Cocaine exposure is associated with subtle compromises of infants' and mothers' social-emotional behavior and dyadic features of their interaction in the face-to-face still-face paradigm.

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

An approach to studying circadian rhythms of adolescent humans.

The "long nights" protocol was designed to evaluate sleep processes and circadian rhythm parameters in young humans. A total of 19 children (10 boys, ages 11.2 to 14.1 years [mean = 12.7 +/- 1.0], and 9 girls, ages 12.2 to 14.4 years [mean = 13.1 +/- 0.7]) took part in the study. Sleep/wake initially was assessed at home using actigraphy and diary for 1 week on each child's self-selected schedule followed by an 8-night fixed light-dark (LD) condition, while sleeping from 22:00 to 08:00 h and wearing an eye mask to exclude as much light as possible. Phase measurements included 4-night mean actigraphically estimated sleep onset and offset as well as 1-night dim light salivary melatonin onset (DLSMO) phase at the end of each condition. Subjects then lived in the laboratory for 6 consecutive cycles: Day 1 LD = 14:10 h, lights out 22:00 to 08:00 h; Days 2-4 LD = 6:18 h, lights out 18:00 to 12:00 h; Days 5-6 = constant routine in continuous dim light (about 20 lux); Night 6 = 14 h recovery sleep. Phase markers (sleep onset, sleep offset, DLSMO) were significantly less dispersed after the fixed LD as compared to the self-selected condition, indicating efficacy of the LD protocol. Phase markers were correlated at the self-selected assessment (sleep onset vs. sleep offset r = .72; DLSMO vs. sleep onset r = .82; DLSMO vs. sleep offset r = .76) but not on the fixed schedule, probably due to restricted range. The constant routine provided additional phase markers, melatonin offset and midphase. Offset phase of melatonin secretion was significantly correlated with age (r = .62) and Tanner stage (r = .62). In conclusion, these preliminary data indicate a relationship between adolescent development and circadian phase. Thus, the long nights protocol is a feasible way in which to assess circadian parameters in young humans as well as to examine intrinsic sleep processes.

Intelligence quotient scores of 4-year-old children: social-environmental risk factors.

Verbal IQ scores in a socially heterogeneous sample of 215 4-year-old children were highly related to a cumulative environmental risk index composed of maternal, family and cultural variables. Different combinations of equal numbers of risk factors produced similar effects on IQ, providing evidence that no single factor identified here uniquely enhances or limits early intellectual achievement and that cumulative effects from multiple risk factors increase the probability that development will be compromised. The multiple risk index predicted substantially more variance in the outcome measure than did any single risk factor alone, including socioeconomic status. High-risk children were more than 24 times as likely to have IQs below 85 than low-risk children.

Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures?

STUDY OBJECTIVES: This study provides estimates of reliability for aggregated values from 1 to 7 recording nights for five commonly used actigraphic measures of sleep patterns, reliability as a function of night type (weeknight or weekend night), and stability of measures over several months. DESIGN AND SETTING: Data are from three studies that obtained 7 nights of actigraph data (using Mini Motionlogger actigraphs and associated validated algorithms [ASA]) on children and adolescents living at home on self-selected sleep-wake schedules. PARTICIPANTS: Participants were 169 children aged 12-60 months, and 55 adolescents aged 11-16 years. MEASUREMENTS AND RESULTS: Up to 28% of weekly recordings may be unacceptable for analysis in young participants because of illness, technical problems, and participant noncompliance; studies aiming to collect 5 nights of actigraph data should record for at least 1 full week. Reliability estimates for values aggregated over any 5 nights were adequate (> or = .70) for sleep start time, wake minutes, and sleep efficiency. Measures of sleep minutes and sleep period were less reliable and may require 7 or more nights for estimates of stable individual differences. Reliability for 1- or 2-night aggregates were poor for all measures. We found significant and high correlations between summer and fall session measures for all five variables when weekend nights were included. CONCLUSIONS: Five or more nights of usable recordings are required to obtain reliable actigraph measures of sleep for children and adolescents.

Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days.

