Post-Traumatic Stress Symptoms after Pediatric Injury: Relation to Pre-Frontal Limbic Circuitry.

Pre-frontal limbic circuitry is vulnerable to effects of stress and injury. We examined microstructure of pre-frontal limbic circuitry after traumatic brain injury (TBI) or extracranial injury (EI) and its relation to post-traumatic stress symptoms (PTSS). Participants aged 8 to 15 years who sustained mild to severe TBI (n = 53) or EI (n = 26) in motor vehicle incidents were compared with healthy children (n = 38) in a prospective longitudinal study. At the seven-week follow-up, diffusion tensor imaging was obtained in all groups; injured children completed PTSS ratings using a validated scale. Using probabilistic diffusion tensor tractography, pathways were seeded from bilateral amygdalae and hippocampi to estimate the trajectory of white matter connecting them to each other and to targeted pre-frontal cortical (PFC) regions. Microstructure was estimated using fractional anisotropy (FA) in white matter and mean diffusivity (MD) in gray matter. Pre-frontal limbic microstructure was similar across groups, except for reduced FA in the right hippocampus to orbital PFC pathway in the injured versus healthy group. We examined microstructure of components of pre-frontal limbic circuitry with concurrently obtained PTSS cluster scores in the injured children. Neither microstructure nor PTSS scores differed significantly in the TBI and EI groups. Across PTSS factors, specific symptom clusters were related positively to higher FA and MD. Higher hyperarousal, avoidance, and re-experiencing symptoms were associated with higher FA in amygdala to pre-frontal and hippocampus to amygdala pathways. Higher hippocampal MD had a central role in hyperarousal and emotional numbing symptoms. Age moderated the relation of white and gray matter microstructure with hyperarousal scores. Our findings are consistent with models of traumatic stress that implicate disrupted top-down PFC and hippocampal moderation of overreactive subcortical threat arousal systems. Alterations in limbic pre-frontal circuitry and PTSS place children with either brain or body injuries at elevated risk for both current and future psychological health problems.

Sleep disturbances and internalizing behavior problems following pediatric traumatic injury.

OBJECTIVE: This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury. METHOD: Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes. RESULTS: Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury. CONCLUSIONS: Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record

Altered stress system reactivity after pediatric injury: Relation with post-traumatic stress symptoms.

Injury is the leading cause of death and disability in childhood. Injured children are at high risk for developing alterations in stress response systems and post-traumatic stress symptoms (PTSS) that may compromise long-term physical and psychological health. In a prospective, observational cohort study, we examined individual differences in, and correlates of, stress-reactivity of the hypothalamic-pituitary-adrenal axis (HPA; salivary cortisol) and autonomic nervous system (ANS; salivary alpha amylase, sAA) following pediatric injury. Participants were 8-15 years of age and hospitalized for traumatic brain injury (TBI; n=55; M age=13.9 yrs; 40 males) or extracranial injury (EI; n=29; M age 12.3 yrs, 20 males) following vehicular accidents. Six months post-injury, saliva was collected before and after the Trier Social Stress Test and later assayed for cortisol and sAA. Relative to a healthy non-injured comparison group (n=33; M age=12.5 yrs, 16 males), injured children (ages 8-12 years), but not adolescents (ages 13-15 yrs), had higher cortisol levels; regardless of age, injured participants showed dampened cortisol reactivity to social evaluative threat. Compared to participants with EI, children with TBI had elevated cortisol and adolescents had elevated sAA. With respect to PTSS, individual differences in sAA were negatively correlated with avoidance in the TBI group and positively correlated with emotional numbing within the EI group. Importantly, psychological and neurobiological sequelae were weakly related to injury severity. Given the high prevalence of pediatric injury, these sequelae affect many children and represent a significant public health concern. Consequently, surveillance of post-traumatic sequelae should include the full spectrum of injury severity. Monitoring the activity, reactivity, and regulation of biological systems sensitive to environmental insults may advance our understanding of individual differences in sequelae and adaptation following traumatic pediatric injury.

Recovery of Working Memory Following Pediatric Traumatic Brain Injury: A Longitudinal Analysis.

