diminished sleep and energy, and appetite disturbances (APA, 2000). Some children demonstrate internalizing behaviors as early as preschool age, including anxiety (Franz et al., 2013; Henin et al., 2005; Hudson & Dodd, 2012; Mesman et al., 2001, Mian et al., 2012) and depression (Bufferd et al., 2011, 2014; Dougherty et al., 2010; Lavigne et al., 2009; Luby et al., 2009a, 2009b). Studies typically rely on maternal reports that demonstrate preschool-aged children exhibit symptoms of anxiety and depression and, in some cases, meet criteria for diagnosis (Bufferd et al., 2011, 2014; Domenèch-Llaberia et al., 2009; Dougherty et al., 2010; Fuhrmann, Equit, Schmidt, & von Gontard, 2012). Several studies that have examined rates of anxiety and depression diagnoses in young children based on maternal report have estimated that 0.5-19.6% met criteria for any anxiety disorder and 0.3-2.1% of preschool-aged children met criteria for depression (Bufferd et al., 2011; Egger & Angold, 2006; Lavigne et al., 2009). The rates of preschool psychopathology are roughly similar to that of school-aged children and adolescents (Bufferd et al., 2011; Copeland, Angold, Shanahan, & Costello, 2014; Egger & Angold, 2006; Gadow, Sprafkin, & Nolan, 2001). Despite these efforts to detect early emerging psychopathology, very little work has focused on examining internalizing problems in Mexican/Mexican-American preschool-aged children, and even less so with preschool-aged children of Mexican/Mexican-American farmworker families. One study using maternal-report measures in a farmworker sample found that 31.5% and 1.9% of their school-age children met criteria for anxiety and depression QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 7 diagnoses, respectively (Kupersmidt & Martin, 1997). In another study with Mexican/Mexican- American preschool-aged farmworker children that assessed mother-reported internalizing symptoms, approximately 9% of children fell within the criteria for clinical concern for internalizing behaviors on a symptom checklist measure (de Leon Siantz et al., 2010). However, more information is needed about the rate of emotional difficulties in children from these vulnerable families. Comorbidity Some children exhibit co-occurring symptoms or meet criteria for two or more disorders simultaneously (Wichstrøm & Berg-Nielsen, 2014; Wichstrøm et al., 2012; Wilens et al., 2002). Similar to older children, adolescents, and adults, comorbid symptoms and disorders are common in children (Franz et al., 2013; Wichstrøm & Berg-Nielsen, 2014; Wichstrøm et al., 2012). In particular, anxiety and depression often co-occur in young children (Bufferd et al., 2011; Egger & Angold, 2006; Lavigne et al., 2009). For example, in a community sample of Norwegian preschool-aged children, children with an anxiety diagnosis were seven times more likely to meet criteria for a depression diagnosis than those without an anxiety diagnosis (Wichstrøm et al., 2012). Similarly, Franz and colleagues (2013) found that in a large sample of preschool-age children, those with a generalized anxiety disorder were 3.7 times more likely to also have comorbid depression. For some children, their comorbid symptoms continue throughout the lifespan (Keiley, Lofthouse, Bates, Dodge, & Pettit, 2003; Lavigne, Hopkins, Gauze, & Bryant, 2015; Mesman et al., 2001; Sourander et al., 2006). Given this overlap, the examination of both anxiety and depressive symptoms is important. QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 8 Continuity Longitudinal studies have enhanced our understanding of the course of internalizing behaviors from preschool through school-age, adolescence and adulthood (Keiley et al., 2003; Kessler & Magee, 1994; Mesman et al., 2001; Pihlakoski et al., 2006; Shaw, Keenan, Vondra, Delliquadri, & Giovannelli, 1997; Sourander et al., 2006). It appears that internalizing behavior problems that begin early in childhood may remain stable into adolescence and adulthood (Kovacs & Devlin, 1998; Rapee, 2014). For example, Bufferd and colleagues (2012) reported that children who met criteria for an anxiety diagnosis at age 3 were approximately four times more likely to meet criteria for anxiety at age 6 than children who did not meet criteria at age 3. Similarly, Luby, Gaffrey, Tillman, April, and Belden (2014) found that preschool-onset depression predicted major depression at age 6, even after controlling for several other risk factors. These studies suggest that children with emotional problems are at risk for future disorders. In addition, longitudinal work suggests that many adult disorders have childhood roots; psychopathology can often be traced back to early stages of development and contribute to negative outcomes throughout development (Davis & Sandman, 2012; Maughan & Kim-Cohen, 2005; Rutter, Maughan, & Kim-Cohen, 2006). Therefore, it is important to detect psychopathology early in life to improve children’s developmental trajectories. Impairment Associated with Internalizing Behavior Internalizing behavior in preschool-aged children is associated with deficits in several domains such as peer relationships, academic performance, and family functioning. During early childhood, children begin to form relationships and develop the ability to regulate their emotions and behaviors with adults and peers (Bufferd et al., 2016; Dollar & Stifter, 2012). Preschool- aged children who suffer from psychological problems, such as anxiety and depression, often QUANTITATIVE AND QUALITATIVE CHILD PSYCHOPATHOLOGY 9 also have impaired relationships with others. For example, teachers of children with these difficulties are likely to report low social functioning in children (e.g., targets of teasing; not well-liked by peers; Danzig et al., 2013). In addition, teacher-reports of children’s anxiety and depression correlated with low academic functioning (e.g., difficulty learning; Dobbs, Doctoroff, Fisher, & Arnold, 2006). Preschoolers with internalizing behaviors also tend to experience difficulties with their families. Côté and colleagues (2009) found that family conflict is associated with escalating levels of anxiety and depressive symptoms in preschool-aged children. Another study reported that stress and family conflict showed indirect pathways to higher levels of anxiety and depression in preschool-aged children (Hopkins, Lavigne, Gouze, LeBailly, Bryant, 2013). In addition, stressful family life events are associated with preschool depression such that children who have higher number life stress events are susceptible to experiencing higher levels of depression and anxiety than children who have lower life stress events (Luby, Belden, & Spitznagel, 2006). Another study found that parents of preschool-aged children with anxiety were 3.5 times more likely to report that their child’s behavior had a negative impact on their family’s functioning in comparison to families with children without anxiety disorders (Towe-Goodman, Franz, Copeland, Angold, & Egger, 2014). Mothers of preschool-aged children with anxiety have also reported rejecting feelings towards family life (Yurdşen, Erol, Gençöz, 2013), suggesting that children’s difficulties impair family members as well. Taken together, these studies provide evidence of the impairment associated with childhood psychopathology. Limitations of Previous Studies Although previous studies have identified the presence of emotional problems in preschool-aged children, this work has typically lacked investigation of internalizing behavior in