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1.  Patterns of anxiety symptoms in toddlers and preschool-age children: Evidence of early differentiation 
Journal of anxiety disorders  2011;26(1):102-110.
The degree to which young children’s anxiety symptoms differentiate according to diagnostic groupings is under-studied, especially in children below the age of 4 years. Theoretical (confirmatory factor analysis, CFA) and statistical (exploratory factor analysis, EFA) analytical methods were employed to test the hypothesis that anxiety symptoms among 2–3-year-old children from a non-clinical, representative sample would differentiate in a manner consistent with current diagnostic nosology. Anxiety symptom items were selected from two norm-referenced parent-report scales of child behavior. CFA and EFA results suggested that anxiety symptoms aggregate in a manner consistent with generalized anxiety, obsessive–compulsive symptoms, separation anxiety, and social phobia. Multi-dimensional models achieved good model fit and fit the data significantly better than undifferentiated models. Results from EFA and CFA methods were predominantly consistent and supported the grouping of early childhood anxiety symptoms into differentiated, diagnostic-specific categories.
PMCID: PMC4310674  PMID: 22018968
Anxiety; Preschool; Nosology; DSM; Factor analysis; Internalizing
2.  Advancing a Multidimensional, Developmental Spectrum Approach to Preschool Disruptive Behavior 
Dimensional approaches are gaining scientific traction. However, their potential for elucidating developmental aspects of psychopathology has not been fully realized. The goal of this paper is to apply a multidimensional, developmental framework to model the normal-abnormal spectrum of preschool disruptive behavior. The Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB), a novel measure, was used to model dimensional severity across developmental parameters theorized to distinguish the normative misbehavior of early childhood from clinically salient disruptive behavior. The 4 MAP-DB dimensions are: Temper Loss, Noncompliance, Aggression, and Low Concern for Others.
Parents of a diverse sample of 1,488 preschoolers completed the MAP-DB. Multidimensional item response theory (IRT) was employed for dimensional modeling.
The 4-dimension, developmentally informed model demonstrated excellent fit. Its factor loadings did not differ across demographic subgroups. All dimensions provided good coverage of the abnormal end of the severity continuum, but only Temper Loss and Noncompliance provided good coverage of milder, normatively occurring behaviors. The developmental expectability and quality of behaviors distinguished normative from atypical behaviors. The point at which frequency of behaviors was atypical varied based on dimensional location for Temper Loss, Noncompliance, and Aggression.
The MAP-DB provides an innovative method for operationalizing developmentally specified, dimensional phenotypes in early childhood. Establishing the validity of these dimensional phenotypes in relation to clinical outcomes, neurocognitive substrates and etiologic pathways will be a crucial test of their clinical utility.
PMCID: PMC4244819  PMID: 24342388
developmental psychopathology; dimensional; disruptive behavior; externalizing spectrum; preschool
3.  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
4.  Parsing the Effects Violence Exposure in Early Childhood: Modeling Developmental Pathways 
Objective To prospectively examine pathways from early childhood violence exposure and trauma-related symptoms to school-age emotional health. Methods A longitudinal, birth cohort (N = 437) was assessed with parent reports of lifetime violence exposure and trauma-related symptoms at 3 years of age and later, internalizing and externalizing symptoms, and social competence at school age. Results Early family and neighborhood violence correlated significantly with early trauma-related symptoms and also significantly predicted school-age internalizing and externalizing symptoms and poorer competence, independent of sociodemographic risk and past-year violence exposure. Longitudinal pathways were significantly mediated by arousal and avoidance symptoms at 3 years of age, which increased risk for clinically significant emotional problems and lower competence at school age (adjusted odds ratios = 3.1–6.1, p < 0.01). Conclusions Trauma-related symptoms may mediate developmental pathways from early violence exposure to later emotional health. Interventions that prevent or reduce early trauma-related symptoms may ameliorate the long-term deleterious impact of violence exposure.
PMCID: PMC3263769  PMID: 21903730
longitudinal; post-traumatic stress; preschool; trauma; violence
5.  Early Life Trauma Exposure and Stress Sensitivity in Young Children 
Journal of Pediatric Psychology  2012;38(1):94-103.
