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1.  Behavioral and Socio-Emotional Competence Problems of Extremely Low Birth Weight Children 
To examine behavioral and social-emotional problems in extremely low birth weight (ELBW) children and to assess factors associated with behavioral and social competency outcomes at 30 to 36 months adjusted age.
Study Design
A total of 696 ELBW (401–1000 g) children from the NICHD Neonatal Research Network were included. Behavioral and social-emotional problems were assessed using the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) administered to parents. Unadjusted comparisons were performed between children with or without behavioral or social emotional problems. Logistic regression was used to examine factors associated with behavioral outcomes.
Parents reported behavioral problems in 46.8%, deficits in social-emotional competence in 20.4% and having both behavioral and social-emotional competence problems in 15.4% of ELBW children. Characteristics associated with behavioral problems in logistic regression included female gender, lower household income and a Bayley PDI < 70. Deficits in social competence were associated with Bayley MDI and PDI scores < 70 and Hispanic or Other races compared with White non-Hispanic.
Half of the (51.9%) ELBW children showed behavioral or social-emotional competence problems at 30 months. Low socioeconomic status and low Bayley MDI and PDI scores were associated with behavioral and socio-emotional difficulties.
PMCID: PMC4139103  PMID: 23867957
Premature; Prematurity; Behavior; Socioemotional
2.  The Importance of Early Parenting in At-Risk Families and Children’s Social-Emotional Adaptation to School 
Academic Pediatrics  2010;10(5):330-337.
To determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to children’s social-emotional adaptation to school.
Cohort study of families (n=318) identified as at-risk for maltreatment of their newborns. Quality of early parenting was observed in the home when the child was one year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation.
Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems.
In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well child visits. Well child visit-based interventions to improve the quality of early parenting especially among at-risk families should be studied for their impact on parenting behavior and on children’s successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.
PMCID: PMC3383459  PMID: 20816655
Parenting; Child Rearing; Parent-Child Relations; Social Adjustment; Social Behavior (Aggression, Shyness, Rejection); Vulnerable Populations
3.  Sleep in Infancy Predicts Gender Specific Social-Emotional Problems in Toddlers 
Despite strong evidence linking sleep to developmental outcomes, the longitudinal relationship between sleep and emotional well-being remains largely unknown. To address this gap in our knowledge, the current study examined sleep in infancy, measured via actigraphy, as a predictor of social-emotional problems in toddlers. A total of 47 children (29 males) were included in this longitudinal study. At time one, actigraphy measures of sleep were obtained from 3- to 4-month-old infants. At time two, parents rated their 18- to 24-month-old toddler’s social-emotional well-being using the Brief Infant Toddler Social Emotional Assessment. Results indicated that boys tended to have higher levels of externalizing behaviors than did girls. Additionally, boys with longer sleep durations also showed lower sleep efficiency. In girls, sleep duration in infancy was a significant predictor of autism spectrum disorder behaviors and approached significance as a predictor of externalizing problems in toddlerhood. Our findings are the first to show a relationship between sleep measured in infancy and autism spectrum disorder symptomatology measured in early childhood. They suggest that the etiology of social-emotional problems may differ between genders and raise the possibility that sleep/wake cycles may be differentially related to autism spectrum disorder symptoms in girls and boys.
PMCID: PMC4426713  PMID: 26029685
actigraphy; sleep; infants; toddlers; social-emotional; longitudinal studies
4.  Reliability and Validity of the Dutch Version of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) 
PLoS ONE  2012;7(6):e38762.
The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) is a relatively new and short (42-item) questionnaire that measures psychosocial problems in toddlers and consists of a Problem and a Competence scale. In this study the reliability and validity of the Dutch version of the BITSEA were examined for the whole group and for gender and ethnicity subgroups.
Parents of 7140 two-year-old children were invited in the study, of which 3170 (44.4%) parents completed the BITSEA. For evaluation of the score distribution, the presence of floor/ceiling effects was determined. The internal consistency (Cronbach's alpha) was evaluated and in subsamples the test-retest, parent-childcare provider interrater reliability and concurrent validity with regard to the Child Behavioral Checklist (CBCL). Discriminative validity was evaluated by comparing scores of parents that worry and parents that do not worry about their child's development.
The BITSEA showed no floor or ceiling effects. Psychometric properties of the BITSEA Problem and Competence scale were respectively: Cronbach's alphas were 0.76 and 0.63. Test-retest correlations were 0.75 and 0.61. Interrater reliability correlations were 0.30 and 0.17. Concurrent validity was as hypothesised. The BITSEA was able to discriminate between parents that worry about their child and parents that do not worry. The psychometric properties of the BITSEA were comparable across gender and ethnic background.
The results in this large-scale study of a diverse sample support the reliability and validity of the BITSEA Problem scale. The BITSEA Competence scale needs further study. The performance of the BITSEA appears to be similar in subgroups by gender and ethnic background.
PMCID: PMC3371000  PMID: 22715411
5.  Preventing conduct problems and improving school readiness: evaluation of the Incredible Years Teacher and Child Training Programs in high-risk schools 
School readiness, conceptualized as three components including emotional self-regulation, social competence, and family/school involvement, as well as absence of conduct problems play a key role in young children’s future interpersonal adjustment and academic success. Unfortunately, exposure to multiple poverty-related risks increases the odds that children will demonstrate increased emotional dysregulation, fewer social skills, less teacher/parent involvement and more conduct problems. Consequently intervention offered to socio-economically disadvantaged populations that includes a social and emotional school curriculum and trains teachers in effective classroom management skills and in promotion of parent—school involvement would seem to be a strategic strategy for improving young children’s school readiness, leading to later academic success and prevention of the development of conduct disorders.
