Reviewer’s report
Title: 
Cumulative Risk Exposure and Emotional Symptoms among Early
Adolescent Girls
Version: 
0 
Date: 
08 Mar 2021
Reviewer's report:
The authors used structural equation modelling to assess risk factors and
cumulative risk exposure (CRE) among a large, epidemiological sample of girls,
ages 11-12 years old (n=8,327). CRE was positively associated with "emotional
distress" and the primary risk factors identified, out of the 8 theoretical areas
explored, were low academic attainment, special educational needs, low family
income, and caregiving responsibilities. 
The sample size of emerging adolescent girls (or pre-adolescents in some
classifications), in a narrow but important age band, alongside the assessment
risk factors (especially special educational needs) and broadband symptoms,
rather than a focus on disorders, are substantial strengths of this study. 
Several notable weaknesses in the manuscript must be addressed before the
results can even be adequately interpreted, however. 
Background
First, the generalizability and contextualization of the present study would be
significantly improved by providing greater specificity in the background about
the "significant increase in emotional symptoms" among adolescent girls in the
UK and other countries. 
This literature is very generically referenced and
therefore does not provide enough context within which to place the authors'
findings. 
For example, when the authors refer to "emotional symptoms", are they
specifically focusing on anxious and depressive symptoms (this is somewhat
implied) because those are the primary areas where there is converging evidence,
across countries, that there are increases observed among girls? Or is there a
difference between which symptoms the authors focused on, relative to the
literature on changes among girls in other western or non-western countries? 
Further, what are the main similarities and differences across countries and how
big is the increase observed among girls in various symptom clusters? Are boys
also showing an increase but the increase among girls is significantly greater?
Far too little detail is given to contextualize the findings in the present study
relative to the literature cited to justify the research.
Second, some of the potentially key arguments in support of this research are
presented in too vague a language, particularly around the idea that risk factors
and Cumulative Risk Exposure [CRE] are contextually specific. 
For example,
greater clarity is needed in statements such as "First, it is critical that in this area
of work patterns are established across different populations and contexts, as the
extent to which a factor is "risky" for an outcome can vary substantially (e.g. by
gender and ethnicity; (10))" [Page 3, lines 53-59]. 
I do not think the authors mean "work patterns" but likely mean "work,
patterns…" but the meaning gets lost here. 
Perhaps what they really mean is
something closer to "First, it is critical to look for similarities and differences in
risk factors across different populations and contexts (e.g., age gender, ethnicity,
country)". 
If this an accurate reflection of the intended idea, it is even more
important that additional details are provided in the background about the
"significant increase in emotional symptoms" among girls, and what is currently
known about similarities and differences (patterns and discrepancies) across
countries.
Further, on page 6 the authors state "However, like risk factors, evidence
suggests CRE is contextually specific (10)", yet (1) no details are provided about
key known contextual differences related to CRE and (2) no clarification of the
argument related to contextual specificity is made between "risk factors" and
"CRE". 
Clarifying these details and improving the writing style will strengthen
the argument for studying very early adolescence among girls.
Third, some of the citations may be incorrectly assigned as well. 
For example, on
page 6, lines 21/22 show cite # 12 associated with Cumulative Risk Theory
[CRT], which appears to actually be citation # 10. Cite #12 (Rutter's paper on
secondary schools) is referenced in this same section of the manuscript as
referring to a number of details about CRT, which may or may not be accurate. 
A
careful review of the cites is needed. 
Methods
There is inadequate information about measurement, and timing of measures, in
the Methods section.
Similar to the need to clarify in the 'Background' which "emotional symptoms"
are increasing among girls as reported in the literature, the authors do not
adequately describe what types of "emotional symptoms" are captured by their
measurement which is limited to only the Strengths and Difficulties
Questionnaire. 
'Worry' is the only symptom mentioned. 
Therefore, the
manuscript does not adequately provide readers enough information to assess the
comparability of "emotional symptoms" reported in the literature to the method
used by the authors to assess "emotional symptoms". 
How the ACEs were captured should also be clearly described in the Methods.
There is some reference to this in the 'Generalizability' section but that only
raises further questions and concerns about the authors reporting of their
methodology.
Similarly, the time point for all measures and risk factors should be very clearly
reported in the Methods section and noted in the main tables. This statement in
the 'Generalizability' section came as quite a surprise: "First, although most
candidate risk factors were measured prior to self-report of symptoms (except
caregiving responsibilities), causality cannot be established given the inability to
control for prior symptoms.'
Results
The authors note that too few participants (<1%) had a CRE index score of 4, so
the highest two categories were collapsed. 
However, then then not that floor
effects were still present so the index was treated as categorical. 
If this is
accurate (0,1 classification was used and not 0-3), then it does not appear that the
authors are exclusively testing cumulative risk but rather the presence of risk, yet
the authors state that greater levels of CRE correspond to worsened symptoms. 
Discussion
What do the authors mean to convey by stating "such as use of child in need
status to indicate ACEs rather than the checklists more typically used"? 
The Discussion should be fully revisited in light of the clarifying the details
noted above (Background, Methods, Results).
Limitations
The use of only the Strengths and Difficulties Questionnaire, capturing a very
narrow band of symptoms should explicitly be listed as a significant limitation in
the present study. 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes