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OBJECTIVE: To examine longitudinal associations between early life threat and deprivation on epigenetic age acceleration at ages 9 and 15 years, and to examine associations of age acceleration on later internalizing and externalizing symptoms. METHOD: The study examines a large (n = 2,039) and racially diverse (Black/African American = 44%, Latino = 18%, White = 5%) sample from a national dataset. Epigenetic age acceleration was estimated using the pediatric buccal epigenetic clock. Early life threat and deprivation were measured using composites from the Parent-Child Conflict Tactics Scale and county-level violent and property crime rate data. Internalizing and externalizing symptoms came from parent-reported Child Behavior Checklist. Path analysis models examined associations of threat and deprivation at age 3 years on epigenetic age acceleration at ages 9 and 15. Experiences of threat were further broken down into threat experienced in the home and in the community. RESULTS: Home threat experienced at age 3 years predicted age acceleration at 9 and 15, and community threat experienced at 3 predicted age acceleration at 15, but not at 9. Deprivation was not a significant predictor of accelerated aging. Age acceleration at age 9 predicted externalizing, but not internalizing, symptoms at age 15. Community threat had a direct effect on externalizing. No association emerged with internalizing. CONCLUSION: Findings revealed that threat, not deprivation, was predictive of age acceleration, demonstrating support for this pattern longitudinally, using an epigenetic clock that is accurate in children. The findings provide critical nuance to the examination of threat, and highlight associated risks and possible intervention points for externalizing symptoms.
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Temperament, parenting, and executive functioning (EF) are individual and contextual factors that have been identified to play a role in the development of Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms. Specifically, exuberant temperament in toddlerhood has been associated with both adaptive and maladaptive outcomes, including ADHD symptoms. Therefore, it is important to understand factors that predict which exuberant children experience increased ADHD symptoms and the specific mechanisms through which early exuberant temperament impacts later ADHD symptoms. Using a multi-method, prospective longitudinal design, this study examined a moderated mediation model wherein the interactive effects of observed exuberance and parenting at age 3 predicted the development of parent-reported ADHD symptoms from childhood through adolescence (age 5, 7, 9, 12, and 15) via child EF (i.e., inhibitory control) at age 4. Parent-child dyads (n = 291) from a longitudinal study on child temperament were included. A piecewise model of ADHD symptom growth demonstrated stability in ADHD symptoms from age 5-9 and a decrease from age 9-15. Results support a moderated mediation model wherein an increase in ADHD symptoms throughout childhood was predicted from early childhood exuberant temperament by way of EF, but only for children whose parents displayed less directive parenting. Findings suggest identifiable early markers of risk, including temperament, parenting, and EF- pointing to possible targets for early intervention/prevention.
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Transtorno do Deficit de Atenção com Hiperatividade , Humanos , Pré-Escolar , Adolescente , Criança , Poder Familiar , Temperamento , Estudos Longitudinais , Estudos ProspectivosRESUMO
The purpose of this study was to investigate the cognitive impacts of tablet use on young children's inhibitory control and error monitoring. A total of 70 children (35 boys) aged 3.5 to 5 years completed an age-appropriate go/no-go task and were then randomly assigned to a technology group or a comparison group. In the technology group, children completed a cooking task on a tablet for 15 min. In the comparison group, children completed a similarly structured cooking task with toys for the same length of time. Children then completed the go/no-go task again. Compared with children in the comparison group, children in the technology group demonstrated poorer inhibitory control as evidenced by lower accuracy on no-go trials after the cooking task. However, both groups displayed post-error reaction time slowing. Collectively, these results suggest that brief tablet use can impose selective impairment on young children's cognitive abilities for a short period of time following use.