This randomized trial evaluated the Incredible Years (IY) Teacher Classroom Management and Child Social and Emotion curriculum (Dinosaur School) as a universal prevention program for children enrolled in Head Start, kindergarten, or first grade classrooms in schools selected because of high rates of poverty. Trained teachers offered the Dinosaur School curriculum to all their students in bi-weekly lessons throughout the year. They sent home weekly dinosaur homewrok to encourage parents’ involvement. Part of the curriculum involved promotion of lesson objectives through the teachers’ continual use of positive classroom management skills focused on building social competence and emotional self-regulation skills as well as decreasing conduct problems. Matched pairs of schools were randomly assigned to intervention or control conditions.
Results from multi-level models on a total of 153 teachers and 1,768 students are presented. Children and teachers were observed in the classrooms by blinded observers at the begining and the end of the school year. Results indicated that intervention teachers used more positive classroom management strategies and their students showed more social competence and emotional self-regulation and fewer conduct problems than control teachers and students. Intervention teachers reported more involvement with parents than control teachers. Satisfaction with the program was very high regardless of grade levels.
These findings provide support for the efficacy of this universal preventive curriculum for enhancing school protective factors and reducing child and classroom risk factors faced by socio-economically disadvantaged children.
PMCID: PMC2735210  PMID: 18221346
Aggression; behavior problem; prevention; school; teacher; school readiness
6.  The mental health of preschoolers in a Norwegian population-based study when their parents have symptoms of borderline, antisocial, and narcissistic personality disorders: at the mercy of unpredictability 
Clinical studies have shown that children of parents with mental health problems are most likely to develop psychiatric problems themselves when their parents have a Personality Disorder characterized by hostility. The Personality Disorders that appear most associated with hostility, with the potential to affect children, are Borderline Personality Disorder, Antisocial Personality Disorder and Narcissistic Personality Disorder. The question addressed in this study is whether the risk to children’s mental health extends to the normal population of parents who have subclinical symptomlevels of these disorders.
This inquiry used data from a Trondheim, Norway community sample of 922 preschoolers and one parent for each child. The mean age of the children was 53 months (SD 2.1). Parents reported symptoms of Borderline, Antisocial and Narcissistic Personality Disorders on the DSM-IV ICD-10 Personality Questionnaire, and the children’s symptoms of DSM-IV behavioral and emotional diagnoses were measured with the Preschool Age Psychiatric Assessment, a comprehensive interview. Multigroup Structural Equation Modeling was used to assess the effect of parents’ symptoms on their preschoolers’ behavioral and emotional problems.
The analyses yielded strongly significant values for the effect of parents’ Personality Disorder symptoms on child problems, explaining 13.2% of the variance of the children’s behavioral symptoms and 2.9% of the variance of internalizing symptoms. Biological parents’ cohabitation status, i.e., whether they were living together, emerged as a strong moderator on the associations between parental variables and child emotional symptoms; when parents were not cohabiting, the variance of the children’s emotional problems explained by the parents’ Personality Disorder symptoms increased from 2.9% to 19.1%.
For the first time, it is documented that parents’ self-reported symptoms of Borderline, Antisocial, and Narcissistic Personality Disorders at a predominantly subclinical level had a strong effect on their children’s psychiatric symptoms, especially when the biological parents were not living together. Child service providers need to be aware of these specific symptoms of parental Personality Disorders, which may represent a possible risk to children.
PMCID: PMC3464890  PMID: 22607915
Personality disorder; Psychiatry; Psychopathology; Child; Parent; Generation
7.  Social and emotional difficulties in children with ADHD and the impact on school attendance and healthcare utilization 
The objective of this study was to examine the impact of co-occurring social and emotional difficulties on missed school days and healthcare utilization among children with attention deficit/hyperactivity disorder (ADHD).
Data were from the 2007 U.S. National Health Interview Survey (NHIS) and were based on parental proxy responses to questions in the Sample Child Core, which includes questions on demographics, health, healthcare treatment, and social and emotional status as measured by questions about depression, anxiety, and phobias, as well as items from the brief version of the Strength and Difficulties Questionnaire (SDQ). Logistic regression was used to assess the association between co-occurring social and emotional difficulties with missed school days and healthcare utilization, adjusting for demographics.
Of the 5896 children aged 6–17 years in the 2007 NHIS, 432 (7.3%) had ADHD, based on parental report. Children with ADHD and comorbid depression, anxiety, or phobias had significantly greater odds of experiencing > 2 weeks of missed school days, ≥ 6 visits to a healthcare provider (HCP), and ≥ 2 visits to the ER, compared with ADHD children without those comorbidities (OR range: 2.1 to 10.4). Significantly greater odds of missed school days, HCP visits, and ER visits were also experienced by children with ADHD who were worried, unhappy/depressed, or having emotional difficulties as assessed by the SDQ, compared with ADHD children without those difficulties (OR range: 2.2 to 4.4).
In children with ADHD, the presence of social and emotional problems resulted in greater odds of missed school days and healthcare utilization. These findings should be viewed in light of the limited nature of the parent-report measures used to assess social and emotional problems.
PMCID: PMC3489829  PMID: 23035861
Comorbidities; Attention deficit hyperactivity disorder; Resource use; Outcomes
8.  Prem Baby Triple P: a randomised controlled trial of enhanced parenting capacity to improve developmental outcomes in preterm infants 
BMC Pediatrics  2015;15:15.