Objective The current study replicates and extends work with adults that highlights the relationship between trauma exposure and distress in response to subsequent, nontraumatic life stressors. Methods The sample included 213 2–4-year-old children in which 64.3% had a history of potential trauma exposure. Children were categorized into 4 groups based on trauma history and current life stress. Results In a multivariate analysis of variance, trauma-exposed children with current life stressors had elevated internalizing and externalizing problems compared with trauma-exposed children without current stress and nontrauma-exposed children with and without current stressors. The trauma-exposed groups with or without current stressors did not differ on posttraumatic stress disorder symptom severity. Accounting for number of traumatic events did not change these results. Conclusions These findings suggest that early life trauma exposure may sensitize young children and place them at risk for internalizing or externalizing problems when exposed to subsequent, nontraumatic life stressors.
PMCID: PMC3547236  PMID: 23008502
posttraumatic stress disorder; stress sensitivity; trauma exposure; young children
6.  Exposure to potentially traumatic events in early childhood: differential links to emergent psychopathology 
To examine associations between exposure to potentially traumatic events (PTEs) and clinical patterns of symptoms and disorders in preschool children.
Two hundred and thirteen referred and non-referred children, ages 24 to 48 months (MN = 34.9, SD = 6.7 months) were studied. Lifetime exposure to PTEs (family violence and non-interpersonal events) and recent stressful life events were assessed with the Preschool Age Psychiatric Assessment (PAPA) and Child Life Events Scale. Child psychiatric symptoms and disorders were assessed with parent-reports in the PAPA, a comprehensive, developmentally sensitive interview. Sociodemographic risk, parental anxiety and depressive symptoms (Center for Epidemiologic Studies Depression, Beck Anxiety Inventory), and child developmental level (Mullen Scales of Early Learning) also were assessed.
Violence exposure was broadly associated with psychiatric status in the areas of depression, separation anxiety, posttraumatic stress, and conduct problems, whereas potentially traumatic non-interpersonal exposure was associated with phobic anxiety. The majority of the associations between violence exposure and preschoolers’ symptoms were significant even when other key factors, including economic disadvantage and parental mood and anxiety symptoms, were controlled statistically. However, parental depressive/anxious symptoms may have partially or fully mediated the relationships between violence exposure and depressive and conduct symptoms.
Evidence of robust associations between violence exposure and early childhood internalizing and externalizing disorders and symptoms highlights the need for longitudinal prospective research concerning neurodevelopmental mechanisms and pathways. Findings underscore the relevance of assessing trauma exposure, particularly interpersonal violence, to identify young children at risk.
PMCID: PMC3106304  PMID: 20840502
Early childhood; symptoms; disorders; posttraumatic stress; violence; contextual risk
7.  Social-Emotional Screening Status in Early Childhood Predicts Elementary School Outcomes 
Pediatrics  2008;121(5):957-962.
The goal was to examine whether children who screen positive for social-emotional/behavioral problems at 12 to 36 months of age are at elevated risk for social-emotional/behavioral problems in early elementary school.
The sample studied (N = 1004) comprised an ethnically (33.3% minority) and socioeconomically (17.8% living in poverty and 11.3% living in borderline poverty) diverse, healthy, birth cohort from a metropolitan region of the northeastern United States. When children were 12 to 36 months of age (mean age: 23.8 months; SD: 7.1 months), parents completed the Brief Infant-Toddler Social and Emotional Assessment and questions concerning their level of worry about their child’s behavior, emotions, and social development. When children were in early elementary school (mean age: 6.0 years; SD: 0.4 years), parents completed the Child Behavior Checklist and teachers completed the Teacher Report Form regarding behavioral problems. In a subsample (n = 389), parents reported child psychiatric status.
Brief Infant-Toddler Social and Emotional Assessment screen status and parental worry were associated significantly with school-age symptoms and psychiatric disorders. In multivariate analyses that included Brief Infant-Toddler Social and Emotional Assessment status and parental worry, Brief Infant-Toddler Social and Emotional Assessment scores significantly predicted all school-age problems, whereas worry predicted only parent reports with the Child Behavior Checklist. Children with of-concern scores on the problem scale of the Brief Infant-Toddler Social and Emotional Assessment were at increased risk for parent-reported subclinical/clinical levels of problems and for psychiatric disorders. Low competence scores predicted later teacher-reported subclinical/clinical problems and parent-reported disorders. Worry predicted parent-reported subclinical/clinical problems. Moreover, the Brief Infant-Toddler Social and Emotional Assessment identified 49.0% of children who exhibited subclinical/clinical symptoms according to teachers and 67.9% of children who later met the criteria for a psychiatric disorder.
