with measures of behavior, in order to establish whether the behaviors have clinical significance. Finally, careful attention to gender-related, age-specific, and culture-specific behaviors is essential. Many behaviors must also be assessed in a developmental context. For example, bed-wetting or separation fears at age 4 are normal, but they convey different significance at later years. Similarly, aggression in young children is quite different from such behavior in adolescents, in part because older youth have much greater physical capacity, learned knowledge, and access to other ways to deal with anger. Thus, similar constructs might need to be measured differently across the age spectrum to track the effect of a particular behavioral or emotional construct on later health outcomes.

Addressing Gaps in Measuring Behavioral Influences

Among the influences on children’s health, the salience of behavior to long-term health, especially regarding obesity, HIV/AIDS, sexually transmitted diseases, substance or alcohol use and addiction, motor vehicle accidents, teenage pregnancy, school dropout, and homicide and suicide, is generally accepted (Murray and Lopez, 1996).

In addition to stigma, which makes these areas difficult to address a priori, failure to be conceptually clear about which behavioral constructs are being measured also contributes to difficulties in measurement. Thus, one may assess some form of behavioral problem, but whether it is a measure of a risky behavior (but not ostensibly a sign of health or illness per se) or a measure of the presence or absence of mental health or illness is not always clear. Many surveys include a few behavioral items, but rarely are there clear conceptual linkages to whether the items are related to a health condition per se (mental health or illness) or only to influences on future health (e.g., a risky behavior that may predispose to future adverse health outcomes).

Some of this conceptual confusion may be designed explicitly to avoid the possibility of stigma or stigmatizing a population, especially in surveys conducted by federal agencies of disenfranchised groups that are already prone to stigmatization (e.g., studies of economically depressed groups). As a result, most studies that attempt to assess children’s behavior rely on assessments of single behaviors or overall functioning, without reference to the central health conditions that reflect most of the population-attributable risk for adverse outcomes and persisting disability. One illustration of this lack of conceptual clarity is the extent to which surveys may attempt to measure adolescent suicidal ideation—essentially a normative behavior in youth—but fail to consider in the measurement strategy the assessment of major depressive disorder, the single greatest risk factor for completed suicide (Shaffer and Craft, 1999).

Most existing surveys have not devoted sufficient methodological attention to distinguishing sufficiently between behavioral information gathered for diagnostic purposes (e.g., major depressive disorder) and information obtained for



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