Disruptions of working memory and inhibition mediate the association between exposure to institutionalization and symptoms of attention deficit hyperactivity disorder.

BACKGROUND: Young children raised in institutions are exposed to extreme psychosocial deprivation that is associated with elevated risk for psychopathology and other adverse developmental outcomes. The prevalence of attention deficit hyperactivity disorder (ADHD) is particularly high in previously institutionalized children, yet the mechanisms underlying this association are poorly understood. We investigated whether deficits in executive functioning (EF) explain the link between institutionalization and ADHD. METHOD: A sample of 136 children (aged 6-30 months) was recruited from institutions in Bucharest, Romania, and 72 never institutionalized community children matched for age and gender were recruited through general practitioners' offices. At 8 years of age, children's performance on a number of EF components (working memory, response inhibition and planning) was evaluated. Teachers completed the Health and Behavior Questionnaire, which assesses two core features of ADHD, inattention and impulsivity. RESULTS: Children with history of institutionalization had higher inattention and impulsivity than community controls, and exhibited worse performance on working memory, response inhibition and planning tasks. Lower performances on working memory and response inhibition, but not planning, partially mediated the association between early institutionalization and inattention and impulsivity symptom scales at age 8 years. CONCLUSIONS: Institutionalization was associated with decreased EF performance and increased ADHD symptoms. Deficits in working memory and response inhibition were specific mechanisms leading to ADHD in previously institutionalized children. These findings suggest that interventions that foster the development of EF might reduce risk for psychiatric problems in children exposed to early deprivation.

Telomere length and early severe social deprivation: linking early adversity and cellular aging.

Accelerated telomere length attrition has been associated with psychological stress and early adversity in adults; however, no studies have examined whether telomere length in childhood is associated with early experiences. The Bucharest Early Intervention Project is a unique randomized controlled trial of foster care placement compared with continued care in institutions. As a result of the study design, participants were exposed to a quantified range of time in institutional care, and represented an ideal population in which to examine the association between a specific early adversity, institutional care and telomere length. We examined the association between average relative telomere length, telomere repeat copy number to single gene copy number (T/S) ratio and exposure to institutional care quantified as the percent of time at baseline (mean age 22 months) and at 54 months of age that each child lived in the institution. A significant negative correlation between T/S ratio and percentage of time was observed. Children with greater exposure to institutional care had significantly shorter relative telomere length in middle childhood. Gender modified this main effect. The percentage of time in institutional care at baseline significantly predicted telomere length in females, whereas the percentage of institutional care at 54 months was strongly predictive of telomere length in males. This is the first study to demonstrate an association between telomere length and institutionalization, the first study to find an association between adversity and telomere length in children, and contributes to the growing literature linking telomere length and early adversity.

Early deprivation, atypical brain development, and internalizing symptoms in late childhood.

Children exposed to extreme early-life neglect such as in institutional rearing are at heightened risk for developing depression and anxiety disorders, and internalizing problems more broadly. These outcomes are believed to be due to alterations in the development of neural circuitry that supports emotion regulation. The specific neurodevelopmental changes that contribute to these difficulties are largely unknown. This study examined whether microstructural alterations in white matter pathways predicted long-term risk for internalizing problems in institutionally reared children. Data from 69 children were drawn from the Bucharest Early Intervention Project, a randomized clinical trial of foster care for institutionally reared children. White matter was assessed using diffusion tensor imaging (DTI) when children were between 8 and 10years of age. Internalizing symptoms were assessed at the time of the MRI scan, and once children reached 12-14years of age. Results indicated that neglect-associated alterations in the external capsule and corpus callosum partially explained links between institutional rearing status and internalizing symptoms in middle childhood and early adolescence. Findings shed light on neural mechanisms contributing to increased risk for emotional difficulties among children reared in adverse conditions and have implications for prevention and intervention.

Attachment disorders in infancy and early childhood: a preliminary investigation of diagnostic criteria.

OBJECTIVE: The primary purpose of this study was to compare the reliability of differing sets of criteria for attachment disorders by using a retrospective case review. METHOD: Forty-eight consecutive clinical case summaries from an infant behavior clinic were reviewed by four experienced clinicians. Attachment disorders were coded as present or absent by using competing criteria and were scored by using a continuous scale of relationship functioning. RESULTS: The reliability of alternative criteria was acceptable, but the reliability of DSM-IV criteria in diagnosing attachment disorders was marginal. Preliminary validity for the criteria was demonstrated by the fact that more severe relationship disturbances were seen in infants diagnosed with attachment disorders than in infants diagnosed with other disorders. CONCLUSIONS: Standardized assessments of at-risk populations should be used to replicate these preliminary results; revision of DSM-IV criteria may be necessary to obtain adequate reliability for diagnosing attachment disorders.