Screening with a standardized tool in early childhood has the potential to identify the majority of children who exhibit significant emotional/behavioral problems in early elementary school.
PMCID: PMC3088107  PMID: 18450899
screening; medical home; behavioral problems; Brief Infant-Toddler Social and Emotional Assessment; parental concern
8.  The 5-HTTLPR Polymorphism Moderates the Effect of Stressful Life Events on Drinking Behavior in College Students of African Descent 
Covault et al. (2007) reported that the common functional polymorphism, 5-HTTLPR, in the serotonin transporter gene moderated the association between past-year stressful events and daily reports of drinking in a sample of European-American (EA) college students. We examined this effect in college students of African descent.
Students recruited at a Historically Black University (n=564) completed web-based measures of past-year stressful life experiences and daily reports of drinking and heavy drinking over a 30-day period. Participants were genotyped for the tri-allelic 5-HTTLPR polymorphism and dichotomized as low-activity S’ allele carriers or high-activity L’ homozygotes. Generalized linear models were used to examine the effects of life stress, genotype, and their interaction on the two drinking measures.
In students who completed 15 or more daily surveys (n=393), there was a significant interaction of past-year stressful events, 5-HTTLPR genotype, and gender on the number of drinking days (p=0.002). Similar findings were obtained in relation to heavy drinking days (p=0.007). Men showed a main effect of past-year stressful events on both drinking outcomes (p’s<0.001), but no main or moderator effects of genotype. In women, the S’ allele moderated the impact of past-year life stressors on the frequency of drinking and heavy drinking days (p’s<0.001).
In college students of African descent, past-year stressful events were associated with more frequent drinking and heavy drinking, an effect that was moderated by the 5-HTTLPR polymorphism. However, in contrast to the findings in EA students, in the current sample, 5-HTTLPR moderated the association only among women.
PMCID: PMC3682418  PMID: 22488930
gene-environment interaction; college student drinking; alcohol; 5-HTTLPR; daily reports
9.  Putting Theory to the Test: Modeling a Multidimensional, Developmentally-Based Approach to Preschool Disruptive Behavior 
There is increasing emphasis on dimensional conceptualizations of psychopathology but empirical evidence of their utility is just emerging. In particular, while a range of multidimensional models have been proposed, the relative fit of competing models has rarely been tested. Further, developmental considerations have received scant attention. In this paper, we test a developmentally-based 4-dimension model of disruptive behavior theorized to represent the defining features of disruptive behavior at preschool age: Temper Loss, Noncompliance, Aggression, and Low Concern for Others.
Model testing was conducted in two independent samples of preschoolers: Clinically-Enriched (N=336) and Epidemiologic (N=532). Tau-equivalent confirmatory factor analyses were used to test the fit of the Developmental Model relative to 3 leading competing models (DSM ODD/CD Model, “Callous” Model and an “Irritable/Headstrong/Hurtful” Model). Reliability of the 4 dimensions was also tested. Validity of the dimensions was tested by predicting multi-informant, multi-method ratings of disruptive behavior and impairment, and incremental utility relative to DSM symptoms.
In both samples, the Developmental Model demonstrated a superior fit compared to the competing models within the full sample, and across key demographic sub-groups. Validity was also demonstrated, including incremental utility relative to DSM-IV disruptive behavior symptoms.
Critical next steps for achieving scientific consensus about the optimal dimensional model of disruptive behavior and its clinical application are discussed.
PMCID: PMC3674547  PMID: 22632619
disruptive behavior; developmental psychopathology; dimensional; early childhood; preschool behavior problems
10.  Defining the developmental parameters of temper loss in early childhood: implications for developmental psychopathology 
Temper modulation problems are both a hallmark of early childhood and a common mental health concern. Thus, characterizing specific behavioral manifestations of temper loss along a dimension from normative misbehaviors to clinically significant problems is an important step toward identifying clinical thresholds.