Very preterm birth (<32 weeks gestation) is associated with motor, cognitive, behavioural and educational problems in children and maternal depression and withdrawal. Early interventions that target parenting have the greatest potential to create sustained effects on child development and parental psychopathology. Triple P (Positive Parenting Program) has shown positive effects on child behaviour and adjustment, parenting practices and family functioning. Baby Triple P for Preterm infants, has been developed to target parents of very preterm infants. This study tests the effectiveness of Baby Triple P for Preterm infants in improving child and parent/couple outcomes at 24 months corrected age (CA).
Families will be randomised to receive either Baby Triple P for Preterm infants or Care as Usual (CAU). Baby Triple P for Preterm infants involves 4 × 2 hr group sessions at the hospital plus 4 × 30 min telephone consultations soon after transfer (42 weeks C.A.). After discharge participants will be linked to community based Triple P and intervention maintenance up to 24 months C.A. Assessments will be: baseline, post-intervention (6 weeks C.A.), at 12 and 24 months C.A. The primary outcome measure is the Infant Toddler Social & Emotional Assessment (ITSEA) at 24 months C.A. Child behavioural and emotional problems will be coded using the mother-toddler version of the Family Observation Schedule at 24 months C.A. Secondary outcome will be the Bayley Scales of Infant and Toddler Development (BSID III) cognitive development, language and motor abilities. Proximal targets of parenting style, parental self-efficacy, parental mental health, parental adjustment, parent-infant attachment, couple relationship satisfaction and couple communication will also be assessed. Our sample size based on the ITSEA, has 80% power, predicted effect size of 0.33 and an 85% retention rate, requires 165 families are required in each group (total sample of 330 families).
This protocol presents the study design, methods and intervention to be analysed in a randomised trial of Baby Triple P for Preterm infants compared to Care as Usual (CAU) for families of very preterm infants. Publications of all outcomes will be published in peer reviewed journals according to CONSORT guidelines.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN12612000194864.
PMCID: PMC4363360  PMID: 25884634
Preterm infants; Behavioral family intervention; Child behavioral adjustment; Child emotional adjustment; Child cognitive and language development; Parenting support/education
9.  Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study) 
Neurotoxicology and teratology  2010;33(1):78-87.
We previously reported an association between prenatal cocaine exposure (PCE) and childhood behavior problems as observed by the parent or caretaker. However, these behavior problems may not manifest in a structured environment, such as a school setting.
We determined whether there is an association between PCE and school behavior problems and whether ratings of behavior problems from the teacher differ from those noted by the parent or caretaker.
The Maternal Lifestyle Study, a multicenter study, enrolled 1388 children with and without PCE at one month of age for longitudinal assessment. Teachers masked to prenatal drug exposure status completed the Teacher Report Form (TRF/6-18) when children were 7, 9, and 11 years old. We also administered the Child Behavior Checklist-parent report (CBCL) to the parent/caretaker at same ages and then at 13 years. We performed latent growth curve modeling to determine whether high PCE will predict externalizing, internalizing, total behavior, and attention problems at 7 years of age and whether changes in problems' scores over time differ between those exposed and non-exposed from both teacher and parent report. Besides levels of PCE as predictors, we controlled for the following covariates, namely: site, child characteristics (gender and other prenatal drug exposures), family level influences (maternal age, depression and psychological symptomatology, continuing drug use, exposure to domestic violence, home environment, and socioeconomic status), and community level factors (neighborhood and community violence).
The mean behavior problem T scores from the teacher report were significantly higher than ratings by the parent or caretaker. Latent growth curve modeling revealed a significant relationship between intercepts of problem T scores from teacher and parent ratings; i.e., children that were rated poorly by teachers were also rated poorly by their parent/caretaker or vice versa. After controlling for covariates, we found high PCE to be a significant predictor of with higher externalizing behavior problem T scores from both parent and teacher report at 7 years (p=0.034 and p=0.021, respectively) in comparison to non-PCE children. These differences in scores from either teacher or caregiver were stable through subsequent years or did not change significantly over time. Boys had higher T scores than girls on internalizing and total problems by caretaker report; they also had significantly higher T scores for internalizing, total, and attention problems by teacher ratings; the difference was marginally significant for externalizing behavior (p=0.070). Caretaker postnatal use of tobacco, depression, and community violence were significant predictors of all behavior problems rated by parent/caretaker, while lower scores on the home environment predicted all behavior outcomes by the teacher report.
Children with high PCE are likely to manifest externalizing behavior problems; their behavior problem scores at 7 years from either report of teacher or parent remained higher than scores of non-exposed children on subsequent years. Screening and identification of behavior problems at earlier ages could make possible initiation of intervention, while considering the likely effects of other confounders.
PMCID: PMC3011027  PMID: 20600844
10.  Clinical Validity of a Brief Measure of Early Childhood Social–Emotional/Behavioral Problems 
Journal of Pediatric Psychology  2013;38(5):577-587.
