$\bullet$ Examines how family risks configurations affect Chinese children’s mental health.

$\bullet$ Uses crisp-set qualitative comparative analysis.

$\bullet$ Supports the cumulative risk model and multifinality/equifinality concepts.

Children’s development is associated with physiological, psychological, and social changes [1, 2] that can lead to various internal conflicts and pressures, placing them at high risk for mental health problems. Disrupted family structures, impoverished socioeconomic status, and disharmonious family atmosphere can also severely affect children’s mental health, potentially leading to psychiatric disorders such as depression, anxiety, conduct disorders, attention deficit issues, and even suicide [3, 4, 5, 6, 7]. Moreover, children often struggle to articulate their psychological distress and lack adequate support systems, which increases the likelihood of their mental health issues being overlooked and potentially developing into psychiatric disorders.

The problem of early mental health issues and the need for early intervention is particularly pressing in China, where rapid social and economic shifts are continually reshaping the environments in which children grow and develop [8]. As these transformations unfold, the family unit, traditionally a central pillar of Chinese society [9], is also experiencing changes. Shifts in family dynamics—such as evolving parenting styles, changes in family structures due to urban migration, and changing societal expectations—have far-reaching effects on children’s mental health [10]. Consequently, understanding how family risk factors influence children’s mental health in the context of contemporary China is vital for academic inquiry and plays a crucial role in informing intervention strategies designed to improve children’s overall well-being.

Family risks rarely occur in isolation as the presence of one risk factor, such as parental divorce, often correlates with other risk factors, such as family conflict. The cumulative risk model (CRM) suggests that exposure to multiple risk factors can have a greater negative impact on children’s development than exposure to individual factors alone [11, 12, 13, 14]. Additionally, different combinations of family risks can lead to distinct developmental outcomes, irrespective of the total number of risks [15, 16, 17]. However, traditional research has largely relied on correlation-based methods, such as regression analyses, which primarily examine the additive and independent effects of individual variables. These approaches are limited in capturing the complex interactions and combinations of risk factors, especially when multiple risks co-occur and interact simultaneously. Therefore, there remains a significant gap in understanding how different configurations or combinations of family risks uniquely contribute to children’s developmental outcomes.

To address this limitation, the present study employs qualitative comparative analysis (QCA), an emerging person-centered analytical method that differs from traditional regression analyses [18] and is increasingly applied in psychological and behavioral research [19]. While regression analyses focus on the effects of individual variables and often face challenges related to collinearity and limited interpretability of multiple interaction terms, QCA explicitly examines combinations of causal conditions. This method does not assume independence among variables, allowing for a comprehensive exploration of all possible configurations of family risk factors [20]. By using QCA, this study aims to clarify how specific combinations of risk factors contribute uniquely to developmental outcomes, providing nuanced insights that traditional methodologies may overlook.

We followed the key principles outlined by Li et al. [12], including systematicity, typicality, correlation, development, uniqueness, and feasibility (for detailed selection criteria, please refer to Chen et al. [21]) to identify six key risk factors across three family domains: family structure (parental divorce and parent–child separation), family resources (poverty and low parental education), and family atmosphere (low intimacy and high conflict). Although not exhaustive, these factors represent the most widely recognized risks identified in research, both in China [22] and internationally [15, 23]. Moreover, we followed the dichotomous coding practices established in previous CRM literature to ensure that only significant risks were considered [11, 12, 21, 24].

Regarding mental health indicators, we focused on three critical dimensions of children’s mental health—internalizing problems, externalizing problems, and attention problems—as identified by the well-established Pediatric Symptom Checklist (PSC) [25]. These indicators encompass a broad range of emotional, behavioral, and attentional difficulties that are prevalent among school-aged children and closely linked to significant short- and long-term impairments in academic and social functioning [26, 27, 28, 29, 30, 31]. Given the high prevalence and the significant short- and long-term consequences of these social, emotional, and behavioral problems among children, identifying the family risk configurations that contribute to them is of crucial importance.