STUDY OBJECTIVES: This study examined effects on adolescent sleep patterns, sleepiness, and circadian phase of a school transition requiring an earlier start. DESIGN AND SETTING: Adolescents were evaluated in 9th and 10th grades; school start time in 9th grade was 0825 and in 10th grade was 0720. Assessments at each point included 2 weeks of actigraphy and sleep diaries at home, followed by a 22-hour laboratory evaluation, including evening saliva samples every 30 minutes in dim light for determination of dim-light salivary melatonin onset phase (DLSMO), overnight sleep monitoring, and multiple sleep latency test (MSLT). PARTICIPANTS: Twenty-five females and 15 males, ages 14 to 16.2 were enrolled; 32 completed the study in 9th grade and 26 completed in 10th grade. INTERVENTIONS: Participants kept their own schedules, except that laboratory nights were scheduled based upon school-night sleep patterns. MEASUREMENTS AND RESULTS: According to actigraphy, students woke earlier on school days in 10th than in 9th grade, but they did not go to sleep earlier and they slept less. DLSMO phase was later in 10th grade (mean = 2102) than 9th grade (mean = 2024). Sleep latency on MSLT overall was shorter in 10th (mean = 8.5 minutes) than in 9th (mean = 11.4 minutes), particularly on the first test of the morning at 0830 (5.1 vs 10.9 minutes). Two REM episodes on MSLT occurred in 16% of participants in 10th grade; one REM episode occurred in 48%. When those with REM sleep on one or both morning MSLTs (n = 11) were compared to those without morning REM, significant differences included shorter sleep latency on the first test, less slow wave sleep the night before, and later DLSMO phase in those who had morning REM. CONCLUSIONS: Early start time was associated with significant sleep deprivation and daytime sleepiness. The occurrence of REM sleep on MSLT indicates that clinicians should exercise caution in interpreting MSLT REM sleep in adolescents evaluated on their "usual" schedules. Psychosocial influences and changes in bioregulatory systems controlling sleep may limit teenagers' capacities to make adequate adjustments to an early school schedule.

Hospitalized children of substance-abusing parents and physically and sexually abused children: a comparison.

The symptoms and diagnoses of 58 psychiatrically hospitalized children aged 12 or under who were children of substance abusing parents (COSAPs) were compared with a matched group of 51 children who were not COSAPs. These two groups were further subdivided according to history or lack of history of physical and/or sexual abuse. Symptoms and diagnoses of COSAPs and physically and/or sexually abused (P/SAs) children differed significantly from the hospitalized group who were neither COSAPs nor P/SAs. Being a COSAP and/or P/SA are strong correlates of psychiatric hospitalization for the children studied. Both high-risk groups should be awarded special diagnostic and treatment consideration that would include their systematic identification and focused treatment.

Child and family factors that ameliorate risk between 4 and 13 years of age.

Protective processes in at-risk children between 4 and 13 years of age were examined in a longitudinal study. A multiple risk index was used at 4 years to identify 50 high-risk children and 102 who were at low risk. Cognitive and social-emotional status were measured at each time point. The following indicators of protective processes were related to positive change in cognitive and/or social-emotional function in the high-risk children between 4 and 13 years: mother-child interaction; child perceived competence, locus of control, life events, and social support; and maternal parenting values, social support, depression, and expressed emotion. Many of these factors were also related to improvement in the low-risk children. Some variables showed an interaction effect, where impact was substantially higher in the high-risk group compared with the low-risk group. The utility of multiple risk constructs and process oriented approaches to protective factors are discussed.

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.

Is major depressive disorder in childhood a distinct diagnostic entity?

One approach to validation of the construct of major depressive disorder in childhood was examined. Multivariate analyses of parents' responses on the Child Behavior Checklist (CBCL) were undertaken to determine whether a depressive symptom component would emerge and whether a group of children with pure depressive disorder could be isolated. The study involved 284 children (91 inpatients and 193 outpatients) aged 6 to 11 years. Principal components analyses identified a weak depression component among the CBCL items. Other components were aggressive, anxious, withdrawn, and immature. Cluster analyses designed to isolate a group of children with pure depressive disorder did not accomplish that goal. The results suggest that current enthusiasm for the diagnosis of major depressive disorder in children may be misplaced, and that a dimensional dysthymic syndrome that accompanies many other problems may better explain patterns of symptoms in children. The importance of the use of multiple methods to validate important psychiatric diagnoses is discussed.

Sleep and psychological characteristics of children on a psychiatric inpatient unit.

