Are Infant-Toddler Social-Emotional and Behavioral Problems Transient?

Are Infant-Toddler Social-Emotional and Behavioral Problems Transient? MARGARET J. BRIGGS-GOWAN, PH.D., ALICE S. CARTER, PH.D., JOAN BOSSON-HEENAN, B.A., AMANDA E. GUYER, PH.D., AND SARAH M. HORWITZ, PH.D.

ABSTRACT Objective: To examine the persistence of parent-reported social-emotional and behavioral problems in infants and toddlers. Method: The sample comprised 1,082 children ascertained from birth records. Children were 12 to 40 months old in year 1 (1998 Y 1999) and 23 to 48 months old in year 2 (1999 Y 2000). Eighty percent participated in year 1 and 91% were retained in year 2. Social-emotional and behavioral problems were measured by high scores (Q90th percentile) on the Internalizing, Externalizing, and/or Dysregulation domains of the Infant-Toddler Social and Emotional Assessment (ITSEA). Parents reported on sociodemographic factors, family life impairment, parenting stress, and family functioning. Results: Among children with any high ITSEA domain score in year 1, 49.9% had persistent psychopathology, as indicated by the continued presence of a high score in year 2. In multivariate analyses, persistence was significantly more likely when parents reported co-occurring problems (i.e., problems in multiple ITSEA domains), high family life disruption, and high parenting distress in year 1. Homotypic persistence rates (i.e., same domain persistence) ranged from 38% to 50%. Only for dysregulation was homotypic persistence greater when co-occurring problems were present than for dysregulation alone. Persistence patterns were similar for boys and girls. Conclusion: Findings indicate that infant-toddler social-emotional/behavioral problems are not transient and highlight the need for early identification, multidomain and family assessment, and effective early intervention. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(7):849 Y 858. Key Words: infant-toddler, persistence, socialemotional, behavioral problems.

Despite increasing consensus that psychopathology exists in infancy and toddlerhood (National Center for Toddlers and Families, 1994; Zeanah, 2000), relatively little is known about the course and persistence of early-emerging social-emotional and behavioral problems. An understanding of the extent to which these early-emerging problems persist over time is essential to our understanding of their clinical Accepted January 31, 2006. Dr. Briggs-Gowan and Ms. Bosson-Heenan are with the Department of Psychiatry, University of Connecticut Health Center, Farmington CT; Dr. Carter is with the Psychology Department, University of Massachusetts, Boston; Dr. Horwitz is with Case Western Reserve University, Cleveland; Dr. Guyer is with the National Institute of Mental Health, Bethesda, MD. This research was supported by National Institute of Mental Health grant R01MH55278. Correspondence to Dr. Margaret J. Briggs-Gowan, Department of Psychiatry, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030; e-mail: [email protected]. 0890-8567/06/4507 Y 0849Ó2006 by the American Academy of Child and Adolescent Psychiatry. DOI:10.1097/01.chi.0000220849.48650.59

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significance and to the development of appropriate intervention services for children with significant psychopathology. Early childhood (birth to 3 years) is characterized by rapid developmental change and consequently many parents and professionals believe that early social-emotional and behavioral problems are developmentally transient (e.g., Bthe terrible twos[) and likely to diminish as children grow older. This view conflicts with a small but growing body of evidence that some early-emerging social-emotional and behavioral problems persist (Fischer et al., 1984; Keenan and Wakschlag, 2000; Lavigne et al., 1998; Mathiesen and Sanson, 2000) and may be a barrier preventing children from receiving needed intervention services. In this article, patterns of persistence of psychopathology, measured by extreme social-emotional/behavioral problems, and factors related to persistence are examined in a representative community sample of young children. Psychopathology in young children is often conceptualized as falling along the three broad domains of

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internalizing, externalizing, and dysregulation (National Center for Toddlers and Families, 1994; Zeanah, 2000). Information about clusters of social-emotional/behavioral problems can be assessed in each domain and examined dimensionally or by assigning cutpoints. Scores above the cutpoints reflect the presence of multiple behaviors within a given domain, which is used to indicate psychopathology. Psychopathology also may be assessed using psychiatric classification systems. However, young children also may evidence social-emotional/behavioral problems in the internalizing, externalizing, and/or dysregulation domains that do not occur so frequently or intensely as to be considered clinically significant psychopathology (Carter and Briggs-Gowan, 2005). For the purpose of clarity in this article, psychopathology is used to refer to psychiatric disorders or high levels of social-emotional/ behavioral problems. Social-emotional/behavioral problems refer to dimensionally measured problem behaviors that include both normal and atypical ranges of behavior. In early childhood, internalizing problems include difficulties with anxiety, depression/withdrawal, fears, and shyness/inhibition. Externalizing problems include aggression, overactivity, impulsivity, and inattention. Recently, extreme problems in the regulation of state, affect, and sensory processing have been addressed in the regulatory disorders of the Diagnostic Classification System for 0Y3 (National Center for Toddlers and Families, 1994). Although conceptualizing extreme regulatory problems as a form of psychopathology is controversial, there is considerable evidence that children with difficult temperament are vulnerable to developing social-emotional/behavioral problems and psychiatric disorders (Bates et al., 1985; Guerin et al., 1997; Keenan et al., 1998; Prior et al., 1993; Shaw et al., 1996). This suggests that difficulties with regulation may play a role in the emergence or maintenance of psychopathology. Therefore, it is important to examine the extent to which extreme dysregulation persists and/or contributes to the persistence of psychopathology in other areas.

