Mental Health: A Report by the Surgeon General

A landmark study on risks from the environment (Rutter & Quinton, 1977) showed that several factors can endanger a child’s mental health. Dysfunctional aspects of family life such as severe parental discord, a parent’s psychopathology or criminality, overcrowding, or large family size can predispose to conduct disorders and antisocial personality disorders, especially if the child does not have a loving relationship with at least one of the parents (Rutter, 1979). Economic hardship can indirectly increase a child’s risk of developing a behavioral disorder because it may cause behavioral problems in the parents or increase the risk of child abuse (Dutton, 1986; Link et al., 1986; Wilson, 1987; Schorr, 1988). Exposure to acts of violence also is identified as a possible cause of stress-related mental health problems (Jenkins & Bell, 1997). Studies point to poor caregiving practices as being a risk factor for children of depressed parents (Zahn-Waxler et al., 1990).

The quality of the relationship between infants or children and their primary caregiver, as manifested by the security of attachment, has long been felt to be of paramount importance to mental health across the life span. In this regard, the relationship between maternal problems and those factors in children that predispose them to form insecure attachments, particularly young infants’ and toddlers’ security of attachment and temperament style and their impact on the development of mood and conduct disorders, is of great interest to researchers. Many investigators have taken the view that the nature and the outcome of the attachment process are related to later depression, especially when the child is raised in an abusive environment (Toth & Cicchetti, 1996), and to later conduct disorder (Sampson & Laub, 1993). The relationship of attachment to mental disorders has been the subject of several important review articles (Rutter, 1995; van IJzendoorn et al., 1995).

There is controversy as to whether the key determinant of “insecure” responses to strange situations stems from maternal behavior or from an inborn predisposition to respond to an unfamiliar stranger with avoidant behaviors, such as is found in socially phobic children (Belsky & Rovine, 1987; Kagan et al., 1988; Thompson et al., 1988; Kagan, 1994, 1995). Kagan demonstrated that infants who were more prone to being active, agitated, and tearful at 4 months of age were less spontaneous and sociable and more likely to show anxiety symptoms at age 4 (Snidman et al., 1995; Kagan et al., 1998). These findings are of considerable significance, because long-term study of such highly reactive, behaviorally inhibited infants and toddlers has shown that they are excessively shy and avoidant in early childhood and that this behavior persists and predisposes to later anxiety (Biederman et al., 1993). There is also some controversy as to whether “difficult” temperament in an infant is an early manifestation of a behavior problem, particularly in children who go on to demonstrate such problems as conduct disorder (Olds et al., 1999). One analysis of the attachment literature suggests that abnormal or insecure forms of attachment are largely the product of maternal problems, such as depression and substance abuse, rather than of individual differences in the child (van IJzendoorn et al., 1992).

The relationship between a child’s temperament and parenting style is complex (Thomas et al., 1968); it may be either protective if it is good or a risk factor if it is poor. Thus, a difficult child’s chances of developing mental health problems are much reduced if he or she grows up in a family in which there are clear rules and consistent enforcement (Maziade et al., 1985), while a child exposed to inconsistent discipline is at greater risk for later behavior problems (Werner & Smith, 1992).

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