In a prospective longitudinal study, the trajectory of verbal and visual-spatial working memory (WM) development was examined 2-, 6-, 12-, and 24-months following complicated-mild to severe pediatric traumatic brain injury (TBI; n = 55) relative to an orthopedic injury comparison group (n = 47). Individual growth curve modeling revealed an interaction of age, severity, and time for verbal, but not visual-spatial WM. The youngest children with severe TBI had the lowest scores and slowest verbal WM growth. WM outcome is best understood in light of age at injury and TBI severity. Findings support the early vulnerability hypothesis and highlight the need for long-term follow-up.

Relations between mental health diagnoses, mental health treatment, and substance use in homeless youth.

BACKGROUND: Youth experiencing homelessness have elevated rates of mental illness and substance use compared to the general population. However, the extent to which underlying mental health issues may contribute to substance use as a way to manage symptoms and whether mental health treatment may reduce risk for substance use is unclear. This paper investigated these relations in a community sample of homeless youth. METHODS: Youth ages 13-24 (N=416) were interviewed as part of a community count and survey of homeless youth in Houston, Texas. A path analysis examined relations among lifetime diagnoses of ADHD, bipolar disorder, and depression; past-month marijuana, alcohol, and synthetic marijuana use, and hypothesized mediators of past-year mental health treatment and perceived unmet need for treatment. RESULTS: Rates of prior mental disorder diagnoses were high, with extensive comorbidity across the three diagnoses (n=114, 27.3% had all three diagnoses). Relations varied by diagnoses and substances. ADHD was positively related to current marijuana use (ß=0.55 (0.16), p<0.001), a relation that mental health treatment did not mediate. Depression was positively related to synthetic marijuana use through unmet need (ß=0.25 (0.09), p=0.004) and to alcohol use through unmet need (ß=0.20 (0.10), p=0.04) CONCLUSIONS: This study provides new information about relations between prior mental health diagnoses and substance use in homeless youth. Findings support the need to consider prior mental disorder diagnoses in relation to current substance use and to assess for whether youth perceive they have unmet needs for mental health treatment.

Long-Term School Outcomes of Children and Adolescents With Traumatic Brain Injury.

OBJECTIVE: To better understand the impact of age at injury, severity of injury, and time since injury on long-term school outcomes of children with traumatic brain injury (TBI). PARTICIPANTS: Four groups of children: complicated mild/moderate TBI (n = 23), severe TBI (n = 56), orthopedic injury (n = 35), and healthy controls (n = 42). Children with TBI were either 2 years postinjury or 6 years postinjury. DESIGN: Cross-sectional design. MEASURES: School records as well as parental ratings of functional academic skills and school competency. RESULTS: Children with severe TBI had consistently high usage of school services and low school competency ratings than children with orthopedic injuries and healthy controls. In contrast, children with complicated-mild/moderate TBI were significantly more likely to receive school support services and have lower competence ratings at 6 years than at 2 years postinjury. Students injured at younger ages had lower functional academic skill ratings than those injured at older ages. CONCLUSIONS: These findings highlight the increasing academic challenges faced over time by students with complicated-mild/moderate TBI and the vulnerability of younger children to poorer development of functional academic skills.

Phase II Clinical Trial of Atorvastatin in Mild Traumatic Brain Injury.