Mathiesen and Sanson, 2000), Bat-risk[ samples (Rose et al., 1989; Shaw et al., 1998), and samples enriched for psychopathology by overselection of children with high scores on symptom checklists (Lavigne et al., 1998). Despite methodological differences, these studies have yielded fairly consistent evidence that parental reports of infant-toddler internalizing and externalizing problems correlate with later social-emotional/behavioral problems (Briggs-Gowan and Carter, 1998; Fischer et al., 1984; Mathiesen and Sanson, 2000; Mesman et al., 2001; Rose et al., 1989; Shaw et al., 1998; Smith et al., 2004). Some of these studies have suggested that stability may be more consistent and stronger for externalizing problems than for internalizing problems (Briggs-Gowan and Carter, 1998; Mesman and Koot, 2001l Mesman et al., 2001). Many of these studies have focused on homotypic stability, that is, the stability of behaviors within the same domain over time. Within early childhood, several studies suggest low to moderate homotypic stability in early internalizing problems, with correlations from 0.23 to 0.52 (Briggs-Gowan and Carter, 1998; Fischer et al., 1984; Mathiesen and Sanson, 2000). Early childhood internalizing problems also have been linked with school-age internalizing problems; however, results have been inconsistent, with one study indicating greater stability among boys (Mesman et al., 2001) and another greater stability among girls (Fischer et al., 1984). When examined dimensionally, externalizing problems demonstrate moderate to strong stability, with longitudinal correlations from 0.31 to 0.70 (BriggsGowan and Carter, 1998; Mathiesen and Sanson, 2000; Mesman et al., 2001; Rose et al., 1989; Shaw et al., 1998; Smith et al., 2004). Notably, toddler externalizing behaviors have significantly predicted externalizing disorders at age 5 (Keenan et al., 1998). Although two studies found no sex differences in the stability of externalizing problems (Fischer et al., 1984; Smith et al., 2004), one study reported stronger longitudinal pathways for boys than girls (Mesman et al., 2001).

Stability in Social-Emotional/Behavioral Problems

Categorical Persistence

Most studies that have followed children beginning in early childhood have employed dimensional measures to assess aspects of internalizing and externalizing problems and/or Bdifficult temperament.[ Longitudinal studies that have examined the stability of social-emotional/ behavioral problems have varied considerably in sample type, including community samples (Fischer et al., 1984;

Although the stability of early psychopathology is more relevant to decisions about clinical intervention than the stability of dimensional reports of social-emotional/ behavioral problems, few studies have examined the persistence of psychopathology defined using symptom cutpoints or diagnostic classifications. Mathiesen and Sanson (2000) found that 37% of 18-month-olds with

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ARE INFANT-TODDLER PROBLEMS TRANSIENT?

moderately high emotional/behavioral problems continued to have problems in the same area at 30 months. Similarly, in the study of Lavigne et al. (1998), approximately half of 2-year-olds who met criteria for a psychiatric disorder continued to meet criteria for a disorder 1 year later. Furthermore, toddlers extreme in behavioral inhibition have been found to be at increased risk of later internalizing disorders (Biederman et al., 2001; Schwartz et al., 1999). Most of these studies do not appear to have examined sex differences in persistence rates. However, Lavigne and colleagues (1998) reported that internalizing disorders were more persistent among 2- and 3-year-old boys (50%) than among girls (29%), and that there was no sex difference in the persistence of externalizing disorders. Information concerning the heterotypic continuity of early social-emotional/behavioral problems is limited. Although some studies have suggested that internalizing problems may decrease the risk of developing externalizing problems (Mesman et al., 2001; Schwartz et al., 1999), others have found no link between problems in one domain and risk of developing problems in another (Lavigne et al., 1998; Mesman and Koot, 2001). A high level of co-occurrence across domains, noted by Lavigne and colleagues (1998), may underlie these conflicting results.