Infant temperament, sleep organization, and nighttime parental interventions.

Objective measures of sleep-wake organization derived from time-lapse video recordings were compared with parental perceptions of infant temperament in 23 infants 6 months of age. Although both mothers' and fathers' ratings of infant temperament were correlated with variables reflecting sleep continuity, results for fathers were much more striking. Infants who required care giving during the night were rated as significantly more difficult and arrhythmic by fathers than by mothers. All infants awakened during the night. Some of them soothed themselves and returned to sleep; however, others signaled and required care giving interventions from their parents before returning to sleep. No differences in variables reflecting the biology of sleep distinguished "signaling" infants and "self-soothing" infants, although feedings at bedtime (breast or bottle) were more common in the signaling group.

Do women grieve after terminating pregnancies because of fetal anomalies? A controlled investigation.

OBJECTIVE: To test the hypothesis that grief responses do not differ between women who terminate their pregnancies for fetal anomalies and women who experience spontaneous perinatal losses. METHODS: A case-control study was conducted. Twenty-three women who underwent terminations through the genetics service of a tertiary referral obstetric hospital from January 1991 to April 1992 were assessed psychiatrically 2 months after the termination. The grief responses of these women on the Perinatal Grief Scale and the Beck Depression Inventory were compared to a demographically similar group of women assessed 2 months after they experienced spontaneous perinatal loss. Differences between the groups were assessed through one-way analysis of covariance. RESULTS: After matching women in the two groups, it became clear that women who terminated for fetal anomalies were significantly older than women in the comparison group, and age was inversely correlated with intensity of grief. Therefore, age was covaried in comparing the grief responses of women in the two groups. Neither statistically significant nor clinically meaningful differences were found in symptomatology between the groups. By the time of assessment, four of 23 women (17%) who terminated their pregnancies were diagnosed with a major depression, and five of 23 (22%) had sought psychiatric treatment. CONCLUSIONS: Women who terminate pregnancies for fetal anomalies experience grief as intense as those who experience spontaneous perinatal loss, and they may require similar clinical management. Diagnosis of a fetal anomaly and subsequent termination may be associated with psychological morbidity.

Adaptation following perinatal loss: a critical review.

Parental adaptation following perinatal loss has received increasing attention in the past 20 years. From early anecdotal accounts to recent more rigorous investigations, it is clear that perinatal loss in the developed world is a significant psychological trauma for parents. Major immediate consequences are likely for virtually all affected families, and long-term sequelae are likely for some. Despite widespread attention to the experience of families who lose a stillborn or newborn infant, including major changes in hospital practices regarding management of these families, many important questions remain unanswered. We know little, for instance, about which parents are at greatest risk for disordered mourning or what additional measures might minimize their psychological morbidity. In fact, because of a tendency to focus exclusively on affective symptomatology following the loss, other important features of the process of mourning have been overlooked or examined unsystematically. Suggestions for specific and general directions for further research are discussed.

Sleep disorders in early childhood: association with insecure maternal attachment.

Psychological, family, and social characteristics relating to attachment relationships were measured in mothers of 20 sleep-disordered toddlers, comparing them with 21 mothers of toddlers without sleep problems. The groups were matched on measures of socioeconomic status, child and maternal age, maternal education, marital status, and family size. Results showed that 100% of mothers of sleep-disordered children were classified as insecure with respect to attachment, as assessed by the Adult Attachment Interview, compared with 57% of control group mothers (p less than 0.002). There were no group differences on measures of maternal defensiveness, self-esteem, marital satisfaction, and social support. These results suggest that maternal current perspectives on their relationship history, rather than general psychosocial adjustment, are crucial contributors to the onset and perpetuation of sleep disorders in early childhood.

Infant development and developmental risk: a review of the past 10 years.

OBJECTIVE: To review critically the research on infant developmental risk published in the past 10 years. METHOD: A brief framework on development in the first 3 years is provided. This is followed by a review of pertinent studies of developmental risk, chosen to illustrate major risk conditions and the protective factors known to affect infant development. Illustrative risk conditions include prematurity and serious medical illness and infant temperament, infant-caregiver attachment, parental psychopathology, marital quality and interactions, poverty and social class, adolescent parenthood, and family violence. RESULTS: Risk and protective factors interact complexly. There are few examples of specific or linear links between risk conditions and outcomes during or beyond the first 3 years of life. Infant development is best appreciated within the context of caregiving relationships, which mediate the effects of both intrinsic and extrinsic risk conditions. CONCLUSIONS: Complex and evolving interrelationships among risk factors are beginning to be elucidated. Linear models of cause and effect are of little use in understanding the development of psychopathology. Refining our markers of risk and demonstrating effective preventive interventions are the next important challenges.