Statins constitute a class of medications commonly used in the treatment of elevated cholesterol. However, in experimental studies, statins also have other non-cholesterol-mediated mechanisms of action, which may have neuroprotective effects. The aim of this study was to determine whether administration of atorvastatin for 7 days post-injury would improve neurological recovery in patients with mild traumatic brain injury (mTBI). The hypothesis was that atorvastatin administration would reduce post-concussion symptoms and also that atorvastatin administration for 1 week post-injury would be safe. One hundred forty patients with mTBI were planned to be enrolled and randomly assigned to receive atorvastatin 1 mg/kg (up to 80 mg/kg) per day or placebo for 7 days starting within 24 h of injury. Assessments of post-concussion syndrome, post-traumatic stress and depressive symptoms, cognition, memory, verbal fluency, functional, and work status were performed at baseline, 1 week, and 1 and 3 months. The result on the Rivermead Post-Concussion Symptoms Questionnaire at 3 months was the primary outcome. Enrollment in the trial was stopped early because of difficulty in recruiting sufficient numbers of subjects. Fifty-two patients with mTBI were enrolled; 28 patients received atorvastatin and 24 received placebo. The median Rivermead score was 2 for the atorvastatin group, compared to 3.5 for the placebo group, at 3 months post-injury (χ2(1) = 0.0976; p = 0.7547). The change in the Rivermead score between baseline and 3 months was also analyzed. The median decrease in score was 4 for the atorvastatin group and 10.5 for the placebo group (χ2(1) = 0.8750; p = 0.3496). No serious adverse events occurred, and there was no significant difference in the incidence of adverse events in the two treatment groups. Atorvastatin administration for 7 days post-injury was safe, but there were no significant differences in neurological recovery post-mTBI with atorvastatin.

Longitudinal diffusion tensor imaging after pediatric traumatic brain injury: Impact of age at injury and time since injury on pathway integrity.

Following pediatric traumatic brain injury (TBI), longitudinal diffusion tensor imaging may characterize alterations in initial recovery and subsequent trajectory of white matter development. Our primary aim examined effects of age at injury and time since injury on pathway microstructure in children ages 6-15 scanned 3 and 24 months after TBI. Microstructural values generated using tract-based spatial statistics extracted from core association, limbic, and projection pathways were analyzed using general linear mixed models. Relative to children with orthopedic injury, the TBI group had lower fractional anisotropy (FA) bilaterally in all seven pathways. In left-hemisphere association pathways, school-aged children with TBI had the lowest initial pathway integrity and showed the greatest increase in FA over time suggesting continued development despite incomplete recovery. Adolescents showed limited change in FA and radial diffusivity and had the greatest residual deficit suggesting relatively arrested development. Radial diffusivity was persistently elevated in the TBI group, implicating dysmyelination as a core contributor to chronic post-traumatic neurodegenerative changes. The secondary aim compared FA values over time in the total sample, including participants contributing either one or two scans to the analysis, to the longitudinal cases contributing two scans. For each pathway, FA values and effect sizes were very similar and indicated extremely small differences in measurement of change over time in the total and longitudinal samples. Statistical approaches incorporating missing data may reliably estimate the effects of TBI and provide increased power to identify whether pathways show neurodegeneration, arrested development, or continued growth following pediatric TBI. Hum Brain Mapp 37:3929-3945, 2016. © 2016 Wiley Periodicals, Inc.

Psychometric Analysis of the Three-Factor Eating Questionnaire-R18V2 in Adolescent and Young Adult-Aged Central Nervous System Tumor Survivors.

PURPOSE: Adolescent and young adult (AYA)-aged central nervous system (CNS) tumor survivors are an understudied population that is at risk of developing adverse health outcomes, such as obesity. Long-term follow-up guidelines recommend monitoring those at risk of obesity, thus motivating the need for an eating behavior questionnaire. An abbreviated online version of the Three-Factor Eating Questionnaire (TFEQ-R18v2) has been developed, but its applicability to this population is not yet known. This study investigated the instrument's factor structure and reliability in this population. METHODS: AYA-aged CNS tumor survivors (n = 114) aged 15-39 years completed the TFEQ-R18V2 questionnaire online. Confirmatory factor analysis was used to examine the fit of the three-factor structure (uncontrollable eating, cognitive restraint, and emotional eating [EE]) and reliability (internal consistency of the TFEQ-R18v2). Associations between the three factors and body mass index (BMI) were assessed by linear regression. RESULTS: The theorized three-factor structure was supported in our population (RMSEA = 0.056 and CFI = 0.98) and demonstrated good reliability (α of 0.81-0.93). EE (ß = 0.07, 95% CI 0.02-0.13) was positively associated with BMI, whereas the other two subscale scores were not. CONCLUSION: The TFEQ-R18v2 instrument holds promise for research and clinical use among AYA-aged CNS tumor survivors. The instrument may be a useful tool for researchers to develop tailored weight management strategies. It also may be a valuable tool for clinicians to monitor survivors who are at risk of obesity and to facilitate referral. Our results also suggest that EE in this population should be further investigated as a potential target for intervention.