Objective To address a pressing need for measures of clinically significant social–emotional/behavioral problems in young children by examining several validity indicators for a brief parent-report questionnaire. Methods An ethnically and economically diverse sample of 213 referred and nonreferred 2- and 3-year-olds was studied. The validity of the Brief Infant–Toddler Social–Emotional Assessment (BITSEA) Problem Index and Internalizing and Externalizing scales was evaluated relative to a “gold standard” diagnostic interview, as well as the Child Behavior Checklist (CBCL). Results The validity of the BITSEA Problem Index relative to Diagnosis (sensitivity = 72.7%–80.8%, specificity = 70.0%–83.3%) and clinical-range CBCL scores (sensitivity = 80.0%–96.2%, specificity = 75.0%–89.9%) was supported in the full sample and within minority/nonminority groups. Additional results supported the validity of the BITSEA Internalizing and Externalizing scales. Conclusions Documented validity suggests that the BITSEA may be a valuable tool to aid screening, identification, and assessment efforts targeting early-emergent social–emotional/behavioral problems. Practical implications and generalizability are discussed.
PMCID: PMC3666122  PMID: 23603252
assessment; early childhood; psychiatric diagnosis; screening; social–emotional/behavioral problems; surveillance
11.  Early Identification of Children At Risk for Costly Mental Health Service Use 
Children and adolescents with serious and persistent conduct problems often require large public expenditures. Successfully diverting one high risk child from unfortunate outcomes may result in a net savings to society of nearly $2 million, not to mention improving the life of that child and his or her family. This figure highlights the potential of prevention, which often rests on the ability to identify these children at a young age. This study examined the ability of a short conduct-problems screening procedure to predict future need for mental health assistance, special education services, and the juvenile justice system during elementary school ages. The screen was based on teacher and parent report of child behavioral habits in kindergarten, and was used to identify children as either at risk or not at risk for behavioral problems. Service outcomes were derived from a service-use assessment administered to parents at the end of the sixth grade, while special education information was gathered through a survey of school records. Study participants (463 kindergarten children; 54% male, 44% African American) were from economically disadvantaged neighborhoods in four diverse communities across the United States. Results indicated that, while controlling for demographic background variables, the risk indicator strongly predicted which children would require services related to conduct disorder or behavioral/emotional problems. Additional analyses revealed that the dichotomous high risk indicator was nearly as strong as the continuous screening variable in predicting the service-use outcomes, and that the screening of both parents and teachers may not be necessary for determining risk status.
PMCID: PMC2774114  PMID: 12458763
prevention; behavioral disorders; service utilization
12.  Regional Cerebral Development at Term Relates to School-Age Social-Emotional Development in Very Preterm Children 
Preterm children are at risk for social-emotional difficulties, including autism and attention deficit hyperactivity disorder. We assessed the relationship of regional brain development in preterm children, evaluated via MRI at term-equivalent postmenstrual age (TEA), to later social-emotional difficulties.
MR images obtained at TEA from 184 very preterm infants (gestation <30 weeks or birthweight <1250 g) were analyzed for white matter abnormalities, hippocampal volume, and brain metrics. 111 infants underwent diffusion tensor imaging, which provided values for fractional anisotropy (FA) and apparent diffusion coefficient (ADC). Social-emotional development was assessed with the Infant Toddler Social and Emotional Assessment (ITSEA) at age 2 and the Strengths and Difficulties Questionnaire (SDQ) at age 5.
Higher ADC in the right orbitofrontal cortex was associated with social-emotional problems at age 5 (peer problems, p<0.01). In females, smaller hippocampal volume was associated with increased hyperactivity (p<0.01), peer problems (p<0.05) and SDQ total score (p<0.01). In males, a smaller frontal region was associated with poorer prosocial (p<0.05) scores. Many of the hippocampal findings remained significant after adjusting for birthweight z score, intelligence, social risk, immaturity at birth, and parental mental health. These associations were present in children who had social-emotional problems in similar domains at age 2 and those who did not.
Early alterations in regional cerebral development in very preterm infants relate to specific deficits in social-emotional performance by school-age. These results vary by gender. Our results provide further evidence for a neuroanatomical basis for behavioral challenges found in very preterm children.
PMCID: PMC3411187  PMID: 22265364
Preterm infant; Neurodevelopment; social-emotional development; orbitofrontal cortex; Hippocampus
13.  “Together at school” - a school-based intervention program to promote socio-emotional skills and mental health in children: study protocol for a cluster randomized controlled trial 
BMC Public Health  2014;14:1042.
Schools provide a natural context to promote children’s mental health. However, there is a need for more evidence-based, high quality school intervention programs combined with an accurate evaluation of their general effectiveness and effectiveness of specific intervention methods. The aim of this paper is to present a study protocol of a cluster randomized controlled trial evaluating the “Together at School” intervention program. The intervention program is designed to promote social-emotional skills and mental health by utilizing whole-school approach and focuses on classroom curriculum, work environment of school staff, and parent-teacher collaboration methods.
The evaluation study examines the effects of the intervention on children’s socio-emotional skills and mental health in a cluster randomized controlled trial design with 1) an intervention group and 2) an active control group. Altogether 79 primary school participated at baseline. A multi-informant setting involves the children themselves, their parents, and teachers. The primary outcomes are measured using parent and teacher ratings of children’s socio-emotional skills and psychological problems measured by the Strengths and Difficulties Questionnaire and the Multisource Assessment of Social Competence Scale. Secondary outcomes for the children include emotional understanding, altruistic behavior, and executive functions (e.g. working memory, planning, and inhibition). Secondary outcomes for the teachers include ratings of e.g. school environment, teaching style and well-being. Secondary outcomes for both teachers and parents include e.g. emotional self-efficacy, child rearing practices, and teacher-parent collaboration. The data was collected at baseline (autumn 2013), 6 months after baseline, and will be collected also 18 months after baseline from the same participants.