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Cognição , Função Executiva , Criança , Pré-Escolar , Humanos , Masculino , Jogos e Brinquedos , Tempo de ReaçãoRESUMO
OBJECTIVE: This study examined emotion socialization and neural activity during frustration as predictors of emotion regulation (ER) difficulties, and the interplay of emotion socialization and neural activity, in children with and without hyperactivity/impulsivity (H/I). METHOD: At Time 1, neural activity (P1, N2, P3) during a frustration task, H/I symptoms, and emotion socialization were assessed in 68 children (aged 4-7 years old). At Time 2 (1.5-2 years later), child-report, maternal-report, and observation measures of ER difficulties were assessed. RESULTS: H/I symptoms moderated the relation between predictors and ER difficulties; there were significant relations for children with high, but not low, levels of H/I. Further, as emotion socialization quality increased, relations between event-related potentials and later ER difficulties became weaker. CONCLUSION: The processes underlying ER difficulties differ for children with H/I symptoms. High quality emotion socialization may have a protective effect for children whose neural patterns indicate risk for later ER difficulties.
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Transtorno do Deficit de Atenção com Hiperatividade , Regulação Emocional , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Criança , Pré-Escolar , Emoções/fisiologia , Humanos , Comportamento Impulsivo , SocializaçãoRESUMO
Level 2 (L2) driving automation systems that maintain latitudinal and longitudinal control of the vehicle decrease mental workload and result in drivers failing to monitor and respond to potential roadway hazards. This issue is potentially important for young drivers with symptoms of Attention Deficit Hyperactivity Disorder (ADHD) since they have known difficulties anticipating and mitigating potential hazards on the road, a skill which requires attention. The objective of this study is to investigate how the use of partially automated (L2) systems and manual systems impacts hazard anticipation and mitigation among young drivers with varying levels of ADHD symptomatology. Sixty-eight drivers, classified into two groups - high and low ADHD symptomatology-navigated twice through three scenarios on a driving simulator, once with an L2 and once with a manual system. The results indicated that: (i) the hazard anticipation skills of drivers with both high and low ADHD symptomatology were depressed in the L2 condition relative to the manual condition; (ii) the hazard mitigations skills of drivers with both high and low ADHD symptomatology were depressed in the L2 condition relative to the manual condition on two measures, but improved on a third measure; and (iii) the hazard anticipation and mitigation skills of drivers with high and low ADHD symptomatology were differentially impacted, both within and across the two levels of automation. Taken together, the results indicate the pernicious and often hard to predict consequences of higher levels of automation for different populations of younger drivers.
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Transtorno do Deficit de Atenção com Hiperatividade , Condução de Veículo , Acidentes de Trânsito , Automação , HumanosRESUMO
Objective: We examined behavioral and neural markers of emotion competence in young children as predictors of psychopathology, and as mediators of the relation between hyperactivity/impulsivity (H/I) and psychopathology. Method: At Time 1 (T1), children (n = 49; ages 4-7 years) with and without H/I symptoms completed a frustration task. Frustration, observed emotion, and neural activity (P1, N2, and P3 event-related potentials) were measured. Symptoms of psychopathology were collected 18 months later (Time 2; T2). Results: T1 lability, negative affect, and frustration predicted T2 depression and aggression symptomatology, controlling for T1 symptoms. Children with difficulty allocating neural resources during and after frustration were at risk for depression, aggression, and anxiety symptoms, controlling for earlier symptoms. P3 amplitudes during recovery mediated the relation between H/I and later depression. Conclusion: Markers of emotion competence contribute to psychopathology symptoms, particularly in children at risk for attention-deficit/hyperactivity disorder (ADHD). Emotion competence skills may be useful intervention targets.
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Transtorno do Deficit de Atenção com Hiperatividade , Ansiedade , Criança , Pré-Escolar , Emoções , Humanos , Comportamento Impulsivo , PsicopatologiaRESUMO
Objective: Children with ADHD often have sleep complaints and cognitive deficits. The aim of this pilot study was to determine whether sleep extension improves inhibitory control, a primary cognitive deficit in ADHD. Method: Children with (n = 11) and without (n = 15) ADHD participated in a within-subject sleep extension intervention that targeted nocturnal sleep duration. Sleep was assessed with actigraphy and polysomnography. Inhibitory control was assessed with a Go/No-Go task. Results: For children without ADHD, there was a significant main effect of time, such that morning inhibitory control was 10% greater than evening inhibitory control. However, inhibitory control did not differ between the baseline and extension conditions in this group. For children with ADHD, although morning inhibitory control did not differ from evening inhibitory control, sleep extension improved inhibitory control by 13% overall. Conclusion: These results suggest that a sleep extension intervention improves inhibitory control in children with ADHD.