Parent-reported patterns of temper loss were delineated in a diverse community sample of preschoolers (n = 1,490). A developmentally sensitive questionnaire, the Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB), was used to assess temper loss in terms of tantrum features and anger regulation. Specific aims were: (a) document the normative distribution of temper loss in preschoolers from normative misbehaviors to clinically concerning temper loss behaviors, and test for sociodemographic differences; (b) use Item Response Theory (IRT) to model a Temper Loss dimension; and (c) examine associations of temper loss and concurrent emotional and behavioral problems.
Across sociodemographic subgroups, a unidimensional Temper Loss model fit the data well. Nearly all (83.7%) preschoolers had tantrums sometimes but only 8.6% had daily tantrums. Normative misbehaviors occurred more frequently than clinically concerning temper loss behaviors. Milder behaviors tended to reflect frustration in expectable contexts, whereas clinically concerning problem indicators were unpredictable, prolonged, and/or destructive. In multivariate models, Temper Loss was associated with emotional and behavioral problems.
Parent reports on a developmentally informed questionnaire, administered to a large and diverse sample, distinguished normative and problematic manifestations of preschool temper loss. A developmental, dimensional approach shows promise for elucidating the boundaries between normative early childhood temper loss and emergent psychopathology.
PMCID: PMC3633202  PMID: 22928674
Developmental psychopathology; temper tantrums; disruptive behavior; preschool psychopathology; dimensional
11.  Prevalence of DSM-IV Disorder in a Representative, Healthy Birth Cohort at School Entry: Sociodemographic Risks and Social Adaptation 
The aims of this paper are as follows: to present past-year prevalence data for DSM-IV disorders in the early elementary school years; to examine the impact of impairment criteria on prevalence estimates; to examine the relation of sociodemographic and psychosocial risk factors to disorders; and to explore associations between ”internalizing” and ”externalizing” disorders and social competence and family burden as further validation of the impairing nature of these disorders.
As part of a longitudinal representative population study of children born healthy between July 1995 and September 1997 in the New Haven–Meriden Standard Metropolitan Statistical Area of the 1990 Census (n = 1,329), parents of a subsample enriched for child psychopathology (n = 442; 77.6% response rate, 69.5% of eligible sample) were interviewed in the child's kindergarten or first-grade year with the Diagnostic Interview Schedule for Children, Version IV (DISC-IV). Parents were surveyed about sociodemographic and psychosocial characteristics, and both parents and teachers were surveyed about social competence.
Approximately one in five (21.6 %) children met criteria for psychiatric disorder(s) with impairment. Sociodemographic and psychosocial correlates included persistent poverty beginning in early childhood, limited parental education, low family expressiveness, stressful life events, and violence exposure. Finally, diagnostic status was significantly associated with poorer social competence and family burden.
That approximately one in five children evidenced a psychiatric disorder with impairment during the transition to formal schooling highlights the importance of integrating psychiatric epidemiological and developmental approaches to inform conversations about school readiness and intervention planning.
PMCID: PMC3166638  PMID: 20610138
child psychiatric disorders; prevalence; social competence; family burden; impairment
12.  Persistence of Maternal Depressive Symptoms throughout the Early Years of Childhood 
Journal of Women's Health  2009;18(5):637-645.
The purpose of these analyses was to examine the persistence and predictors of elevated depressive symptoms in 884 women over their children's preschool years.
Depressive symptoms in women with young children are surprisingly consistent throughout their children's preschool years. Of the 82.6% of women without elevated depressive symptoms at the initial assessment (study child was 11–42 months of age), 82.4% remained without symptoms over two follow-up assessments. Of 17.4% of women with elevated symptoms at baseline, 35.6% had elevated symptoms at one of the two follow-ups, and 27.4% had elevated symptoms at both follow-ups. Persistently elevated depressive symptoms were related to low education, high levels of anxiety, high parenting distress, and low levels of emotional support at baseline.
Women who report symptoms of depression when their children are young are highly likely to continue to report such symptoms. These results support the need to screen for elevated depressive symptoms at varying intervals depending on prior screening results and for screening in locations where women most at risk routinely visit, such as well-child clinics. Further, these results point to the need for a system to identify and manage this common treatable condition because these elevated symptoms continue throughout their children's preschool years for a substantial portion of women.
PMCID: PMC2858294  PMID: 19445615

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