Does processing speed mediate the effect of pediatric traumatic brain injury on working memory?

OBJECTIVE: Processing speed (PS) and working memory (WM), core abilities that support learning, are vulnerable to disruption following traumatic brain injury (TBI). Developmental increases in WM are related to age-related changes in PS. The purpose of this study was to investigate whether WM deficits in children with TBI are mediated by PS. METHOD: The performance of children with complicated mild, moderate, and severe TBI (n = 77) was examined relative to an orthopedic injury (n = 30) and a healthy comparison group (n = 40) an average of 4 years after injury (range 8 months to 12 years). Coding was utilized as a measure of PS, while the WM measures included complex verbal and visual-spatial span tasks with parallel processing requirements. Mediation analysis examined whether TBI might have an indirect effect on WM through PS. RESULTS: Children in the TBI group performed more poorly than the combined comparison groups on coding and visual-spatial WM. Verbal WM scores were lower in TBI and the healthy comparison relative to the orthopedic group. TBI severity group differences were found on coding, but not WM measures. The relation between coding and both the WM tasks was similar. Bootstrap regression analyses suggested that PS, as measured by coding, might partially mediate the effect of group performance on WM. CONCLUSIONS: TBI disrupts core PS and WM abilities that scaffold more complex abilities. Importantly, slowed PS was associated with WM deficits commonly identified following pediatric TBI. Implications of our findings regarding the relation between PS and WM may suggest interventions for children and adolescents following TBI.

Impacts of a Comprehensive School Readiness Curriculum for Preschool Children at Risk for Educational Difficulties.

This article reports findings from a cluster-randomized study of an integrated literacy- and math-focused preschool curriculum, comparing versions with and without an explicit socioemotional lesson component to a business-as-usual condition. Participants included 110 classroom teachers from randomized classrooms and approximately eight students from each classroom (N = 760) who averaged 4.48 (SD = 0.44) years of age at the start of the school year. There were positive impacts of the two versions of the curriculum on language, phonological awareness, math, and socioemotional outcomes, but there were no added benefits to academic or socioemotional outcomes for the children receiving explicit socioemotional instruction. Results are discussed with relevance to early childhood theory, policy, and goals of closing the school readiness gap.

White matter and reading deficits after pediatric traumatic brain injury: A diffusion tensor imaging study.

Pediatric traumatic brain injury often results in significant long-term deficits in mastery of reading ability. This study aimed to identify white matter pathways that, when damaged, predicted reading deficits in children. Based on the dual-route model of word reading, we predicted that integrity of the inferior fronto-occipital fasciculus would be related to performance in sight word identification while integrity of the superior longitudinal fasciculus would be related to performance in phonemic decoding. Reading fluency and comprehension were hypothesized to relate to the superior longitudinal fasciculus, inferior fronto-occipital fasciculus, and cingulum bundle. The connectivity of white matter pathways was used to predict reading deficits in children aged 6 to 16 years with traumatic brain injury (n = 29) and those with orthopedic injury (n = 27) using tract-based spatial statistics. Results showed that children with traumatic brain injury and reduced microstructural integrity of the superior longitudinal fasciculus demonstrated reduced word-reading ability on sight word and phonemic decoding tasks. Additionally, children with traumatic brain injury and microstructural changes involving the cingulum bundle demonstrated reduced reading fluency. Results support the association of a dorsal pathway via the superior longitudinal fasciculus with both sight word reading and phonemic decoding. No association was identified between the inferior fronto-occipital fasciculus and sight word reading or phonemic decoding. Reading fluency was associated with the integrity of the cingulum bundle. These findings support dissociable pathways predicting word reading and fluency using Diffusion Tensor Imaging and provide additional information for developing models of acquired reading deficits by specifying areas of brain damage which may predict reading deficits following recovery from the acute phase of TBI.

A safety awareness program for women with diverse disabilities: a randomized controlled trial.