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Transtorno do Deficit de Atenção com Hiperatividade , Transtornos do Sono-Vigília , Criança , Humanos , Projetos Piloto , Polissonografia , SonoRESUMO
BACKGROUND: Children with the temperament of behavioral inhibition (BI) face increased risk for social anxiety. However, not all children with BI develop anxiety symptoms. Inhibitory control (IC) has been suggested as a moderator of the pathway between BI and social anxiety. This study uses longitudinal data to characterize development of IC and tests the hypothesis that IC moderates associations between early BI and later social anxiety symptoms. METHODS: Children completed a Go/Nogo task at ages 5, 7, and 10 years as part of a longitudinal study of BI (measured at 2-3 years) and social anxiety symptoms (measured at 12 years). To assess IC development, response strategy (criterion) and inhibitory performance (d') were characterized using signal detection theory. Latent growth models were used to characterize the development of IC and examine relations among BI, IC parameters, and social anxiety symptoms. RESULTS: IC response strategy did not change between 5 and 10 years of age, whereas IC performance improved over time. BI scores in toddlerhood predicted neither initial levels (intercept) nor changes (slope) in IC response strategy or IC performance. However, between ages 5 and 10, rate of change in IC performance, but not response strategy, moderated relations between BI and later parent-reported social anxiety symptoms. Specifically, greater age-related improvements in IC performance predicted higher levels of social anxiety in high BI children. CONCLUSIONS: IC development in childhood occurs independent of BI levels. However, rapid increases in IC performance moderate risk for social anxiety symptoms in children with BI. Implications for theory and practice are discussed.
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Ansiedade/fisiopatologia , Comportamento Infantil/fisiologia , Desenvolvimento Infantil/fisiologia , Função Executiva/fisiologia , Inibição Psicológica , Fobia Social/fisiopatologia , Temperamento/fisiologia , Criança , Pré-Escolar , Feminino , Humanos , Estudos Longitudinais , Masculino , Modelos Estatísticos , Detecção de Sinal PsicológicoRESUMO
Affective images engage motivational systems that shape emotional experience and cognitive processes. However, relatively little work has examined motivated attention toward distinct categories of approach motivation, particularly social motivation, in children. In the current study, event-related potentials (ERPs) were collected while children (n = 43; 22 females; Mage = 8.49 years) completed a picture-viewing task using a novel stimulus set of child relevant images representing social and non-social categories of reward-related images. Results showed that the frontal N400 (fN400) was more prominent for intrapersonal images that showed individuals playing alone or achieving rewards (e.g. medals). For the LPP, males showed the greatest reactivity to non-social object-based reward images. In contrast, females showed a larger LPP response for interpersonal images that showed scenes of social interaction between individuals. Overall, LPP reactivity to intrapersonal images was correlated with greater behavior regulation problems. Collectively, these results highlight unique patterns of neural prioritization to distinct categories of social and non-social reward-related stimuli that may serve as important markers in tracking connections between approach motivation and the development of self-regulation in children.
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Atenção/fisiologia , Potenciais Evocados/fisiologia , Motivação/fisiologia , Recompensa , Comportamento Social , Criança , Sinais (Psicologia) , Eletroencefalografia , Emoções , Face , Feminino , Humanos , Masculino , Estimulação Luminosa , Fatores Sexuais , Análise e Desempenho de TarefasRESUMO
Children with attention-deficit/hyperactivity disorder (ADHD) often experience emotional dysregulation. Dysregulation can arise from heightened attention to emotional stimuli. Emotional attention biases are associated with a number of adverse socioemotional outcomes including reward sensitivity and externalizing behaviors. As reward sensitivity and externalizing behaviors are common in children with ADHD, the aim of the current study was to determine whether emotional attention biases are evident in young children with clinically significant ADHD symptoms. To test this, children with (n = 18) and without (n = 15) symptoms of ADHD were tested on a Dot Probe task. Provided recent evidence that emotional attention biases are attenuated by sleep, the task was performed before and after overnight sleep. Children with ADHD symptoms displayed positive, but not negative, attention biases at both time points, whereas typically developing children did not preferentially attend toward or away from positive or negative stimuli. Sleep did not alter attention biases in either group. Collectively, these results indicate that children with ADHD symptoms have stable, positive attention biases.