Contributing Factors

Some studies have indicated greater persistence among children with higher levels of social-emotional/ behavioral problems (Lavigne et al., 1998; Mathiesen and Sanson, 2000; Prior et al., 1992). This is not surprising because the greater the number or severity of problems, the greater the behavioral change needed for difficulties to remit. Persistence also may be greater among children whose difficulties interfere with their ability to engage in age-appropriate activities and/or negatively affect social relationships (i.e., impairment). Restricted exposure to developmentally appropriate situations and activities may constrain a child_s opportunities to learn to master challenging tasks, such as learning to control aggressive impulses when frustrated by peer interactions. Such associations between impairment and persistence have been identified in older children (Costello et al., 1999). However, Lavigne and colleagues (1998) found that in young children, persistence of externalizing disorders was not related to a global measure of impairment. Given the increased focus on impairment in current diagnostic

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systems, such as the DSM-IV (American Psychiatric Association, 1994), addressing the role of impairment in persistence is clearly important. Although some studies have sought to identify risk factors for persistent psychopathology, relatively few factors have been identified. Mathiesen and Sanson (2000) found that although many factors were associated with the onset of toddlers_ psychopathology, none of a comprehensive array of risk factors, including sociodemographic factors, maternal symptomatology, social support, and life events, distinguished children with stable versus remitting psychopathology. In contrast, Mesman and Koot (2001) found that stressful life events and physical health problems were associated with risk of later disorder. Finally, Lavigne and colleagues (1998) found that low family cohesiveness was associated with persistence of early externalizing disorders, but that negative maternal affect and child cognitive level were not associated with persistence of either internalizing or externalizing disorders. An understanding of the persistence, or course, of psychopathology in young children is critical to improving identification and intervention efforts in early childhood. Identifying those children whose difficulties are particularly intransigent would aid decision making regarding eligibility for targeted prevention and intervention programs. In this work, the persistence of high levels of parent-reported internalizing, externalizing, and dysregulation problems is examined in a sociodemographically diverse, representative, community sample of children first studied at approximately 1 to 3 years of age. Patterns of overall persistence, homotypic persistence, and heterotypic persistence are examined, with attention paid to the role that having problems in multiple or co-occurring areas may have on persistence. In addition, factors that may contribute to persistence are examined, including child sex, child age, problem severity, disruptions in family routine attributed to child behavior, sociodemographic risk, and potential risks and stressors within the family. METHOD Participants The sample studied is an age- and sex-stratified healthy birth cohort randomly selected from birth records at the State of Connecticut Department of Public Health for children born in a Standard Metropolitan Statistical Area of the 1990 Census

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(Briggs-Gowan et al., 2001). Children likely to have developmental delays caused by prematurity, low birth weight, or birth complications were excluded, as were parents unable to participate in English and families that had moved out of the state. Of an eligible sample of 1,605, 1,280 families participated (80% response rate) in year 1. These participants were sociodemographically similar to families living in the region (Briggs-Gowan et al., 2001). Of year 1 participants, 1,169 (91.3%) participated in the year 2 survey. Seventeen children were subsequently deemed ineligible because of significant developmental delays identified during the study (e.g., autism spectrum disorders). Longitudinal analyses were restricted to children with complete ITSEA data, the same respondent over time, and a minimum interval of 6 months between the year 1 and year 2 surveys. Most of the analyzed sample (89%) had a 9- to 15-month interval (mean 12.3 months; SD = 1.8 months); 5.5% had 6- to 8-month intervals, and 5.8% had 15- to 22-month intervals. The final sample included in analyses (N = 1,082) was similar to the sample (n = 178) not available for analyses (because of nonparticipation, respondent change, incomplete data, or time interval restrictions) with respect to child sex, marital status, and poverty status, but differed significantly (p G .05) on year 1 child age in months (mean 24.2, SD = 7.0 versus mean 28.1, SD = 7.5, respectively), minority ethnicity (36% versus 61%), and respondent educational attainment of high school degree or less (27% versus 41%). Weights were employed in all analyses to adjust for potential biases in the retained sample. Weights accounted for unequal selection probabilities, differential nonresponse in the initial study, and differential attrition. Information from birth records concerning sociodemographic background (e.g., parental age, education and race) and birth status (e.g., birth weight and gestational age) were used to adjust for differential nonresponse and attrition in calculating final sampling weights. Weighting resulted in nonwhole integers for cell counts; these were rounded in the results to aid readability. The majority of children ($97%) were within the target child age ranges of 12 to 35 months in year 1 and 24 to 47 months in year 2. The remaining children were slightly outside these age ranges because of variability in the length of time needed to locate subjects and obtain participation. In year 1, 547 were 12 to 23 months, 508 were 24 to 35 months, and 27 were 36 to 40 months. In year 2, 12 children were 23 months, 532 were 24 to 35 months, 513 were 36 to 47 months, and 25 were 48 months. Boys and girls were equally represented (49.7% boys). Children were ethnically diverse (64.1% white, 18.7% black, 4.7% Hispanic, 9.2% multiethnic minority, 2.0% Asian, and 1.3% other ethnicity). Most respondents were mothers (97.7%) and married/cohabiting with a partner (79.0%). Approximately 27% of respondents had completed a high school education or less, 32% had some education beyond high school, and 41% had a college degree or more. Median annual income was $50,000, with 19.3% of families living on incomes below the poverty line and 16.0% living in borderline poverty (i.e., below 185% of poverty). Measures Sociodemographic Variables. Parents answered questions about sociodemographic factors, such as child sex, age, ethnicity, parental education, marital status, and household income. Infant-Toddler Social and Emotional Assessment (ITSEA). The Internalizing, Externalizing, and Dysregulation domains of the ITSEA, a 166-item parent report measure of social-emotional/ behavioral problems and competencies in 12- to 48-month-olds, were