Women with diverse disabilities (N = 213), recruited through 10 centers for independent living (CILs), were randomly assigned to either a personal safety awareness program or usual care. The 8-week program, led by CIL staff, was designed to increase safety awareness, abuse and safety knowledge, safety skills, safety self-efficacy, social support, and safety promoting behaviors. All participants completed pre-, post-, and 6-month follow-up questionnaires. Results revealed that participation in a brief safety awareness program may improve safety protective factors among women with disabilities who vary widely in their experience with abuse. The program holds promise for enhancing safety among women with disabilities.

Assessing recovery and disability after physical trauma: the Pediatric Injury Functional Outcome Scale.

OBJECTIVE: To establish reliability and validity of the Pediatric Injury Functional Outcome Scale (PIFOS), a brief injury-specific rating scale covering motor, self-care, communication, social-emotional, cognition, physical, and academic areas. METHODS: In a prospective longitudinal study, the PIFOS structured interview was administered to parents of children 3-15 years of age at 3 and 12 months after hospitalization for traumatic brain injury (TBI) or orthopedic injury (OI). RESULTS: The total score had good internal consistency (α = .90-.93) and inter-rater reliability (α = .90) and correlated significantly with injury severity and neurodevelopmental outcomes. Generalized linear modeling showed the PIFOS was sensitive to the type and severity of injury, showed specific initial and persisting difficulties following TBI and OI, and was responsive to change during the first year after injury. Both groups had residual difficulties with coordination, emotionality, social participation, and discomfort. CONCLUSION: The PIFOS is useful in examining recovery in natural history and intervention studies.

Physician behaviors to promote informed decisions for prostate cancer screening: a National Research Network study.

Clinical guidelines for prostate cancer screening (PCS) advise physicians to discuss the potential harms and benefits of screening. However, there is a lack of training programs for informed decision-making (IDM), and it is unknown which IDM behaviors physicians have the most difficulty performing. Identifying difficult behaviors can help tailor training programs. In the context of developing a physician-IDM program for PCS, we aimed to describe physicians' use of nine key IDM behaviors for the PCS discussion and to examine the relation between the behaviors and physician characteristics. A cross-sectional sample of The American Academy of Family Physicians National Research Network completed surveys about their behavior regarding PCS (N = 246; response rate = 58%). The surveys included nine physician key IDM behaviors for PCS and a single-item question describing their general practice style for PCS. The most common IDM behavior was to invite men to ask questions. The two least common reported behaviors concerned patients uncertain about screening (i.e., arrange follow-up and provide additional information for undecided men). Physicians reported difficulty with these two behaviors regardless whether they reported to discuss or not to discuss PCS with patients. Reported use of key IDM behaviors was associated with a general practice style for PCS and being affiliated with a residency-training program. Physician training programs for IDM should include physician skills to address the needs of patients uncertain about screening. Future research should determine if actual behavior is associated with self-reported behavior for the PCS discussion.

Using growth curve analysis to examine challenges in instrumentation in longitudinal measurement in home visiting.

Home visitation programs aim to decrease child maltreatment, yet limited longitudinal data exists concerning their screening and assessment instruments. "At risk" families (N = 2,054) were screened using the Family Stress Checklist and referred to Healthy Families Indiana. The Home Observation Measurement of the Environment Scale (HOME) and Community Life Skills Scale (CLS) were administered at multiple intervals. Growth curve analyses indicate families with lower HOME and CLS scores received more home visits and visits between assessments. However, these instruments may have "ceiling effects" and may be unsuitable for longitudinal assessment and program evaluation. Programmatic changes were made based on evaluation results.

"My Baby & Me": effects of an early, comprehensive parenting intervention on at-risk mothers and their children.