This study protocol outlines a trial which aims to add to the current state of intervention programs by presenting and studying a contextually developed and carefully tested intervention program which is tailored to fit a national school system. Identification of effective intervention elements to promote children’s mental health in early school years is crucial for optimal later development.
Trial registration register: NCT02178332.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1042) contains supplementary material, which is available to authorized users.
PMCID: PMC4201723  PMID: 25287298
Children; Intervention; Promotion; Mental health; Socio-emotional skills; Whole school approach
14.  Evaluation of an early detection tool for social-emotional and behavioral problems in toddlers: The Brief Infant Toddler Social and Emotional Assessment - A cluster randomized trial 
BMC Public Health  2011;11:494.
The prevalence of social-emotional and behavioral problems is estimated to be 8 to 9% among preschool children. Effective early detection tools are needed to promote the provision of adequate care at an early stage. The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) was developed for this purpose. This study evaluates the effectiveness of the BITSEA to enhance social-emotional and behavioral health of preschool children.
Methods and Design
A cluster randomized controlled trial is set up in youth health care centers in the larger Rotterdam area in the Netherlands, to evaluate the BITSEA. The 31 youth health care centers are randomly allocated to either the control group or the intervention group. The intervention group uses the scores on the BITSEA and cut-off points to evaluate a child's social-emotional and behavioral health and to decide whether or not the child should be referred. The control group provides care as usual, which involves administering a questionnaire that structures the conversation between child health professionals and parents. At a one year follow-up measurement the social-emotional and behavioral health of all children included in the study population will be evaluated.
It is hypothesized that better results will be found, in terms of social-emotional and behavioral health in the intervention group, compared to the control group, due to more adequate early detection, referral and more appropriate and timely care.
Trial registration
Current Controlled Trials NTR2035
PMCID: PMC3146861  PMID: 21702936
15.  Negative Emotionality Moderates Associations among Attachment, Toddler Sleep, and Later Problem Behaviors 
Secure parent-child relationships are implicated in children’s self-regulation, including the ability to self-soothe at bedtime. Sleep, in turn, may serve as a pathway linking attachment security with subsequent emotional and behavioral problems in children. We used path analysis to examine the direct relationship between attachment security and maternal-reports of sleep problems during toddlerhood, and the degree to which sleep serves as a pathway linking attachment with subsequent teacher-reported emotional and behavioral problems. We also examined infant negative emotionality as a vulnerability factor that may potentiate attachment-sleep-adjustment outcomes. Data were drawn from 776 mother-infant dyads participating in the NICHD Study of Early Child Care (SECC). In the full sample, after statistically adjusting for mother and child characteristics, including child sleep and emotional and behavioral problems at 24 months, we did not find evidence for a statistically significant direct path between attachment security and sleep problems at 36 months; however, there was a direct relationship between sleep problems at 36 months and internalizing problems at 54 months. Path models that examined the moderating influence of infant negative emotionality demonstrated significant direct relationships between attachment security and toddler sleep problems, and sleep problems and subsequent emotional and behavioral problems, but only among children characterized by high negative emotionality at 6 months of age. In addition, among this subset, there was a significant indirect path between attachment and internalizing problems through sleep problems. These longitudinal findings implicate sleep as one critical pathway linking attachment security with adjustment difficulties, particularly among temperamentally vulnerable children.
PMCID: PMC3579637  PMID: 23421840
Sleep; attachment security; emotional and behavioral adjustment; toddler development; negative emotionality
16.  Relations of Maternal Socialization and Toddlers' Effortful Control to Children's Adjustment and Social Competence 
Developmental psychology  2007;43(5):1170-1186.
The authors examined the relations of maternal supportive parenting to effortful control and internalizing problems (i.e., separation distress, inhibition to novelty), externalizing problems, and social competence when toddlers were 18 months old (n = 256) and a year later (n = 230). Mothers completed the Coping With Toddlers' Negative Emotions Scale, and their sensitivity and warmth were observed. Toddlers' effortful control was measured with a delay task and adults' reports (Early Childhood Behavior Questionnaire). Toddlers' social functioning was assessed with the Infant/Toddler Social and Emotional Assessment. Within each age, children's regulation significantly mediated the relation between supportive parenting and low levels of externalizing problems and separation distress, and high social competence. When using stronger tests of mediation, controlling for stability over time, the authors found only partial evidence for mediation. The findings suggest these relations may be set at an early age.
PMCID: PMC2096418  PMID: 17723043
toddlers' effortful control; maternal socialization; social functioning; problem behaviors
17.  Dose–Response Effect of Mother–Infant Clinical Home Visiting on Aggressive Behavior Problems in Kindergarten 
The Objective of this follow-up study was to assess the long-term effects of clinical infant home-visiting services on child outcomes at school entry.
Participants were 63 five-year-olds from low-income families, half of whom were referred to parent–infant home-visiting services during the first 18 months of life due to concerns about the caretaking environment. Families received between 0 and 18 months of weekly home visits based on infant age at entry into the study. At age 5, children were rated by teachers on the Preschool Behavior Questionnaire for behavior problems in the classroom and by parents both on the Simmons Behavior Checklist for behavior problems at home and on the Achenbach Social Competence Items for positive play behaviors with friends.
With initial family risk status and child gender controlled, teacher-rated hostile behavior problems decreased in dose–response relation to the duration of early home-visiting services, which accounted for 15% of the variance in child hostile behavior. Parents' reports of positive play behaviors were positively linearly related to service duration. Parents' reports of behavior problems were less reliably related to service duration than teacher reports.