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employed (Carter and Briggs-Gowan, 2005; Carter et al., 2003). The Internalizing domain measures general anxiety, depression/withdrawal, inhibition to novelty/shyness, and separation distress. The Externalizing domain measures aggression/defiance, peer aggression, and activity/impulsivity. The Dysregulation domain measures problems with regulation of state, affect, and sensory processes across the areas of negative emotionality, eating, sleep, and sensory sensitivities. Items are rated on a 3-point scale from not true/rarely to very true/often. Across several studies, the ITSEA has demonstrated acceptable internal consistency, test-retest reliability, and validity relative to other parent report checklists and independent behavioral observations (Carter and Briggs-Gowan, 2005). Domain cutpoints are set at the 90th percentile. A Total ITSEA Problems T score was calculated as the sum of the three domain scores standardized within 6-month age bands and sex. Family Life Impairment Scale (FLIS). The 21-item FLIS assesses the extent to which the parent views the young child_s behavior, personality, or special needs as limiting the child_s participation in activities that are typical for families with young children (e.g., visiting family, dining at family restaurants, going grocery shopping) or as negatively affecting the parent (e.g., by placing restrictions on the parent_s socialization with friends or intimate time with her partner). The FLIS was developed for this study as a brief measure that would be appropriate for a normative sample of children, most of whom would not have disabilities or chronic health problems. Worry About Child. Parents rated their level of worry about their child_s behavior, social development, and emotional development on a 5-point scale (1 = not at all worried to 5 = extremely worried). Parenting Stress Index Short Form. The Parent Distress (PD) and Parent-Child Dysfunctional Interaction (PCDI) scales were employed (Abidin, 1990). PD addresses general stress and dissatisfaction in the parenting role. PCDI measures whether the child meets parental expectations and reinforces the parent. These scales have acceptable reliability and validity. Clinical cutpoints available from the author (Abidin) were employed. Center for Epidemiologic Studies Depression Inventory. The 20item Center for Epidemiologic Studies Depression Inventory selfreport checklist assesses adult depressive symptoms. It has demonstrated high internal consistency (coefficient ! from .84 to .90) and modest test-retest reliability (r = 0.51 to 0.67; Radloff, 1977). A clinical cutpoint of 16 was employed. Beck Anxiety Inventory. This self-report measure consists of statements that describe common symptoms of anxiety (Beck et al., 1988). Symptoms are rated on a 4-point scale from Bnot at all bothered[ to Bseverely bothered.[ Psychometric properties are adequate. A clinical cutpoint of 16 was employed. Family Environment Scale (FES). The FES Expressiveness and Conflict subscales were employed (Moos and Moos, 1983). These subscales have acceptable reliability and validity in measuring disruptions in family functioning. Cutpoints indicating Conflict scores in the upper 80th percentile and Expressiveness scores in the lowest 20th percentile were employed. Life Events. The child stressful life events measure, developed as a companion to the ITSEA, comprises 14 items that children may have experienced in their lifetime (e.g., hospitalization, injury, separation from parent, violence). The parent life events comprises 38 items selected from the Life Events Inventory (Cochrane and Robertson, 1973), based on having the highest severity weights and greatest applicability to young families. Social support was measured with the Tangible and Emotional Informational Support measures of the Medical Outcomes Study (Sherbourne and Stewart, 1991). The scales comprise 12 items and have demonstrated adequate psychometric properties.

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ARE INFANT-TODDLER PROBLEMS TRANSIENT?

Procedure Parents were invited to participate via mail and telephone. Most parents answered the questions as self-report questionnaires. Less than 5% of parents were read questions verbatim by research staff. Informed consent procedures were followed. All of the procedures were approved by the institutional human subjects review board. Parents who declined participation were not contacted further. Parents received $25 for participating. Similar procedures were used in both years. RESULTS Initial Problems

In the overall sample, 20.3% of children were reported to have any ITSEA problem, defined as one or more Internalizing, Externalizing, and/or Dysregulation score above the 90th percentile based on the sex of the child and 6-month age bands (Table 1). Approximately 14.2% of children had a single high domain score (i.e., Bpure[ problems) and 6.1% had multiple high domain scores (i.e., Bco-occurring[ problems in two or three domains). Notably, 30.1% of children with Any Problem had co-occurring problems. Rates of problems were similar for boys and girls across all pure and cooccurring groups. In year 2, similar rates of problems were reported across these groupings. Persistence

Overall Problem Persistence. The rate of overall problem persistence, defined as the presence of Any ITSEA Problem in year 2 among children with any ITSEA problem year 1, was 49.9% (Table 1) and was similar for boys (47.6%) and girls (52.6%). Similar rates of persistence were obtained among younger children (12Y23 months: 54.5%) and older children (24Y40 months: 45.3%), # 2 = 1.62, not significant. Although not a focus of this article, the incidence of any ITSEA problem in year 2 among children with no year 1 problem was 14.0%. Homotypic and Heterotypic Persistence. Homotypic persistence was defined as the presence of a high score in the same domain over time, regardless of the presence of co-occurring problems in other domain(s). Homotypic persistence rates were 37.8% for the Internalizing domain, 49.9% for the Externalizing domain, and 38.7% for the Dysregulation domain, with no significant differences in rates across the domains. Rates of homotypic persistence were comparable for boys and girls: Internalizing, 30.4% versus 46.1%; Externalizing, 47.4% versus 52.7%; and

