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Original Investigation
November 2018

Emotional and Behavioral Symptom Network Structure in Elementary School Girls and Association With Anxiety Disorders and Depression in Adolescence and Early Adulthood: A Network Analysis

Author Affiliations
  • 1Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM) U1018, Paris-Saclay University, Paris, France
  • 2Assistance Publique-Hôpitaux de Paris (AP-HP), Bicêtre Hôpitaux Universitaires Paris Sud, Public Health and Epidemiology Department, Le Kremlin-Bicêtre, France
  • 3Division of Psychology and Language Sciences, University College London, London, United Kingdom
  • 4Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
  • 5Department of Clinical Psychology, Leiden University, Leiden, the Netherlands
  • 6Bordeaux Population Health Research Centre, INSERM U1219, University of Bordeaux, Bordeaux, France
  • 7McGill Group for Suicide Studies, Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
  • 8Research Unit on Children’s Psychosocial Maladjustment, University of Montreal, Montreal, Quebec, Canada
JAMA Psychiatry. 2018;75(11):1173-1181. doi:10.1001/jamapsychiatry.2018.2119
Key Points

Question  Is the network structure of emotional and behavioral symptoms among elementary school girls indicative of later anxiety disorder or major depression occurrence?

Findings  In this network analysis of 932 elementary school girls from an ongoing population-based cohort study, bridge symptoms between disruptive and internalizing symptom communities (symptom clusters in networks) were identified. These symptoms exhibited the strongest relationships with anxiety disorders at ages 15 and 22 years.

Meaning  Bridge symptoms appear to play a central role in the developmental process leading to long-term anxiety and have potential relevance as early targets in disease-prevention or health-promotion interventions.


Importance  The onset of adult psychopathologic disorders can be traced to behavioral or emotional symptoms observed in childhood, which could be targeted in early interventions to prevent future mental disorders. The network perspective is a novel conceptualization of psychopathologic disorders that could help to identify target symptoms with a distinct role in the emergence of mental illness.

Objective  To assess whether the network structure of emotional and behavioral symptoms among elementary school girls is associated with anxiety disorders or major depression in early adulthood.

Design, Setting, and Participants  The Quebec Longitudinal Study of Kindergarten Children is an ongoing, prospective, population-based study of kindergarten children attending French-speaking state schools in the Canadian province of Quebec in 1986-1988. This study included 932 girls whose parents completed the Social Behavior Questionnaire when the girls were ages 6 (baseline), 8, and 10 years; 780 participants were interviewed to assess the presence of mental disorders at age 15 and/or 22 years. Data analysis was conducted from December 2016 to April 2018.

Main Outcomes and Measures  Gaussian graphical models were estimated for 33 symptoms (eg, internalizing, externalizing, and prosocial behaviors) assessed using the Social Behavior Questionnaire to evaluate the temporal stability of the symptom network through childhood. At follow-up time points, mental disorders were assessed using the DSM-III-R, and symptom networks were reestimated at ages 6 to 10 years, this time including a variable indicative of future diagnosis.

Results  At baseline, the mean (SD) age of the 932 girls was 6.0 (0.3) years. Among the 780 women assessed at follow-up, 270 (34.6%) and 128 (16.4%) had developed anxiety disorders and major depression, respectively. Symptoms clustered in internalizing and externalizing communities. Five symptoms—irritable, blames others, not liked by others, often cries, and solitary—emerged as bridge symptoms between the disruptive and internalizing communities. These symptoms were those that were connected with the highest regularized edge weights (from 0.015 to 0.076) to future anxiety disorders once added to the network. Bootstrapped 95% CIs ranged from (95% CI, −0.063 to 0.068) to (95% CI, 0.561 to 0.701) for positive edges and from (95% CI, −0.156 to 0.027) to (95% CI, −0.081 to 0.078) for negative edges included in the regularized network.

Conclusions and Relevance  Bridge symptoms between disruptive and internalizing communities are identified for the first time in childhood, and these findings suggest that these symptoms could be central in indicating probable later anxiety disorders. The study suggests that bridge symptoms should be investigated further as potential early targets in disease-prevention interventions.