Early home-visiting services reduced the incidence of aggressive behavior problems among socially at-risk children for up to 3.5 years after the end of services.
PMCID: PMC1896103  PMID: 15167086
aggression; intervention; preschool; conduct disorder; oppositional disorder
18.  Psychiatric outcomes at age seven for very preterm children: rates and predictors 
Uncertainty remains about the rate of specific psychiatric disorders and associated predictive factors for very preterm (VPT) children. The aims of this study were to document rates of psychiatric disorders in VPT children aged 7 years compared with term born children, and to examine potential predictive factors for psychiatric diagnoses in VPT children.
Participants were 177 VPT and 65 term born children. Perinatal medical data were collected, which included brain abnormalities detected using magnetic resonance imaging. The Infant-Toddler Social-Emotional Assessment (ITSEA) and Strengths and Difficulties Questionnaire (SDQ) were administered at 2 and 5 years respectively. At 7 years of age, the Developmental and Well-being Assessment (DAWBA) was used to indicate psychiatric diagnoses.
Compared with term born children, VPT children had three times the odds of meeting criteria for any psychiatric diagnosis at age 7 years (odds ratio 3.03; 95% confidence interval 1.23, 7.47, p = .02). The most common diagnoses were anxiety disorders (11% VPT, 8% term), attention-deficit/hyperactivity disorder (10% VPT, 3% term) and autism spectrum disorder (4.5% VPT, 0% term). For VPT children, those with severe global brain abnormalities (p = .02), those who displayed social-emotional problems at age 5 (p = .000) and those with higher social risk at age 7 (p = .001) were more likely to meet criteria for a psychiatric illness at age 7.
Compared with term born children, VPT children have higher rates of psychiatric diagnoses at early school age, predicted by neonatal brain abnormalities, prior social-emotional problems and social factors.
PMCID: PMC3821531  PMID: 23347471
Preterm; psychiatric disorder; brain abnormality; predictor; mental health
19.  Screening for Autism Spectrum Disorders with the Brief Infant-Toddler Social and Emotional Assessment 
PLoS ONE  2014;9(5):e97630.
Using parent-completed questionnaires in (preventive) child health care can facilitate the early detection of psychosocial problems and psychopathology, including autism spectrum disorders (ASD). A promising questionnaire for this purpose is the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). The screening accuracy with regard to ASD of the BITSEA Problem and Competence scales and a newly calculated Autism score were evaluated.
Data, that was collected between April 2010 and April 2011, from a community sample of 2-year-olds (N = 3127), was combined with a sample of preschool children diagnosed with ASD (N = 159). For the total population and for subgroups by child's gender, area under the Receiver Operating Characteristic (ROC) curve was examined, and across a range of BITSEA Problem, Competence and Autism scores, sensitivity, specificity, positive and negative likelihood ratio's, diagnostic odds ratio and Youden's index were reported.
The area under the ROC curve (95% confidence interval, [95%CI]) of the Problem scale was 0.90(0.87–0.92), of the Competence scale 0.93(0.91–0.95), and of the Autism score 0.95(0.93–0.97). For the total population, the screening accuracy of the Autism score was significantly better, compared to the Problem scale. The screening accuracy of the Competence scale was significantly better for girls (AUC = 0.97; 95%CI = 0.95–0.98) than for boys (AUC = 0.91; 95%CI = 0.88–0.94).
The results indicate that the BITSEA scales and newly calculated Autism score have good discriminative power to differentiate children with and without ASD. Therefore, the BITSEA may be helpful in the early detection of ASD, which could have beneficial effects on the child's development.
PMCID: PMC4031151  PMID: 24851868
20.  Mental Health Problems in Young Children Investigated by US Child Welfare Agencies 
To examine the prevalence/predictors of mental health (MH) problems and services use in 12–36 month old children who had been investigated for maltreatment.
Data came from the second National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal study of youth ages 0–17.5 years referred to US child welfare agencies. These analyses involved 1117 children 12–36 months of age. Sociodemographic, social services, developmental and health data were collected on the children and caregivers. Outcomes were scores over the clinical cutoffs on the Brief Infant Toddler Social and Emotional Assessment (BITSEA) Scales for 12–18 month olds and the Child Behavior Checklist (CBCL) for 19–36 month olds.
34.6% of 12–18 month olds scored high on the Problem Scale of the BITSEA, and 20.9% on the Competence Scale while 10.0% of 19–36 month olds scored over the CBCL clinical cut-off. Black children were less likely to have elevated scores on the BITSEA Problem Scale but children who lived with a never married caregiver were 5 times more likely to have elevated scores. Competence problems were associated with prior child welfare history. Elevated CBCL scores were associated with living with a depressed caregiver. Few children with identified MH problems, 2.2%, received a MH service. When we added parent skills training that might be related to the treatment of child problems, 19.2% received a service.
Identifiable MH problems are common but few children receive services for those problems. The lack of services received by these young, multi-challenged children is a services systems and social policy failure. Keywords: child mental health problems; child welfare; mental health services use
PMCID: PMC3367393  PMID: 22632617
21.  The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis 
PLoS Medicine  2012;9(11):e1001349.