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Dysregulation, 39.7% versus 37.7%, respectively (p > .05). In addition, there were no significant difference between younger and older children in rates of homotypic persistence of Internalizing (35.8% versus 39.9%), Externalizing (55.7% versus 43.4%), or Dysregulation (38.8% versus 38.7%) problems. Heterotypic persistence was defined as the presence of problem(s) in different areas over time. Of the 110 children with persistent problems, only 11.8% (n = 13) had problems solely in a new area in year 2. All shifts were from one pure group to another pure group and most (12/13) involved Dysregulation (4 Dysregulation to Internalizing, 3 Dysregulation to Externalizing, 5 Externalizing to Dysregulation, and 1 Internalizing to Externalizing). Rates of Persistence in Pure and Co-occurring Groupings. As a first step in examining the possible influence of cooccurring problems (present in 30.1% of children with Any Problem), mutually exclusive groups were formed TABLE 1 Rates of Initial Problems and Overall Persistence (Weighted) (N = 1,082) Any ITSEA Year 1 Problem Year ITSEA 2 (Overall Problem(s) Persistence) Year 1 ITSEA Domains Any internalizing problem Any externalizing problem Any dysregulation problem Any problem (Internalizing, Externalizing, and/or Dysregulation domain) No problem Mutually exclusive groupings Internalizing only Externalizing only Dysregulation only Internalizing and Externalizing Internalizing and Dysregulation Externalizing and Dysregulation Internalizing, Externalizing, and Dysregulation

NY1(%)

NY2 (% NY2/NY1)

105 (9.7) 55 (52.0) 101 (9.4) 64 (63.3) 105 (9.7) 61 (58.0) 220 (20.3) 110 (49.9)

862 (79.7) 120 (14.0) 57 (5.3) 51 (4.7) 45 (4.2) 7 (0.6)

19 (33.5)A 26 (51.1)A,B 15 (33.6)A 4 (55.2)A,C

15 (1.4)

11 (73.2)B,C

18 (1.7)

14 (78.2)B,C

26 (2.4)

21 (79.2)C

Note: Cells that do not share a common superscript letter differ significantly, p G .01. ITSEA = Infant-Toddler Social and Emotional Assessment; Y1 = year 1; Y2 = year 2.

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based on the combination of problems in year 1 (Table 1). Across the pure groups, overall persistence rates ranged from 33.5% for Internalizing only to 51.1% for Externalizing only, with no significant differences in rates across the pure groups. In the co-occurring groups, persistence rates ranged from 55.2% for Internalizing/ Externalizing to 79.2% for Internalizing/Externalizing/ Dysregulation, with no significant differences in persistence across the co-occurring groups. The co-occurring groups tended to be significantly more persistent than the pure groups. However, Externalizing only and Internalizing/Externalizing were exceptions to this pattern: the Externalizing only group differed only from the Internalizing/Externalizing/Dysregulation group and the Internalizing/Externalizing group did not differ from any other group. When children with co-occurring problems were compared with children with pure problems, those with co-occurring problems were approximately 4.7 times more likely to have Any Problem in year 2, #2 = 22.09, p G .0001, relative risk ratio (RR) = 4.65, 95% confidence interval (CI) = 2.43Y8.86. Bivariate analyses were employed to examine whether, for each domain separately, the presence of co-occurring problems significantly increased the likelihood of (1) overall problem persistence and (2) homotypic persistence within that domain (Table 2). For all domains, overall persistence was significantly more likely in the co-

occurring group than in the pure group, with increased RR ranging from approximately 2.9 for Externalizing to 6.7 for Dysregulation. However, the impact of cooccurring problems on homotypic persistence varied with domain. For Dysregulation, homotypic persistence was approximately 4.5 times more likely in the co-occurring group (53.5%) than in the pure group (20.1%). Yet, co-occurring problems had no significant effect on the homotypic persistence of Internalizing or Externalizing problems. Severity. Because the impact of co-occurrence on persistence may be related to overall problem severity, an analysis of variance (ANOVA) was examined in which the Total ITSEA Problems T score was the dependent variable and overall persistence status and child sex were independent variables. The overall model was significant, F3,216 = 9.10, p G .0001, as was the effect of persistence status, F1,216 = 26.84, p G .0001, with higher Total Problems in the persistent group (mean = 66.83, SD = 8.91) than in the remitting group (mean = 61.07, SD = 7.61). There was no significant sex effect (F1,216 = 0.01) nor was there a significant interaction between sex and persistence status (F1,216 = 0.88; data not shown). Factors Related to Overall Problem Persistence. As a first step in identifying sociodemographic and parent/ family functioning factors associated with increased risk