Implications of research on infant development for psychodynamic theory and practice.

Recent research on infant development is reviewed to consider its implications for psychodynamic theory and practice. To address the question of the importance of early experiences for development, research on continuities and discontinuities in development, temperament, motivational systems in infancy, affect development and regulation, development of the sense of self, and infant-caregiver attachment are reviewed. Two major implications emerge, both emphasizing the need for more complexities in our conceptualizations. First, research on infant development underscores the importance of context in development and cautions about the limits of reductionistic thinking and theories. Second a major paradigmatic shift away from the fixation-regression model of psychopathology and development is indicated. A new model that better fits available data is proposed instead. In this continuous construction model, there is no need for regression, and ontogenetic origins of psychopathology are no longer necessarily tied to specific critical or sensitive periods in development. Implications for psychodynamic treatment are also described.

Traumatic loss in a one-year-old girl.

This Grand Rounds presents the case of a girl who, at the age of 1 year, witnessed her mother's violent death. She was first seen by a child psychiatrist at age 4 years and has remained symptomatic for more than 5 years after the traumatic event. The case is discussed from the standpoint of the interrelationships among posttraumatic stress, memory, attachment, and mourning.

Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood.

OBJECTIVE: To explore several key aspects of the diagnosis and assessment for posttraumatic stress disorder (PTSD) in infants and young children. METHOD: Fifteen traumatized, clinic-referred children, and a comparison sample of 12 at-risk children, all younger than 48 months of age, were assessed with a standardized procedure and a semistructured diagnostic interview. The assessments were videotaped and reviewed by two blind raters for scoring DSM-IV PTSD criteria and an alternative set of PTSD criteria for young children. Raters were debriefed and consensus ratings were used to make best-estimate diagnoses. RESULTS: The investigation of procedural validity showed that 12% of the diagnostic criteria present in these children could be detected by a clinician through direct observation or interaction with the children. The remainder of criteria were apparent only through caregiver report. Problematic aspects of parental reporting were most evident for the avoidance/numbing of responsiveness criteria. The traumatized subjects showed significantly more alternative criteria of PTSD than DSM-IV criteria of PTSD. The main sources of rater disagreement are described. CONCLUSIONS: Additional sources of information would complement the multidimensional assessment of PTSD in young children. The set of alternative criteria appears to show greater criterion validity than the DSM-IV criteria.

Representations of attachment in mothers and their one-year-old infants.

Attachment classifications in mothers and their 1-year-old infants were independently and concurrently assessed using the Adult Attachment Interview and the Strange Situation Procedure. Overall concordance was significant (k = 0.62), with strong links apparent between mothers classified dismissing and infants classified avoidant and between mothers classified autonomous and infants classified secure. Mothers' classified preoccupied were not more likely to have infants classified resistant. Mothers' perceptions and interpretations of the emotional distress of an infant observed in a 4-minute videotape were related to both infant and mother attachment classifications. These results are compatible with the suggestion that attachment classification reflect differences in internal working models of relationships. Other measures of maternal psychosocial adjustment were not related to infant attachment classifications.

Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood.

OBJECTIVE: The reliability and validity of DSM-IV criteria and an alternative set of criteria for posttraumatic stress disorder (PTSD) are assessed in infants and young children (younger than 4 years of age). METHOD: This study was conducted in three phases. Phase 1 applied DSM-IV criteria for PTSD to 20 case reports of severely traumatized infants from the literature. Phase 2 used an expanded checklist of symptoms that were developmentally sensitive and behaviorally anchored to create an alternative set of criteria for PTSD in infants. Phase 3 compared the DSM-IV criteria to the alternative criteria on 12 new cases of traumatized infants. RESULTS: Infants and young children who have experienced severe traumas show many symptoms of impairment, similar to posttraumatic symptoms in older children and adults. The alternative criteria were more reliable and more valid for diagnosing PTSD in infancy than DSM-IV criteria. CONCLUSIONS: Clinicians ought to be aware that infants and young children can develop posttraumatic disorders after traumatic events. Criteria for diagnosing these disorders in standard nosologies may need revision for use with children younger than 48 months of age.

Evaluation of a preventive intervention for maltreated infants and toddlers in foster care.