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Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Atenção/fisiologia , Desenvolvimento Infantil/fisiologia , Emoções/fisiologia , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estimulação Luminosa/métodos , Sono/fisiologiaRESUMO
Temperamental negative affect and insufficient sleep have been independently associated with behavior problems during early childhood. However, it is unknown whether these factors interact to contribute to behavioral difficulties in young children. The current study examined the interactions between temperamental negative affect and both sleep onset time and sleep midpoint, assessed by actigraphy, in predicting externalizing and internalizing behaviors in a sample of 117 children (34-69 months of age). Children with high temperamental negative affect and either later sleep onset time or later sleep midpoint were more likely to exhibit externalizing and internalizing behaviors. These results emphasize the association between temperamental negative affect and behavioral difficulties, particularly for children with insufficient sleep.
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Afeto/fisiologia , Sintomas Comportamentais/fisiopatologia , Comportamento Infantil/fisiologia , Sono/fisiologia , Temperamento/fisiologia , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
A growing literature indicates that attention deficit/hyperactivity disorder (ADHD) involves difficulty processing threat-related emotion faces. This deficit is especially important to understand in young children, as threat emotion processing is related to the development of social skills and related behavioral regulation. Therefore, the current study aimed to better understand the neural basis of this processing in young children with ADHD symptoms. Forty-seven children between 4 and 7 years of age were included in the analysis, 28 typical developing and 19 with clinically significant levels of ADHD hyperactive/impulsive symptoms. Participants completed a passive affective face-viewing task. Event-related potentials were assessed for each emotion, and parental report of child behavior and emotion regulation abilities was assessed. Children with ADHD symptoms showed altered N170 modulation in response to specific emotion faces, such that the N170 was less negative in response to fearful compared to neutral faces, whereas typically developing children showed the opposite pattern. Groups did not differ in reactivity to anger or non-threat-related emotion faces. The N170 difference in fearful compared to neutral faces correlated with reported behavior, such that less fear reactivity predicted fewer prosocial behaviors. Abnormalities in the underlying neural systems for fear processing in young children with ADHD symptoms may play an important role in social and behavioral deficits within this population.
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Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Sinais (Psicologia) , Emoções/fisiologia , Potenciais Evocados/fisiologia , Criança , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
Emotion reactivity and regulation are frequently impaired in individuals with attention-deficit/hyperactivity disorder (ADHD), yet few studies have examined these factors in young children with ADHD, and none have explored the neural correlates of emotion reactivity and regulation in this group through event-related potentials (ERPs). Children aged 4 to 7 with (n = 25; 18 boys) and without (n = 29; 20 boys) ADHD symptoms completed an attention task composed of four blocks: baseline, frustration, suppression, and recovery. In the frustration and suppression blocks, negative affect was induced by false negative feedback. During the suppression block, children were asked to suppress emotional expressions. Neural reactivity, assessed via the N2 and P3 components, suggests that children with ADHD symptoms processed the emotional induction differently than typically developing (TD) children. TD children demonstrated decreased N2 and increased P3 amplitudes at frontal and frontocentral regions across task conditions whereas children with ADHD symptoms showed relatively stable N2 and P3 amplitudes. This pattern suggests that young children with ADHD symptoms are not as effective as their TD peers in modulating attention allocation and cognitive control in emotionally laden situations. The present study underscores that emotional contexts may exacerbate attentional control deficits in young children with ADHD symptoms.