Rosana Norman and colleagues conduct a systematic review and meta-analysis to assess the relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
Methods and Findings
A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16–2.04], emotional abuse [OR = 3.06; 95% CI 2.43–3.85], and neglect [OR = 2.11; 95% CI 1.61–2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67–2.20], emotional abuse [OR = 1.41; 95% CI 1.11–1.79], and neglect [OR = 1.36; 95% CI 1.21–1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17–5.32], emotional abuse [OR = 3.37; 95% CI 2.44–4.67], and neglect [OR = 1.95; 95% CI 1.13–3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50–2.10], emotional abuse [OR = 1.75; 95% CI 1.49–2.04], and neglect [OR = 1.57; 95% CI 1.39–1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.
This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.
Please see later in the article for the Editors' Summary
Editors' Summary
Child maltreatment—the abuse and neglect of children—is a global problem. There are four types of child maltreatment—sexual abuse (the involvement of a child in sexual activity that he or she does not understand, is unable to give consent to, or is not developmentally prepared for), physical abuse (the use of physical force that harms the child's health, survival, development, or dignity), emotional abuse (the failure to provide a supportive environment by, for example, verbally threatening the child), and neglect (the failure to provide for all aspects of the child's well-being). Most child maltreatment is perpetrated by parents or parental guardians, many of whom were maltreated themselves as children. Other risk factors for parents abusing their children include poverty, mental health problems, and alcohol and drug misuse. Although there is considerable uncertainty about the frequency and severity of child maltreatment, according to the World Health Organization (WHO) about 20% of women and 5%–10% of men report being sexually abused as children, and the prevalence of physical abuse in childhood may be 25%–50%.
Why Was This Study Done?
Child maltreatment has a large public health impact. Sometimes this impact is immediate and direct (injuries and deaths), but, more often, it is long-term, affecting emotional development and overall health. For child sexual abuse, the relationship between abuse and mental disorders in adult life is well-established. Exposure to other forms of child maltreatment has also been associated with a wide range of psychological and behavioral problems, but the health consequences of physical abuse, emotional abuse, and neglect have not been systematically examined. A better understanding of the long-term health effects of child maltreatment is needed to inform maltreatment prevention strategies and to improve treatment for children who have been abused or neglected. In this systematic review and meta-analysis, the researchers quantify the association between exposure to physical abuse, emotional abuse, and neglect in childhood and mental health and physical health outcomes in later life. A systematic review uses predefined criteria to identify all the research on a given topic; a meta-analysis is a statistical approach that combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 124 studies that investigated the relationship between child physical abuse, emotional abuse, or neglect and various health outcomes. Their meta-analysis of data from these studies provides suggestive evidence that child physical abuse, emotional abuse, and neglect are causally linked to mental and physical health outcomes. For example, emotionally abused individuals had a three-fold higher risk of developing a depressive disorder than non-abused individuals (an odds ratio [OR] of 3.06). Physically abused and neglected individuals also had a higher risk of developing a depressive disorder than non-abused individuals (ORs of 1.54 and 2.11, respectively). Other mental health disorders associated with child physical abuse, emotional abuse, or neglect included anxiety disorders, drug abuse, and suicidal behavior. Individuals who had been non-sexually maltreated as children also had a higher risk of sexually transmitted diseases and/or risky sexual behavior than non-maltreated individuals. Finally, there was weak and inconsistent evidence that child maltreatment increased the risk of chronic diseases and lifestyle risk factors such as smoking.
What Do These Findings Mean?
By providing suggestive evidence of a causal link between non-sexual child maltreatment and mental health disorders, drug use, suicide attempts, and sexually transmitted diseases and risky sexual behavior, these findings contribute to our understanding of the non-injury health impacts of child maltreatment. Although most of the studies included in the meta-analysis were undertaken in high-income countries, the findings suggest that this link occurs in both high- and low-to-middle-income countries. They also suggest that neglect may be as harmful as physical and emotional abuse. However, they need to be interpreted carefully because of the limitations of this meta-analysis, which include the possibility that children who have been abused may share other, unrecognized factors that are actually the cause of their later mental health problems. Importantly, this confirmation that physical abuse, emotional abuse, and neglect in childhood are important risk factors for a range of health problems draws attention to the need to develop evidence-based strategies for preventing child maltreatment both to reduce childhood suffering and to alleviate an important risk factor for later health problems.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides information on child maltreatment and its prevention (in several languages); Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence is a 2006 report produced by WHO and the International Society for Prevention of Child Abuse and Neglect
The US Centers for Disease Control and Prevention provides information on child maltreatment and links to additional resources
The National Society for the Prevention of Cruelty to Children (NSPCC) is a not-for-profit organization that aims to end all cruelty to children in the UK; Childline is a resource provided by the NSPCC that provides help, information, and support to children who are being abused
The Hideout is a UK-based website that helps children and young people understand domestic abuse
Childhelp is a US not-for-profit organization dedicated to helping victims of child abuse and neglect; its website includes a selection of personal stories about child maltreatment
PMCID: PMC3507962  PMID: 23209385
22.  Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses 
BMC Public Health  2008;8:124.
The aim of this study was to assess the prevalence in the general population of parents' concerns about the development of their child, to identify groups at risk and to assess the association between parents' concerns and professional judgement.
We obtained cross-sectional data on a Dutch nationally representative sample of children aged 14 months, 3 3/4, 5–6 and 8–12 years within the setting of routine well-child visits provided to the entire population. A total of 4,107 participated (response rate 85.3%). Data were about concerns that parents reported by questionnaire before the visit regarding behavioural and emotional problems, developmental delay, consequences of disease and contact with peers that needed professional assistance, and about the assessment of these domains by doctors and nurses during the visit. Moreover, we obtained data on parent-reported psychosocial problems using the Infant-Toddler Social and Emotional Assessment and the Child Behavior Checklist.