OBJECTIVE: To determine the effectiveness of an intervention designed to improve outcomes for infants and toddlers in foster care. METHOD: Records were reviewed for all children who were adjudicated as in need of care in a specific parish in Louisiana between 1991 and 1998. This period included 4 years before and 4 years after a comprehensive intervention was implemented. Children adjudicated between 1991 and 1994 were the comparison group, and those adjudicated between 1995 and 1998 were the intervention group. RESULTS: After the intervention, more children were freed for adoption and fewer children were returned to their birth families than before the intervention. There was no difference in length of time in care before and after the intervention. With regard to the same child returning in a subsequent incident of maltreatment, relative risk reduction for the intervention group ranged from 53% to 68%. With regard to the same mother maltreating another child subsequently, relative risk reduction for the intervention group ranged from 63% to 75%. CONCLUSIONS: A comprehensive preventive intervention for maltreated infants and toddlers in foster care substantially reduced rates of recidivism but had no effect on length of time in care.

Beyond insecurity: a reconceptualization of attachment disorders of infancy.

Some young children are not merely insecurely attached and at risk for later problems; by virtue of the severity of their attachment disturbances they are already disordered. This article reviews and critiques the approaches of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) and the International Classification of Diseases (10th ed.; ICD-10; World Health Organization, 1992) to attachment disorders and finds that they have not made use of findings from developmental research on attachment in developing their criteria. An alternative system of classifying attachment disorders that is compatible with the major findings from developmental research on infant-caregiver attachment is presented. Finally, many areas in need of empirical contributions are indicated.

Clinical approaches to families in early intervention.

Clinical approaches to families with infants in early intervention programs require more sophisticated and individualized plans that have been traditionally available. Clinicians in early intervention programs, including those trained in child-oriented disciplines, will increasingly be expected to develop comprehensive family focused interventions. Empirical findings support the legislative mandate of PL99-457 in requiring that families have an active role in specifying the intervention services they require. In addition, the broader concept of risk that now includes multi-problem families also complicates the job of the early interventionist. As parents must learn to adapt to their infant's unique characteristics, early interventionists must adapt to the unique characteristics of each family with whom they are involved. To aid in this process, we apply the concept of a working alliance to the aspect of the parent-professional relationship that early interventionists must develop and maintain in providing empathic and individualized care to families in early intervention. Sensitivity to the families' unique characteristics, responsitivity to their concerns, positive connotation of parents' and infants' behavior, a nonjudgmental attitude, and a willingness to monitor one's feelings and responses elicited by the family are clinical principles essential for developing and maintaining the working alliance.

Atypical panic attacks and lack of resolution of mourning.

A number of psychologic and biologic contributors to panic disorder have been identified. Three cases of young adult women who experienced atypical panic attacks are described. The attacks are atypical because they had ideational or situational precipitants and because they were inevitably accompanied by intrusive visual images of a deceased loved one. In each case, there was also the persistence of irrational beliefs and/or unintegrated feelings about the deceased, corroborating that the intrusive images and panic attacks occurred in the context of unresolved mourning. Although the association between panic attacks and intrusive images apparently has not been reported previously, both phenomena have been associated with lack of resolution of mourning. The discussion considers similarities in these cases and in reports of Vietnam veterans suffering from posttraumatic stress disorder and panic attacks. Together, these similarities suggest that unresolved traumas of various kinds may at times contribute to the development of atypical panic attacks accompanied by intrusive visual images.

Disturbances of attachment in young children adopted from institutions.

In this article, the author describes a discrepancy between popular media accounts of reactive attachment disorder (RAD) and its clinical and scientific description. The literature on serious disturbances of attachment in children adopted out of institutions is reviewed. The author concludes that children adopted from institutions are at dramatically increased risk for disturbances, although the majority of such children do not demonstrate problems. Both the duration of deprivation and the postinstitutional caregiving environment seem to be importantly related to outcome. Inhibited/withdrawn RAD is exceedingly uncommon in children adopted from institutions (at least after 1 or more years), but disinhibited/indiscriminate RAD is quite persistent. Long after children become attached to adoptive parents, a number of them continue to exhibit indiscriminate sociability. Three explanations for this divergence of recovery curves are considered. It is likely that future systematic studies will illuminate many areas that are unclear at this time.

Measuring difficult temperament in infancy.

Thirty-four couples rated their 6-month-old first-born infants' temperaments with Bates' Infant Characteristics Questionnaire (ICQ) and Carey's Infant Temperament Questionnaire (ITQ). Mothers and infants were videotaped in their homes during feedings on two consecutive days to assess mother and infant behavior. Results indicated that parents had moderate agreement about their own infant's temperament on the ICQ. There was little convergence between the ICQ and the ITQ measures of infant difficulty. ICQ parent-rated unpredictable infants were rated by observers as less responsive during the feedings. These results are discussed in the context of the meaning and measurement of infant temperament.