This study examined the efficacy of a multimodule parenting intervention, "My Baby & Me," that began prenatally and continued until children reached 2.5 years of age. The intervention targeted specific parenting skills designed to alter trajectories of maternal and child development. Of 361 high-risk mothers (193 adolescents, 168 adults) enrolled across 4 states, half were randomly assigned to the high-intensity (HI) home visitation coaching program (55 sessions), and half to a low-intensity (LI) condition that included monthly phone calls from a coach, printed informational materials, and community resource referrals. Videotaped observations of mother-child play were coded at 5 time points for multiple maternal and child behaviors and skills. Compared to mothers in the LI group, mothers in the HI group showed higher levels of contingent responsiveness, higher quality verbal stimulation, and more verbal scaffolding by 30 months, with higher levels of warmth and greater decreases in physical intrusiveness and negativity when their children were 24 months. By 30 months, children in the HI group showed more rapid increases and higher levels of engagement with the environment, expressive language skills, and social engagement, as well as more complex toy play and fewer problem behaviors than those in the LI group. Gains in maternal responsive behaviors mediated the effects of the intervention on child outcomes. Results were comparable for adolescent and adult mothers. A strong theoretical framework, consistent focus on maternal responsiveness, high dosage, and trusting relationships with coaches are thought to explain the positive outcomes.

Examining patterns of association with defensive information processing about colorectal cancer screening.

To reduce negative psychological affect from information or behavior that is inconsistent with one's positive self-concept, individuals use a variety of defensive strategies. It is unknown whether correlates differ across defenses. We examined correlates of four levels of defensive information processing about colorectal cancer screening. Cross-sectional surveys were completed by a convenience sample of 287 adults aged 50-75 years. Defenses measures were more consistently associated with individual differences (especially avoidant coping styles); however, situational variables involving health-care providers also were important. Future research should examine changes in defenses after risk communication and their relative impact on colorectal cancer screening.

Enhancing early child care quality and learning for toddlers at risk: the responsive early childhood program.

Despite reports of positive effects of high-quality child care, few experimental studies have examined the process of improving low-quality center-based care for toddler-age children. In this article, we report intervention effects on child care teachers' behaviors and children's social, emotional, behavioral, early literacy, language, and math outcomes as well as the teacher-child relationship. The intervention targeted the use of a set of responsive teacher practices, derived from attachment and sociocultural theories, and a comprehensive curriculum. Sixty-five childcare classrooms serving low-income 2- and 3-year-old children were randomized into 3 conditions: business-as-usual control, Responsive Early Childhood Curriculum (RECC), and RECC plus explicit social-emotional classroom activities (RECC+). Classroom observations showed greater gains for RECC and RECC+ teachers' responsive practices including helping children manage their behavior, establishing a predictable schedule, and use of cognitively stimulating activities (e.g., shared book reading) compared with controls; however, teacher behaviors did not differ for focal areas such as sensitivity and positive discipline supports. Child assessments demonstrated that children in the interventions outperformed controls in areas of social and emotional development, although children's performance in control and intervention groups was similar for cognitive skills (language, literacy, and math). Results support the positive impact of responsive teachers and environments providing appropriate support for toddlers' social and emotional development. Possible explanations for the absence of systematic differences in children's cognitive skills are considered, including implications for practice and future research targeting low-income toddlers.

Longitudinal mediators of social problem solving in spina bifida and typical development.

OBJECTIVE: The current study examined the role of early executive functions (EF) and social language (SL) as well as responsive parenting as mediators of the effect of group on social problem-solving skills at 7 years of age for children with spina bifida and typically developing children. METHOD: A mediation analysis was used to determine if the effect of having spina bifida on school age social problem-solving skills was mediated through the effect of group on EF/SL at 3 years of age and responsive parenting at 12 and 18 months. As part of a larger longitudinal study, 103 infants (n = 49 with spina bifida; n = 54 typically developing) received measures of EF/SL at 3 years of age and mother-infant play interactions at 12 and 18 months of age were coded for a range of responsive parenting behaviors. Social problem-solving skills were measured with a game-like observational task at 7 years of age. RESULTS: Group had a direct relation with later social problem-solving as well as an indirect relation through early EF/SL skills that, in turn, had a direct relation with later social problem solving. An indirect effect of responsive parenting on later social skills also was found through a direct effect on EF/SL skills. CONCLUSION: Early precursors of school age difficulties with social problem solving observed for children with spina bifida can be explained, in part, by difficulties in the first 3 years of life with EF/SL. Early responsive parenting appears to positively affect the development of these EF/SL skills. Implications for early intervention are an outcome of this study.