TABLE 2 Effect of Co-occurrence on Rates of Overall and Homotypic Persistence Among Children With Any Problem, Year 1 Year 2 ITSEA Status

Year 1 ITSEA Status Internalizing Pure Internalizing Co-occurring Internalizing Relative risk (95% CI) Externalizing Pure Externalizing Co-occurring Externalizing Relative risk (95% CI) Dysregulation Pure Dysregulation Co-occurring Dysregulation Relative risk (95% CI)

NY1

Overall Problem Persistence NY2 (%)a

Homotypic Persistence NY2 (%)a

57 48

19 (33.5) 35 (74.0) 5.63 (2.42 Y 13.17)

18 (31.9) 21 (44.9) 1.74 (0.78 Y 3.85)

51 50

26 (51.1) 38 (75.7) 2.98 (1.28 Y 6.94)

21 (41.4) 29 (58.4) 1.99 (0.90 Y 4.38)

45 59

15 (33.6) 46 (77.3) 6.74 (2.83 Y 16.04)

9 (20.1) 32 (53.5) 4.57 (1.88 Y 11.12)

Note: Relative risks shown in bold are statistically significant (i.e., confidence intervals exclude 1.0). ITSEA = Infant-Toddler Social and Emotional Assessment; Y1 = year 1; Y2 = year 2 ; CI = confidence interval. a % = NY1/NY2.

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TABLE 3 Bivariate Analysis of Factors Related to Persistence Among Children With Any Problem in Year 1 Factor Remit NFactor/NRemit(%) Persist (Any Problem) NFactor/NPersist(%) Child factors Sex (male) Age group (24 Y 40 mo) Co-occurring problems Sociodemographics Resp. educ. e high school Poor/borderline poor Single parent Minority ethnicity Parenting stress Parent worry about child Family life impairment PSI/parenting distress PSI/P-C dysfunction Parent/family factors Depressive symptoms Anxiety symptoms FES expressiveness FES conflict Parent stressful events Child stressful events Low social support

58/103 (56.2) 58/103 (56.8) 15/103 (14.8)

50/100 (50.4) 46/100 (46.1) 43/100 (43.5)y

36/103 44/103 31/103 48/103

(34.7) (43.2) (30.5) (46.8)

38/109 (38.3) 52/99 (53.1) 36/100 (35.6) 55/100 (55.5)

36/103 43/103 7/103 7/103

(34.5) (41.4) (6.7) (6.6)

45/100 (44.7) 67/100 (66.9)*** 26/100 (25.6)*** 15/100 (15.1)*

24/103 (23.5) 3/103 (3.0) 20/100 (20.2) 17/97 (17.2) 9/103 (8.8) 8/103 (7.6) 22/101 (21.5)

36/100 (36.2)* 14/100 (14.4)** 14/99 (13.8) 22/99 (22.0) 14/100 (14.5) 11/100 (10.5) 27/98 (28.1)

Note: Sample size reduced due to elimination of 17 subjects with missing covariate data. Significance evaluated with continuity adjusted #2. Resp. educ. e high school = respondent educational attainment of less than or equal to a high school degree; PSI = Parenting Stress Index; PSI/ P-C = Parent-Child Dysfunctional Interaction; FES = Family Environment Scale. * p G .10; ** p G .01; *** p G .001; y p G .0001.

of overall persistence (persist versus remit), bivariate # 2 tests were employed (Table 3). Persistence was significantly more likely in the presence of high year 1 parental anxiety, parenting distress, and FLIS disruption in family life than when each of these factors was not high. Persistence status was not significantly associated with any other factor tested. A multivariate stepwise logistic regression model was employed to further examine these associations. The model included all variables that met a significance level of p G .10 in the bivariate analyses, thus restricting the number of variables in the model, as was necessary because of power constraints. Overall problem persistence was significantly more likely when co-occurring problems were present (RR = 3.89), with high parenting distress (RR = 3.96) and with high FLIS disruption (RR = 2.11) (Table 4). Parental depressive symptoms, anxiety symptoms, and PSI-PC did not remain in the final model. No significant interactions were present. A competing model

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in which Total ITSEA Problems and Co-occurring Problems were entered in the first model step indicated comparable model fit (likelihood ratio = 40.82, p G .0001)

TABLE 4 Multivariate Logistic Regression Examining Factors Related to Overall Problem Persistence Among Children With Any Problem in Year 1 (n = 203) Estimate SE RR 95% CI Intercept Y 1.01 0.25 V V Co-occurring 1.36 0.36 3.89*** 1.93 Y 7.85 problems PSI/parenting 1.38 0.48 3.96** 1.55 Y 10.13 distress High family life 0.75 0.31 2.11* 1.14 Y 3.92 impairment Likelihood ratio (5,203) = 39.13, p G .0001 Note: PSI = Parenting Stress Index. * p G .05; ** p G .01; *** p G .001.