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Atenção/fisiologia , Emoções/fisiologia , Potenciais Evocados/fisiologia , Lobo Frontal/fisiologia , Autocontrole , Transtorno do Deficit de Atenção com Hiperatividade , Criança , Pré-Escolar , Eletroencefalografia , Potenciais Evocados P300/fisiologia , Feminino , Lobo Frontal/fisiopatologia , Humanos , MasculinoRESUMO
Sleep disturbances impair cognitive functioning in typically developing populations. Children with attention-deficit/hyperactivity disorder (ADHD), a disorder characterized by impaired inhibitory control and attention, commonly experience sleep disturbances. Whether inhibitory impairments are related to sleep deficits in children with ADHD is unknown. Children with ADHD (n = 18; M age = 6.70 years) and typically developing controls (n = 15; M age = 6.73 years) completed a Go/No-Go task to measure inhibitory control and sustained attention before and after polysomnography-monitored overnight sleep. Inhibitory control and sustained attention were improved following overnight sleep in typically developing children. Moreover, morning inhibitory control was positively correlated with rapid eye movement (REM) theta activity in this group. Although REM theta activity was greater in children with ADHD compared to typically developing children, it was functionally insignificant. Neither inhibitory control nor sustained attention was improved following overnight sleep in children with ADHD symptoms, and neither of these behaviors was associated with REM theta activity in this group. Taken together, these results indicate that elevated REM theta activity may be functionally related to ADHD symptomology, possibly reflecting delayed cortical maturation.
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Transtorno do Deficit de Atenção com Hiperatividade/complicações , Desenvolvimento Infantil/fisiologia , Inibição Psicológica , Transtornos do Sono-Vigília/etiologia , Sono REM/fisiologia , Ritmo Teta/fisiologia , Mapeamento Encefálico , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Testes Neuropsicológicos , Polissonografia , Escalas de Graduação PsiquiátricaRESUMO
Objective: Executive attention is impaired following sleep loss in school-aged children, adolescents, and adults. Whether naps improve attention relative to nap deprivation in preschool-aged children is unknown. The aim of this study was to compare executive attention in preschool children following a nap and an interval of wake. Method: Sixty-nine children, 35-70 months of age, completed a Flanker task to assess executive attention following a nap and an equivalent interval of wake. Results: Overall, accuracy was greater after the nap compared with the wake interval. Reaction time(s) did not differ between the nap and wake intervals. Results did not differ between children who napped consistently and those who napped inconsistently, suggesting that naps benefit executive attention of preschoolers regardless of nap habituality. Conclusions: These results indicate that naps enhance attention in preschool children. As executive attention supports executive functioning and learning, nap promotion may improve early education outcomes.
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Atenção/fisiologia , Função Executiva/fisiologia , Sono , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
Sleep loss alters processing of emotional stimuli in preschool-aged children. However, the mechanism by which sleep modifies emotional processing in early childhood is unknown. We tested the hypothesis that a nap, compared to an equivalent time spent awake, reduces biases in attention allocation to affective information. Children (n = 43; M = 55.40 months, SD = 8.05 months) completed a Dot Probe task, which provides a measure of attention biases to emotional stimuli, following a mid-day nap and an equivalent interval spent awake. No emotional attention biases emerged when children napped. However, when nap-deprived, children exhibited biases towards negative and positive stimuli. This emotional bias after wake was greater in children who napped habitually. Gender differences also emerged such that females were more attentive to positive emotional stimuli whereas males showed heightened attention to negative emotional stimuli, regardless of having napped or not. Moreover, greater slow wave activity (SWA) during the nap was associated with faster responding, which suggests that SWA may promote efficiency of attention allocation. A video abstract of this article can be viewed at: https://www.youtube.com/watch?v=JIoZ8mzxQgg.
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Atenção/fisiologia , Emoções/fisiologia , Sono/fisiologia , Criança , Comportamento Infantil , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
The goal of the present study was to examine whether young children with attention-deficit/hyperactivity disorder (ADHD) symptoms experience difficulties with emotional understanding, reactivity, and regulation. Participants were 64 children, 4 to 7 years of age (43 boys, 20 girls), 29 with ADHD symptoms and 34 typically developing children. Children completed an emotion matching task and parents reported on child lability and emotional regulation. Children also completed a frustrating computer task. Facial expressions of emotions were coded and children self reported affect during the task. Parent reports indicated heightened lability and impaired emotional regulation abilities in children with ADHD symptoms. Compared to typically developing children, children with ADHD symptoms demonstrated emotional understanding impairments in matching similar expressions and matching expressions to situations, but not in producing expression labels or matching expression labels to images. Self-reports of negative affect during the frustration task indicated that children with ADHD symptoms experienced more difficulty with emotional regulation than typically developing children. Behavioral observations during the frustration task indicated that the two groups demonstrated a similar increase in expressed negative affect during frustration; however, children with ADHD symptoms showed higher levels of negative affect across all four conditions of the task. This study suggests that the deficits documented in older children with ADHD are already evident during the preschool years, and distinct from the developmentally appropriate emotional dysregulation seen in typically developing preschoolers.