This study makes a novel contribution to the literature on children’s mental health by introducing a configurational perspective through the use of crisp-set QCA to examine how multiple family risk factors interact to influence mental health outcomes. While prior research has predominantly relied on variable-centered approaches—such as regression or structural equation modeling—that assume linear, additive, and independent relationships among variables, these methods often fail to capture the complex, combinatorial nature of co-occurring risks [19]. The study has employed person-centered methods, such as latent profile analysis (LPA), to identify subgroups with shared patterns of risk exposure, thus accounting for heterogeneity [21]. However, LPA does not offer insights into configurational causality. In contrast, QCA allows identification of multiple sufficient combinations of conditions leading to the same or different outcomes, accommodating asymmetrical causation and providing actionable insights for targeted interventions [18]. Specifically the crisp-set QCA results yielded three main conclusions in the present study. First, none of the hypothesized causal conditions alone were necessary or sufficient for the outcomes to occur. Second, the outcomes were more likely to occur when most of the causal conditions were present. Third, while one configuration consistently led to all three symptom dimensions, three additional configurations were uniquely linked to internalizing symptoms; in contrast, externalizing and attention symptoms shared only that single configuration, with no other distinct causal pathways identified.

Our findings have both theoretical and practical implications for understanding and addressing the cumulative effects of family risks on children’s mental health.

First, the results reinforce the CRM theory, which posits that multiple coexisting risks exert a greater impact than individual factors alone [11, 12, 13, 14]. None of the single causal conditions were necessary or sufficient for the outcomes, supporting the ecological perspective that children’s development is shaped by the interplay of various risk factors within their environments and emphasizing the importance of analyzing configurations of multiple risks rather than isolating individual predictors. One important possible explanation for the lack of significance of individual risk factors is that their effects may not be universal but rather context-dependent—that is, a specific risk may only manifest its impact in the presence (or absence) of certain other conditions. For example, financial hardship might have a stronger effect on a child’s mental health when combined with low parental education and family conflict, but may be less harmful in families with high emotional closeness or effective coping resources. This aligns with the concept of contextual moderation [40], where the influence of a particular factor is conditional upon the broader configuration of surrounding risks. The crisp-set QCA approach is well suited to capture such complexity, as it allows for the identification of these interactive, configurational effects that would otherwise be obscured in traditional analyses focusing on isolated or additive relationships.

These findings have profound implications for the Response to Intervention (RTI) practice, a widely used approach emphasizing early identification and multi-tiered intervention tailored to the child’s specific needs. RTI emphasizes early identification and intervention at varying levels of intensity, tailored to the specific needs of the child [41]. From a screening and prevention perspective, it underscores the critical need to closely monitor children exposed to multiple risks, as they are significantly more likely to develop mental health problems. Given that the likelihood of developing mental disorders increases with the accumulation of risk factors, mental health professionals need to adopt a holistic approach. For instance, traditional assessment methods should consider the cumulative effects of multiple risk factors across ecological domains, rather than simply capturing one or two isolated risks. In addition, case management systems and children’s mental health records need to incorporate a multidimensional view of the child’s environment to ensure that no aspect is overlooked, allowing for more accurate assessments and timely interventions.

From an intervention perspective, however, the results suggest that simultaneous interventions addressing all family risks may be impractical. Instead, targeting a single critical risk factor—such as family functioning or family resources—may effectively disrupt the cumulative effect of multiple risks. Addressing one pivotal stressor can initiate a positive cascade of changes, making interventions more feasible and manageable for clinicians and families alike. For example, improving family functioning—such as enhancing communication and conflict resolution skills among parents—can have a ripple effect that reduces not only the immediate emotional stress on children but also the broader impacts on behavior and social functioning. Similarly, focusing on improving family resources, such as access to education, financial support, or community services, can alleviate the strain on parents and create a more stable environment for the child. Clinicians should therefore tailor interventions to address the most pressing stressor to break the cycle of accumulated risks and to initiate a positive chain of change that supports the child’s mental health, which makes the process more manageable for clinicians and more feasible for families. By combining comprehensive monitoring with targeted intervention, this strategy provides a balanced and efficient framework for addressing mental health challenges in Chinese children.

Second, the findings align with the concepts of multifinality and equifinality, two central principles of developmental psychopathology theory. Multifinality—the phenomenon whereby the same risk factors lead to diverse outcomes [42]—is evident in our results, where an identical configuration of family risks, gender, and residential area contributed to all three symptom dimensions, reflecting a shared underlying mechanism that can lead to varied psychological manifestations. This configuration also suggests that boys are more likely to experience multiple symptom dimensions simultaneously. This finding is consistent with prior research [43, 44, 45, 46], and the co-occurrence of internalizing, externalizing, and attention problems may be explained by their shared susceptibility to adverse family environments, which contribute to emotional dysregulation, impaired executive functioning, and social difficulties [47, 48, 49, 50]. Despite the similarity in the underlying family risk configuration, outcomes may differ depending on various other factors, including the child’s temperament, resilience, coping strategies, and the presence of protective factors such as social support or positive school environments.