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BRIGGS-GOWAN ET AL.

and the same pattern of significant effects. Results indicated shared variance between Total Problems and Co-occurrence; although Total Problems was not significant (p G .20), co-occurrence had smaller RR than in the first model (RR = 2.56, 95% CI 1.00Y6.53, p G .05). DISCUSSION

A primary aim of this work was to document the persistence of parent-reported psychopathology in infants and toddlers in a representative healthy birth cohort. Our findings indicate that even at this young age, elevations in social-emotional and behavioral problems are not transient. Approximately half of the infants and toddlers who were reported to have high social-emotional and behavioral problems continued to have such problems approximately 1 year later. Furthermore, rates were comparable for younger and older children. This level of persistence is consistent with findings reported by others who have studied this phenomenon in early childhood (Fischer et al., 1984; Lavigne et al., 1998; Mathiesen and Sanson, 2000) and parallels rates of persistence documented in school-age children (Briggs-Gowan et al., 2003). Furthermore, although many studies have examined homotypic stability using symptom counts, fewer have examined homotypic persistence using cutpoints or diagnostic status (Lavigne et al., 1998; Mathiesen and Sanson, 2000). Our findings indicate substantial homotypic stability in cutpoint status, with rates of 38% for Internalizing, 39% for Dysregulation, and 50% for Externalizing. These early, stable, and distinctive manifestations of psychopathology support the presence of early differentiation in psychopathological behaviors that may be signs of later disorders or represent the presence of early childhood disorders. In addition to contributing to our understanding of the unfolding of early psychopathology, these findings have implications for identifying children whose socialemotional/behavioral problems are most likely to persist and who are likely to have the greatest need of intervention. Remarkably, persistent social-emotional/ behavioral problems were reported in approximately 75% of children with co-occurring problems. Children with co-occurring problems represented 30% of children with any initial problem and nearly half of children whose problems persisted. These children were approximately 4.7 times more likely to have persistent

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problems than children with pure problems, and 3.9 times more likely after controlling for parenting distress and family disruption. Thus, comprehensive assessment tools capable of identifying problems in multiple domains may aid efforts to identify children at particular risk of persistent problems. There may be several explanations for the link between co-occurrence and overall persistence. For example, when problem behaviors are of greater number or severity, it is simply less probable that all problems will drop below cutpoint thresholds. It also is possible that difficulty with emotion regulation manifests across multiple areas, such as aggression/defiance, separation distress, and sleep problems. Co-occurring problems also may indicate a greater progression of psychopathology, in which problems that began in one area become more pervasive and affect functioning in another area. For example, oppositionality first expressed as defiance may develop an aggressive component and come to be expressed as power struggles at mealtime or bedtime. Our multivariate findings indicated that total problems and co-occurrence shared variance; thus, persistence is likely related to both severity and pervasiveness across domains. Furthermore, co-occurring problems were associated with increased homotypic persistence of dysregulation problems (co-occurring 54%, pure 20%), but not with increased persistence of internalizing or externalizing problems. The presence of problem behaviors in other domains may make it more challenging for parents to help their children to develop more appropriate regulatory skills. Furthermore, the relatively low stability of dysregulation when not accompanied by problems in other areas suggests that the dysregulation construct measured does not have a strong temperamental component. Factors other than co-occurrence also affect persistence, as evidenced by the fact that approximately half of children with persistent problems had initial pure problems. Controlling for co-occurrence, persistence was more likely when parents reported high levels of parenting distress and/or disruption in family life because of their child_s behavior. This is consistent with studies of older children that have linked greater parental burden with symptom severity, impairment, and service use (Angold et al., 1998). Although there are likely bidirectional influences between child psychopathology and parenting distress and family disruption, these

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ARE INFANT-TODDLER PROBLEMS TRANSIENT?

associations highlight the need to include both children and parents in assessment and intervention. The lack of sex differences is notable and contrasts with some prior evidence of sex differences in problem persistence and stability. This difference may reflect in part that the ITSEA employs age- and sex-based cutpoints. Thus, although there are sex differences in some ITSEA subscales (Carter et al., 2003), when compared within age and sex bands, patterns of cooccurrence, overall persistence, and homotypic continuity did not differ for boys and girls. Limitations

The reliance on parental reports without corroboration from direct observation or another informant constrains our ability to establish the clinical significance of the problem behaviors studied. Reporting biases or individual differences in thresholds applied when reporting problems behaviors may affect parental reports. Nevertheless, parental perceptions of extreme social-emotional/behavioral problems, even if not initially clinically significant, may become so when maintained over a period of years. Additional research is warranted to examine the contributions of temperament, emotion regulation, and symptom clusters to the developmental course of psychopathology. Ideally, this future research would incorporate observational methods and newly available structured diagnostic interviews (Del Carmen-Wiggins and Carter, 2004) to allow careful characterization of temperament, emotional regulation, and psychopathology. Clinical Implications

Most broadly, the high rates of persistence observed contrast with a view of early problems as developmentally transient. Early social-emotional/behavioral problems appear to be especially intransigent when problems are present in multiple domains and when parents report high distress in parenting and disruption in family routines. Results also indicate that many parents who reported persistent psychopathology were not worried about their child_s behavior, thus emphasizing the need for systematic early identification strategies, such as screening with normed instruments. Finally, evidence that persistence was related to both cooccurrence of problems across domains and disrupted/ distressed parenting suggests that child psycho-

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pathology and disrupted/distressed parenting may be mutually maintaining, thus emphasizing the need for parentYchild interventions. Disclosure: The Infant-Toddler Social and Emotional Assessment (ITSEA) is licensed for publication with Harcourt Assessment. Drs. Carter and Briggs-Gowan will receive royalties from its publication. The other authors have no financial relationships to disclose.