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Sintomas Afetivos/fisiopatologia , Transtorno do Deficit de Atenção com Hiperatividade/fisiopatologia , Comportamento Infantil/fisiologia , Emoções/fisiologia , Expressão Facial , Reconhecimento Facial/fisiologia , Autocontrole , Percepção Social , Sintomas Afetivos/etiologia , Transtorno do Deficit de Atenção com Hiperatividade/complicações , Criança , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
Children join adoptive families through domestic adoption from the public child welfare system, infant adoption through private agencies, and international adoption. Each pathway presents distinctive developmental opportunities and challenges. Adopted children are at higher risk than the general population for problems with adaptation, especially externalizing, internalizing, and attention problems. This review moves beyond the field's emphasis on adoptee-nonadoptee differences to highlight biological and social processes that affect adaptation of adoptees across time. The experience of stress, whether prenatal, postnatal/preadoption, or during the adoption transition, can have significant impacts on the developing neuroendocrine system. These effects can contribute to problems with physical growth, brain development, and sleep, activating cascading effects on social, emotional, and cognitive development. Family processes involving contact between adoptive and birth family members, co-parenting in gay and lesbian adoptive families, and racial socialization in transracially adoptive families affect social development of adopted children into adulthood.
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Adoção/psicologia , Desenvolvimento Infantil/fisiologia , Família/psicologia , Poder Familiar/psicologia , Criança , Cognição/fisiologia , HumanosRESUMO
Early adversity can negatively impact the development of cognitive functions, although little is known about whether such effects can be remediated later in life. The current study examined one facet of executive functioning - inhibitory control - among children who experienced institutional care and explored the impact of a foster care intervention within the context of the Bucharest Early Intervention Project (BEIP). Specifically, a go/nogo task was administered when children were eight years old and behavioral and event-related potential (ERP) measures were collected. Results revealed that children assigned to care as usual (i.e. institutional care) were less accurate and exhibited slower neural responses compared to children assigned to the foster care intervention and children who had never been institutionalized. However, children in both the care as usual and foster care groups exhibited diminished attention processing of nogo cues as assessed via P300 amplitude. Foster care children also showed differential reactivity between correct and error responses via the error-related negativity (ERN) as compared to children in the care as usual group. Combined, the results highlight perturbations in neural sources of behavioral and attention problems among children experiencing early adversity. Potential implications for academic adjustment in at risk children are discussed.
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Adaptação Psicológica/fisiologia , Criança Institucionalizada/psicologia , Função Executiva/fisiologia , Cuidados no Lar de Adoção/psicologia , Inibição Psicológica , Análise de Variância , Criança , Potenciais Evocados/fisiologia , Feminino , Humanos , Inteligência/fisiologia , Masculino , Tempo de Reação/fisiologia , Ajustamento Social , Fatores de TempoRESUMO
BACKGROUND: Behaviorally inhibited (BI) children who also exhibit enhanced response monitoring might be at particularly high risk for anxiety disorders. The current study tests the hypothesis that response monitoring, as manifest in the error-related negativity (ERN), moderates the association between BI and anxiety. METHODS: Participants (n=113; 73 male) assessed for early-childhood BI were re-assessed as adolescents with a clinical interview and a flanker paradigm that generated behavioral data and event-related potentials (ERPs). Risk for anxiety disorders in adolescents was examined as a function of childhood-BI status and adolescent performance on the flanker paradigm. RESULTS: Adolescents with childhood BI displayed ERP evidence of enhanced response monitoring, manifest as large ERNs. The ERN moderated the relationship between early BI and later clinically significant disorders. CONCLUSIONS: Physiological measures of response monitoring might moderate associations between early-childhood BI and risk for psychopathology. The subset of children with BI and enhanced response monitoring might face greater risk for later-life clinical anxiety than children with either BI or enhanced response monitoring alone.