In contrast, equifinality—the concept that different configurations can result in the same outcome [40]—similarly supported by our identification of multiple distinct risk patterns associated with internalizing problems, particularly among girls. These results suggest that internalizing symptoms (e.g., anxious emotions and depressive moods) may arise through a broader range of pathways due to their multifactorial and often covert nature. Compared to externalizing or attention problems, internalizing symptoms are more likely to be shaped by subtle, cumulative, and subjective experiences—such as perceived emotional neglect, chronic stress, or insecure attachment—which may interact differently with individual vulnerabilities like temperament, self-concept, or emotion regulation capacity [51, 52]. This complexity allows for greater heterogeneity in the configurations leading to internalizing distress [53] and thus resulted in much higher coverage for the identified configurations compared to externalizing and attention problems. Notably, as shown in previous literature [54], girls consistently report higher levels of internalizing symptoms than boys, particularly after the age of six, a trend that intensifies during adolescence. In light of the current findings, this pattern may be partially explained by the broader range of stressors and emotional challenges girls typically encounter during this developmental period, which increases their exposure to multiple psychological risk pathways leading to internalizing problems [55].

Third, the findings of this study challenge conventional assumptions about static family risk factors. Specifically, Incomplete Family Structure, Parent–child Separation, Poor Parental Education Level, and Family Financial Hardship did not consistently emerge as risk factors across the configurations associated with mental health symptoms. In contrast, the detrimental effects of Lack of Family Intimacy and Family Conflict were consistently observed across all causal condition configurations. This observation partially aligns with the findings of Chen et al. [21], who found that separation from parents potentially offered a protective effect for Chinese adolescents. These results suggest that structural or demographic characteristics of families may not be inherently harmful; rather, the emotional quality of family relationships plays a more decisive and stable role in shaping children’s psychological outcomes. Accordingly, interventions aimed at promoting children’s mental health should prioritize strengthening family emotional bonds, fostering open communication, and mitigating family conflicts, rather than focusing solely on modifying family structures or addressing demographic disadvantages. Future research should also shift its focus from static family indicators to dynamic family processes, exploring how variations in emotional connectedness and conflict management contribute to different developmental trajectories.

Following the principles of the CRM theory and the concepts of multifinality and equifinality, this study provides novel insights into the relationships between family risk configurations and mental health symptoms in Chinese children. Using QCA, we demonstrated that mental health outcomes are influenced not by individual risk factors but by specific configurations of multiple risks. The findings highlight the importance of monitoring children exposed to cumulative family risks and suggest that targeted interventions addressing one or two key risk factors—such as family atmosphere or resources—can significantly mitigate overall mental health risks. Future research should explore these configurations longitudinally and expand the scope to include additional risk factors, providing a more comprehensive understanding of children’s developmental trajectories.

This study has some limitations that should be addressed in future research. First, its cross-sectional design limits the ability to draw causal inferences about the relationship between family risk configurations and mental health outcomes. Future longitudinal research is needed to explore how these configurations evolve over time and their long-term impacts on children’s development. Second, the study focused on six key family risk factors, which, while representative, may not capture the full spectrum of risks affecting children. This limited scope may partially account for the relatively low coverage observed for externalizing and attention problems, which are likely influenced by a broader range of factors beyond the family context. Expanding the scope to include additional factors, such as parental mental health, community influences, and school environments, could provide a more comprehensive understanding of cumulative risks and their effects.

The data presented in this study are available upon reasonable request from the corresponding author.

Conception: EF, ZYD, RXG, LM; Design: KFL, MRZ, RXG, LM; Supervision: YXG, QFG, LM; Fundings: LM; Materials: YXG, QFG; Data Collection and/or Processing: KFL, MRZ, YXG; Analysis and/or Interpretation: EF; ZYD; Literature Review: KFL, EF, MRZ, QFG; Writing: KFL, EF, ZYD, RXG; Critical Review: ZYD, MRZ, YXG, QFG, LM. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was approved by the Biomedical Research Ethics Committee, Hunan Normal University (protocol number: 2021-411; date of approval: May 13, 2021). The survey was performed in accordance with relevant guidelines and regulations in accordance with the guidelines of the Declaration of Helsinki. Electronic informed consent was obtained by the schools from all student participants and their parents. This method of obtaining consent was approved by the ethics committee prior to commencing the study.

This work was supported by grants from the MOE Major Projects of Key Research Institute of Humanities and Social Sciences in Universities (22JJD190008; 22JJD190004; 22JJD190007).

Yongxing Guo is the founder and CEO of DiggMind Psychometric Testing Technology Co. All other authors have reported no conflicts relevant to the contents of this paper to disclose.