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BRIGGS-GOWAN ET AL. Lavigne JV, Arend R, Rosenbaum D, Binns HJ, Christoffel KK, Gibbons RD (1998), Psychiatric disorders with onset in the preschool years: I. Stability of diagnoses. J Am Acad Child Adolesc Psychiatry 37: 1246 Y 1254 Mathiesen KS, Sanson A (2000), Dimensions of early childhood behavior problems: stability and predictors of change from 18 to 30 months. J Abnorm Child Psychol 28:15 Y 31 Mesman J, Bongers IL, Koot HM (2001), Preschool developmental pathways to preadolescent internalizing and externalizing problems. J Child Psychol Psychiatry 42:679 Y 689 Mesman J, Koot HM (2001), Early preschool predictors of preadolescent internalizing and externalizing DSM-IV diagnoses. J Am Acad Child Adolesc Psychiatry 40:1029 Y 1036 Moos RH, Moos BM (1983), Family Environment Scale. In: Family Health and Neighborhood Questions. Palo Alto, CA: Consulting Psychologists Press National Center for Toddlers and Families (1994), Diagnostic Classification: 0-3. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Washington, DC: National Center for Toddlers and Families Prior M, Smart D, Sanson A, Oberklaid F et al. (1993), Sex differences in psychological adjustment from infancy to 8 years. J Am Acad Child Adolesc Psychiatry 32:291 Y 304 Prior M, Smart D, Sanson A, Pedlow R, Oberklaid F (1992), Transient

versus stable behavior problems in a normative sample: infancy to school age. J Pediatr Psychol 17:423 Y 443 Radloff LS (1977), The CES-D scale: a self report depression scale for research in the general population. Appl Psychol Meas 1:385 Y 401 Rose SL, Rose SA, Feldman JF (1989), Stability of behavior problems in very young children. Dev Psychopathol 1:5 Y 19 Schwartz CE, Snidman N, Kagan J (1999), Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry 38:1008 Y 1015 Shaw DS, Owens EB, Vondra JI, Keenan K, Winslow EB (1996), Early risk factors and pathways in the development of early disruptive behavior problems. Dev Psychopathol 8:679 Y 699 Shaw DS, Winslow EB, Owens EB, Vondra JI, Cohn JF, Bell RQ (1998), The development of early externalizing problems among children from low-income families: a transformational perspective. J Abnorm Psychol 26:95 Y 107 Sherbourne CD, Stewart AL (1991), The MOS Social Support Survey. Soc Sci Med 32:705 Y 714 Smith L, Calkins SD, Keane SP, Anastopoulos AD, Shelton TL (2004), Predicting stability and change in toddler behavior problems: contributions of maternal behavior and child gender. Dev Psychol 40:29 Y 42 Zeanah CHJ (2000), Handbook of Infant Mental Health, 2nd ed. New York: The Guilford Press

Comparison of Complementary and Alternative Medicine Use: Reasons and Motivations Between Two Tertiary Children_s Hospitals D.R. Cincotta, N.W. Crawford, A. Lim, N.E. Cranswick, S. Skull, M. South, C.V.E. Powell Aims: To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and alternative medicine (CAM) use between two tertiary children_s hospitals. Methodology: A study, using a face-to-face questionnaire, of 500 children attending the University Hospital of Wales, Cardiff, UK, was compared to an identical study of 503 children attending the Royal Children_s Hospital, Melbourne, Australia. Results: One year CAM use in Cardiff was lower than Melbourne (41% v 51%; OR = 0.67, 95% CI 0.52j0.85), reflected in non-medicinal use (OR = 0.41, 95% CI 0.29 Y 0.58), and general paediatric outpatients (OR = 0.38,95% CI 0.21 Y 0.67). Compared to Melbourne, factors associated with lower CAM use in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44 Y 0.77) or nontertiary educated parents (mother: OR = 0.54, 95% CI 0.38 Y 0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18 Y 0.51) and herbs (OR = 0.49, 95% CI 0.34 Y 0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06 Y 0.37), and naturopaths (OR = 0.08, 95% CI 0.02 Y 0.33), but saw more reflexologists (OR = 3.33, 95% CI 1.08 Y 10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92, 95% CI 1.03 Y 3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27 Y 0.73). Most CAM was self-initiated (by parent) in Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31 Y 0.68). Nondisclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent medicinal CAM use in inpatient notes (0/21 v 2/22). Conclusions: The differences in CAM use may reflect variation in sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor communication highlights the importance of local policy development. Archives of Disease in Childhood 2006;91:153 Y 158.

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