Of all parents, 49.3% reported some concerns and 8.7% reported frequent concerns, most frequently on child behaviour. Frequent concerns were most likely to refer to young children, children from labour immigrant families, with fathers of medium educational level and in low-income families. The prevalence rates of professional-assessed parenting problems were much lower than parent-reported ones. The rates of psychosocial problems were highest in the case of shared concerns, but also higher if parents expressed concerns that were not confirmed by professionals.
A very large proportion of parents of young children have concerns regarding their child, but agreement on these concerns with child health professionals is relatively low.
PMCID: PMC2383909  PMID: 18423036
23.  Early sensory over-responsivity in toddlers with autism spectrum disorders as a predictor of family impairment and parenting stress 
Sensory over-responsivity (SOR) affects many individuals with autism spectrum disorders (ASD), often leading to stressful encounters during daily routines.
This study describes the associations between early SOR symptoms and the longitudinal course of restrictions in family life activities and parenting stress across three time points in families raising a child with ASD (n = 174). Covariates were child diagnostic severity, emotional problems, and maternal affective symptoms. At time 1 mean chronological age was 28.5 months. Children were administered the Autism Diagnostic Observation Schedule (ADOS) and Mullen Scales of Early Learning (MSEL). Parents completed the Infant Toddler Sensory Profile (ITSP), Infant Toddler Social Emotional Assessment (ITSEA), Beck Anxiety Index (BAI), and the Center for Epidemiologic Studies Depression Inventory (CES-D) at time 1; and the Parenting Stress Index (PSI) and Family Life Impairment Scale (FLIS) at the three annual time points.
Latent Growth Curve Models indicated that higher SOR scores on the ITSP at time 1 were associated with higher initial levels of family life impairment and parenting stress and with a smaller magnitude of change over time. These associations were independent of severity of ADOS social-communication symptoms, MSEL composite score, ITSEA externalizing and anxiety symptoms, and maternal affective symptoms as measured by the BAI and CES-D. On average FLIS and PSI did not change over time however there was significant individual variability. Concurrently, SOR at time 1 explained 39–45% of the variance in family stress and impairment variables.
An evaluation of SOR should be integrated into the assessment of toddlers with ASD considering their role in family life impairment and stress.
PMCID: PMC3636173  PMID: 23336424
ASD; toddlers; sensory over-responsivity; family impairment; parenting stress
24.  Missed opportunities: mental disorder in children of parents with depression 
The British Journal of General Practice  2012;62(600):e487-e493.
Emerging evidence suggests that early intervention and prevention programmes for mental health problems in the offspring of parents with depression are important. Such programmes are difficult to implement if children with psychiatric disorder are not identified and are not accessing services, even if their parents are known to primary care.
To investigate service use in children of parents who have recurrent depression, and factors that influence such contact.
Design and setting
A total of 333 families were recruited, mainly through primary health care, in which at least one parent had received treatment for recurrent depression and had a child aged 9–17 years.
Psychiatric assessments of parents and children were completed using research diagnostic interviews. The service-use interview recorded current (in the 3 months prior to interview) and lifetime contact with health, educational, and social services due to concerns about the child’s emotions or behaviour.
Only 37% of children who met criteria for psychiatric disorder were in contact with any service at the time of interview. A third, who were suicidal or self-harming and had a psychiatric disorder at that time, were not in contact with any service. Lack of parental worry predicted lower service use, with higher rates in children with comorbidity and suicidality.
Most children with a psychiatric disorder in this high-risk sample were not in contact with services. Improving ease of access to services, increasing parental and professional awareness that mental health problems can cluster in families, and improving links between adult and child services may help early detection and intervention strategies for the offspring of parents with depression.
PMCID: PMC3381275  PMID: 22781997
adolescent; depression; early intervention; primary health care; risk
25.  Toward a new understanding of legacy of early attachments for future antisocial trajectories: Evidence from two longitudinal studies 
Development and psychopathology  2012;24(3):783-806.
Early parent–child attachment has been extensively explored as a contributor to children’s future adaptive or antisocial outcomes, but the specific developmental mechanisms remain to be fully understood. We examined long-term indirect developmental sequelae of early security in two longitudinal community samples followed from infancy to early school age: the Family Study (102 mothers, fathers, and infants) and the Parent–Child Study (112 mothers and infants). Constructs at multiple levels (child characteristics, parent–child security, parental discipline, and child antisocial outcomes) were assessed using a range of methods (extensive behavioral observations in a variety of settings, informants’ ratings). Both studies supported the proposed model of infant attachment as a potent catalyst that moderates future developmental socialization trajectories, despite having few long-term main effects. In insecure dyads, a pattern of coercion emerged between children who were anger prone as toddlers and their parents, resulting in parents’ increased power-assertive discipline. Power assertion in turn predicted children’s rule-breaking conduct and a compromised capacity to delay in laboratory paradigms, as well as oppositional, disruptive, callous, and aggressive behavior rated by parents and teachers at early school age. This causal chain was absent in secure dyads, where child anger proneness was unrelated to power assertion, and power assertion was unrelated to antisocial outcomes. Early insecurity appeared to act as a catalyst for the parent–child dyad embarking on a mutually adversarial path toward antisocial outcomes, whereas security defused such a maladaptive dynamic. The possible mechanisms of those effects were proposed.
PMCID: PMC3732475  PMID: 22781855

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