OBJECTIVE: To assess the association of objective measures of sleep-wake patterns and psychological status and abuse history of children hospitalized in a psychiatric inpatient unit. METHOD: Thirty-nine inpatient children participated in the study. They were monitored for one to three consecutive nights with miniature wrist activity monitors for objective assessment of sleep-wake patterns. In addition, a thorough psychiatric and psychosocial assessment was completed with each child and the parents. RESULTS: Children's self-ratings of depression, hopelessness, and low self-esteem were significantly correlated with objective sleep measures indicating poorer sleep quality. No significant correlations between intelligence scores and sleep measures were found. Nonabused and sexually abused children had better sleep quality than physically abused children. CONCLUSIONS: Sleep quality during hospitalization is strongly associated with self experiences of depression, hopelessness, and low self-esteem in children with severe behavior disorders.

Is major depressive disorder in adolescence a distinct diagnostic entity?

The concept of major depressive disorder in childhood and adolescence is reviewed and it is suggested that contemporary enthusiasm for this diagnosis may have outrun the evidence that it is a distinct categorical entity. To test the hypothesis that major depression is not a qualitatively distinct disorder in adolescence, but rather a continuously distributed, noncategorical syndrome, the behavioral rating scales (CBCL-P) of 216 hospitalized adolescent patients were analyzed first by principal components analysis and then by cluster analysis. Three behavioral syndromes were isolated by principal components analysis. Of three groups of patients identified by a subsequent cluster analysis, one was consistent with the concept of a categorically distinct "nuclear" depression. However, a noncategorical continuously distributed depressive syndrome appears to affect a larger number of patients in this age group, and the "nuclear" disorder may be less prevalent than is currently assumed. One explanation of these findings would combine a categorical model of nuclear depression with a dimensional model of dysthymia.

Infant mental health and variability of parental depression symptoms.

OBJECTIVE: To examine the course of mothers' depression symptoms in association with child and family functioning beyond that explained by diagnostic status. METHOD: A longitudinal high-risk design with 16 months of course-of-illness follow-up was used. Structured clinical and family interviews, direct observation of child social-emotional competence, and parent reports of child behavior problems were included. RESULTS: Parameters of maternal symptom patterns across time were associated with child and family functioning. Most of these effects remained when presence/absence of major depression diagnosis was covaried. CONCLUSIONS: The trajectory of symptoms over time is important to consider in studies of children at risk and may also help to inform how illness in infancy and early childhood is conceptualized.

Prediction of adolescent affective disorder: effects of prior parental affective disorders and child psychopathology.

OBJECTIVE: To examine the role of major parental and child diagnostic factors in predicting episodes of serious affective disorder in adolescents in a nonreferred sample. METHOD: The sample included 139 youngsters (average age 14 years at enrollment) drawn from a health maintenance organization and evaluated at two points in time 4 years apart. Both parents and adolescents were assessed using structured diagnostic instruments scored according to criterion systems. Parent and child lifetime diagnoses identified in the first assessment were used to predict the onset of episodes of serious affective disorder in the adolescents which occurred between the first and second assessment. RESULTS: Stepwise multiple regression analyses of the significant univariate factors showed that the most powerful predictors of episodes of affective disorder were total number of diagnoses the adolescents received prior to first assessment, lifetime duration of parental major depressive disorder, and total number of lifetime nonaffective disorders of the parents. CONCLUSION: Broad risk factors from different domains best predict episodes of affective disorder in children and adolescents.

Early indicators of developmental risk: Rochester Longitudinal Study.

Early indicators of schizophrenic outcomes were sought in a group of children of chronically ill schizophrenic women. A sample of pregnant women with varying degrees of mental illness were examined during the perinatal period and recruited into a 4-year longitudinal evaluation, which included cognitive, psychomotor, social, and emotional assessments at birth, 4, 12, 30, and 48 months of age. The mothers varied on mental health dimensions of diagnosis, severity of symptomatology, and chronicity of illness. Other factors included in the analyses were socioeconomic status (SES), race, sex of child, and family size. Hypotheses were tested to determine the relative impact of three sets of variables on the child's behavior: (1) specific maternal psychiatric diagnosis, (2) severity and chronicity of disturbance independent of diagnosis, and (3) general social status. We found that a specific maternal diagnosis of schizophrenia had the least impact. Neurotic-depressive mothers produced worse development in their children than schizophrenic or personality-disordered mothers. Both social status and severity/chronicity of illness showed a greater impact on development. Children of more severely or chronically ill mothers and lower-SES black children performed most poorly. These results do not support etiological models based on simple biological or environmental transmission of schizophrenia. The role of social and family environmental factors in predicting child cognitive and social-emotional competence was further evaluated using a multiple risk index. Children with high multiple environmental risk scores had much worse outcomes than children with low multiple risk scores.

