J Abnorm Child Psychol DOI 10.1007/s10802-013-9813-1
Infant and Toddler Crying, Sleeping and Feeding Problems and Trajectories of Dysregulated Behavior Across Childhood Catherine Winsper & Dieter Wolke
# Springer Science+Business Media New York 2013
Abstract Infant and toddler regulatory problems (RPs) including crying, sleeping and feeding, are a frequent concern for parents and have been associated with negative behavioral outcomes in early and middle childhood. Uncertain is whether infant and toddler RPs predict stable, trait-like dysregulated behavior across childhood. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). RPs at 6, 15–18, & 24–30 months and childhood dysregulated behavior at 4, 7, 8, & 9.5 years were assessed using mother report. Latent Class Growth Analysis (LCGA) indicated that trajectories of childhood dysregulated behavior were stable over time. All single RPs (i.e., crying, sleeping & feeding problems) were significantly associated with childhood dysregulated behavior. For example, crying problems at 6 months after controlling for confounders (Odds Ratios; 95 % Confidence Intervals): Moderate dysregulated behavior: OR = 1.50, 95 % CI [1.09 to 2.06], high dysregulated behavior: OR= 2.13, 95 % CI [1.49 to 3.05] and very high dysregulated behavior: OR=2.85, 95 % CI [1.64 to 4.94]. Multiple RPs were especially strongly associated with dysregulated behavior. For example, the RP composite at 15–18 months: 1 RP, very high dysregulated behavior: OR=2.79, 95 % CI [2.17 to 3.57], 2 RPs, very high dysregulated behavior: OR=3.46, 95 % CI [2.38 to 5.01], 3 RPs, very high dysregulated behavior: OR=12.57, 95 % CI [6.38 to 24.74]. These findings suggest that RPs in infants and toddlers predict stable dysregulated behavior trajectories across Electronic supplementary material The online version of this article (doi:10.1007/s10802-013-9813-1) contains supplementary material, which is available to authorized users. C. Winsper (*) : D. Wolke Department of Psychology and Division of Mental Health and Wellbeing (Warwick Medical School), University of Warwick, Coventry CV4 7AL, UK e-mail:
[email protected]
childhood. Interventions for early RPs could help prevent the development of chronic, highly dysregulated behavior. Keywords Regulatory problems . Crying . Sleeping . Feeding . Childhood dysregulated behavior . ALSPAC Dimensional temperament traits may be identified as early as infancy manifesting as behavioral dysregulation including: increased irritability, excessive crying, and problems with feeding and sleeping (Hyde et al. 2012). Children evincing extremes of these traits have been characterised as being temperamentally difficult (Caspi and Silva 1995; Schmid et al. 2010). Approximately 20 % of all infants show symptoms of excessive crying, sleeping or feeding problems in the 1st year of life (Hemmi et al. 2011). A subset of infants will manifest concurrent difficulties in feeding, sleeping or crying problems (4 to 10 %). Further, a smaller minority (1 to 2 %) will manifest all three simultaneously defined as multiple regulatory problems (Schmid et al. 2010; von Kries et al. 2006). Regulatory Problems (RPs) are a common concern for parents. They may lead to health seeking behaviors (JamesRoberts 2008), abuse and shaken baby syndrome (Barr et al. 2006), and negative behavioral consequences for the infant (Barr et al. 2006; Schmid et al. 2010; Wolke et al. 2002). Single RPs (i.e., crying (Rao et al. 2004; Wolke et al. 2002; Wolke et al. 2009a), sleeping (Thunström 2002; Wake et al. 2006), and feeding (Dahl and Sundelin 2008) problems) have been associated with subsequent behavioral and cognitive disturbance. Those with multiple RPs are especially at risk (Hemmi et al. 2011; Schmid et al. 2010). While accumulating research demonstrates a robust link between infant and toddler RPs and behavioral problems in childhood (see Hemmi et al. 2011 for review), the degree to which early regulatory problems predict persistent behavioral dysregulation across childhood has yet to be explored. To date, studies have tended to
J Abnorm Child Psychol
investigate predictive associations between RPs and behavioral disturbance assessed at one time point only. Therefore, the extent to which early RPs represent a developmental precursor of trait-like behavioral dysregulation over time is unclear. Rather than assuming that a given determinant such as infant RPs directly predicts a distal criterion such as mental disorder, a cascade model of development proposes that infant behavior provides the starting point for dysregulation through time. Thus, dysregulation may manifest as domain related, age appropriate constructs culminating in a mature phenotype (Shrout and Bolger 2002). In the cognitive domain, early information-processing abilities appear to undergird cognitions across important developmental transformations, from the first year of life to academic achievement in the second decade (Bornstein et al. 2013). Similarly, early problems with behavioral regulation (e.g., persistent crying) may be the starting point for later domain related self- regulation deficits in age appropriate behaviors, (e.g., the control of sustained attention, emotions and behavior in challenging situations). The quality of early parent–child relationships or of family organisation represents one potential mechanism via which infant RPs could cascade into later behavioral dysregulation (Kelly et al. 2013). Caregivers play a critical role in the development of infant self-regulation (Sroufe 1997; Wolke et al. 1994). Extant evidence supports that early RPs such as crying and feeding problems are associated with parental stress (Calkins et al. 2004) and problematic infant-parent interactions (Lindberg et al. 1996). Therefore, infant RPs may increase the risk of behavioral dysregulation across childhood by disrupting infant-parent dyads (Deater–Deckard 1998), subsequently undermining the development of competent self-regulation (Olson et al. 2002). At a biological level, infant and toddler RPs may lead to dysregulation of the Hypothalamic Pituitary-Adrenal (HPA) axis. Crying (Ludington-Hoe et al. 2002) and short sleep and night awakenings (Scher et al. 2005) have both been associated with increased cortisol levels indicative of HPA axis dysregulation. Dysregulation of the HPA axis has also been linked to internalising and attentional problems in early to late childhood (Feder et al. 2004; Scher et al. 2005). Thus, RPs may increase risk of behavioral dysregulation via dysregulation of the HPA axis. If these physiological stress reactions are amplified by prolonged crying and sleeping problems (Ludington-Hoe et al. 2002), and there is an absence of social buffering due to disrupted infant–parent relationships (Gunnar and Donzella 2002) increasing physiological dysregulation may ensue. Childhood RPs’ have recently been classified as the childhood dysregulation syndrome (Althoff et al. 2010; Holtmann et al. 2011a, b). This profile characterises children with affective, cognitive and behavioral dysregulation, and has been operationalised by summing anxious/depressed, impulsive/ aggressive, and attentional problem scales from the Child
Behavior Checklist (CBCL-DP) (Holtmann et al. 2011b). The childhood dysregulation syndrome has been found to predict negative outcomes in adolescence and adulthood including: anxiety, mood and disruptive behavior disorders, drug abuse (Althoff et al. 2010), suicidality (Holtmann et al. 2011b) and personality disorders (Halperin et al. 2011). Further, research suggests that the childhood dysregulation profile is a stable feature throughout childhood (at 7, 10 and 12 years) (Boomsma et al. 2006). Despite growing interest in the childhood dysregulation syndrome, to our knowledge there are no existing studies exploring whether infant and toddler RPs predict this syndrome. This is surprising given reported associations between early RPs and behavioral problems in childhood, which suggest that RPs may be a developmental precursor in a cascade leading to persistent self-regulation difficulties throughout childhood (i.e., the dysregulated behavior syndrome). These childhood self-regulation difficulties may subsequently impact on age appropriate regulation in adolescence and possibly adulthood (Althoff et al. 2010).
The Present Study This study investigated whether persistent crying, sleeping and feeding problems in infancy and toddlerhood (at 6, 15– 18 & 24–30 months) predict stable dysregulated behavior trajectories across childhood (4 to 9.5 years). Potential confounding factors including sex (LaGrange and Silverman 1999), family adversity (Buckner et al. 2003; Evans et al. 2007) and low birth weight (Papoušek and Von Hofacker 1998) were controlled for. It was further investigated whether multiple infant/toddler RPs are stronger predictors of childhood dysregulation than single RPs.
Method Participants and Missing Data The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK birth cohort study examining the determinants of development, health and disease during childhood and beyond. The study has been described in detail elsewhere (Boyd et al. 2013). A total of 14,541 women were enrolled providing they were resident in Avon while pregnant and had an expected delivery date between 1st April 1991 and 31st December 1992. A total of 13,978 children were alive at 12 months forming the original cohort. Ethical approval for the study was obtained from the ALSPAC Law and Ethics committee and the local research ethics committees. From the first trimester of pregnancy parents have completed postal questionnaires about the study child’s health and development.
J Abnorm Child Psychol
The child has attended annual assessment clinics, including face-to face interviews, psychological and physical tests. During the planning stage of the study children from the Avon area were compared with 13,135 children from across the UK (participating in the Child Health and Education Study) on a number of demographic variables. Results suggested that the Avon population was fairly similar to that of the whole of Great Britain (Golding et al. 2001). However, mothers in the Avon area were slightly more likely to live in an owner occupied residence and less likely to be non-white. The final sample for this study included children who had at least one dysregulated behavior measure in childhood, with a total of 10,630 children (76 % of the original cohort alive at 12 months) meeting this criterion. To assess whether drop out had been random or selective, those lost to follow up were compared to those retained in the analyses (Table 1). Those lost to follow up were more often of ethnic minority, of lower birth weight (2,499 g 1 per night N/A N/A N/A N/A N/A
Child regularly woke in night N/A Child regularly got up after a few hours N/A Feeding Difficulty feeding child/slow feeding yes=1; no=0 Did not eat enough/only took small quantities yes=1; no=0 Refused breast milk:6 m/ food :15, 24 m yes=1; no=0 Refused other milk:6 m/choosy with food :15, 24 m yes=1; no=0 Refused solids:6 m/over eats: 15, 24 m yes=1; no=0 Difficulty establishing routine yes=1; no=0 a
Can calm was reverse coded
15–18 and 24–30 months
N/A N/A yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0 yes=1; no=0
J Abnorm Child Psychol
problems scale. Cronbach alphas for 6, 15 and 24 months were 0.51, 0.69 and 0.71 respectively. Multiple Regulatory Problems Composite We also created dichotomous, clinically relevant crying, sleeping and feeding variables with cut-off points of 1 SD above the sample mean (cut points for crying and sleeping problems at 6 months are defined above). These were used to create the multiple regulatory problems composite at 6, 15–18 and 24–30 months with the following four categories: no RPs, 1RP, 2 RPs, and 3 RPs.
0 to 11 (out of a possible 18). FAI index scores were entered into the analysis as a continuous variable in line with recommended use (Bowen et al. 2005). Low Birth Weight was included in the analysis as a confounder due to potential associations with dysregulated behavior (Papoušek and Von Hofacker 1998). Birth weight was entered as a dichotomous variable with low birth weight defined as