Intrinsic circadian period of adolescent humans measured in conditions of forced desynchrony.

Circadian timing was assessed with forced desynchrony (FD) in 10 healthy adolescents (five boys, five girls; mean age 13.7 years). Following 10 days of entrainment to a fixed light-dark (LD) schedule at home, participants were studied under dim light (<20 lux) in the laboratory. A 28-h schedule (FD) was imposed for 12 x 28-h cycles. Saliva was collected at 30- or 60-min intervals throughout; core temperature was measured in constant routines (CR) before and after FD. Intrinsic circadian period was estimated by linear regression using temperature minimum from CRs and dim-light salivary melatonin onsets and offsets from FD. Average intrinsic circadian period for core temperature (n = 7) was 24.30+/-0.20, for melatonin onset was 24.33+/-0.21, and for melatonin offset was 24.35+/-0.21. Intrinsic circadian period in every adolescent was greater than 24 h.

Prenatal drug exposure and maternal and infant feeding behaviour.

OBJECTIVE: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. METHODS: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. RESULTS: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants' feeding problems. CONCLUSIONS: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

Behavioral intervention and post-natal growth in full-term intrauterine growth retarded (IUGR) infants.

The purpose of this study was twofold: (1) to describe the patterns of post-natal growth in full-term infants as a function of IUGR and (2) to assess the impact of an individualized behavioral feeding intervention with the mothers on these patterns of infant growth. Eighty-eight (88) full-term infants, including 54 with IUGR, half of whom received behavioral intervention were included. Weight, length, skinfold thickness, head circumference and Ponderal Index were measured at birth and at 1, 4, 8, 12, and 18 months. Results show positive intervention effects between birth and 1 month in weight, length, skinfold thickness, and Ponderal Index. However, there were no intervention effects at subsequent ages. No evidence was found for catch-up growth in full-term IUGR infants in weight, length, and head circumference. We conclude that an individualized behavioral feeding intervention can accelerate early growth in IUGR infants, but the positive effects on growth are only seen while the intervention lasts (between birth and 1 month). On most parameters of physical growth, there is no lasting catch-up growth over the first 18 months in IUGR full-term infants.

Interpreting research on prenatal substance exposure in the context of multiple confounding factors.

Fetal exposure to specific drugs often occurs in the context of polydrug use, medical complications, and social/environmental risks. Early reports of severe developmental consequences of fetal exposure to illicit drugs, for example, cocaine, have largely been unsupported by recent studies that take these factors into account. Using a database of published studies on cocaine exposure, this article examines how confounding factors are controlled by recruitment and statistical strategies. Rather than attempting to reduce the impact of these factors, it is suggested that multiple risks in children's lives should be included in models of developmental outcomes along with drug exposure. Understanding the complexity of multiple risks in the child's environment and the subtlety of drug exposure effects can guide the choice of clinical treatment and intervention.

Psychological distress in mothers of preterm infants.

The purpose of this study was to identify infant and maternal characteristics that predict psychological distress among mothers of preterm infants admitted to the neonatal intensive care unit (NICU). Infant characteristics included birth weight, gestational age, and ventilatory support, and maternal characteristics included age, parity, and socioeconomic status. Mothers (n = 142) completed questionnaires including a demographic form, the Parental Stressor Scale, and the Symptom Checklist 90-R. In hierarchical regression analyses, maternal NICU-specific distress was more strongly predicted by infant characteristics [F(3,135) = 6.80, p < .05] with maternal variables covaried. Maternal general psychological distress was more strongly predicted by maternal characteristics [F(3,135) = 6.05, p < .05]) with infant variables covaried. Twenty-eight percent of mothers reported clinically significant psychological distress compared with 10% in a normative population. Psychological distress among mothers of preterm infants appears to be common and deserves clinical consideration. The use of standardized questionnaires as part of the assessment process may improve case identification and psychosocial service delivery in the NICU.