Can behaviorally inhibited preschoolers make friends?

Preschoolers who display extremely inhibited behavior are at risk for the development of anxiety disorders. However, behavioral inhibition (BI) is a multifaceted characteristic. Some children with BI are fearful when confronted by unfamiliar adults, peers, and objects; others are fearful when separated from their parents. In the present study, we examined specific features of BI that predicted observed friendship formation among preschoolers who are behaviorally inhibited. We also examined whether teacher ratings of classroom behaviors predicted friendship formation. Sixty highly inhibited children (35 female, Mage = 52.57 months) were observed during eight weekly free-play sessions with initially unfamiliar inhibited peers. Free-play periods occurred before weekly intervention sessions for children with BI and their parents. An observational protocol was developed to identify children who made a friend during the eight weekly sessions. Before the first session, different subtypes of BI were assessed by parents; preschool teachers assessed the children's classroom behaviors with familiar peers. Twenty-six children met the criteria for having made and kept a friend. Probit regression analyses revealed that parent ratings of BI among unfamiliar peers and teacher ratings of children's social anxiety before the intervention were associated with a decreased probability of making a friend. No evidence was found linking children's responses to the intervention and friendship formation. Results suggest that extremelyinhibited preschoolers are capable of making friends. Implications for future research and intervention efforts that focus on individual differences of children with BI are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Testing reciprocal associations between child anxiety and parenting across early interventions for inhibited preschoolers.

BACKGROUND: Given the robust evidence base for the efficacy of evidence-based treatments targeting youth anxiety, researchers have advanced beyond efficacy outcome analysis to identify mechanisms of change and treatment directionality. Grounded in developmental transactional models, interventions for young children at risk for anxiety by virtue of behaviorally inhibited temperament often target parenting and child factors implicated in the early emergence and maintenance of anxiety. In particular, overcontrolling parenting moderates risk for anxiety among highly inhibited children, just as child inhibition has been shown to elicit overcontrolling parenting. Although longitudinal research has elucidated the temporal unfolding of factors that interact to place inhibited children at risk for anxiety, reciprocal transactions between these child and parent factors in the context of early interventions remain unknown. METHOD: This study addresses these gaps by examining mechanisms of change and treatment directionality (i.e., parent-to-child vs. child-to-parent influences) within a randomized controlled trial comparing two interventions for inhibited preschoolers (N = 151): the multicomponent Turtle Program ('Turtle') and the parent-only Cool Little Kids program ('CLK'). Reciprocal relations between parent-reported child anxiety, observed parenting, and parent-reported accommodation of child anxiety were examined across four timepoints: pre-, mid-, and post-treatment, and one-year follow-up (NCT02308826). RESULTS: Hypotheses were tested via latent curve models with structured residuals (LCM-SR) and latent change score (LCS) models. LCM-SR results were consistent with the child-to-parent influences found in previous research on cognitive behavioral therapy (CBT) for older anxious youth, but only emerged in Turtle. LCS analyses revealed bidirectional effects of changes in parent accommodation and child anxiety during and after intervention, but only in Turtle. CONCLUSION: Our findings coincide with developmental transactional models, suggesting that the development of child anxiety may result from child-to-parent influences rather than the reverse, and highlight the importance of targeting parent and child factors simultaneously in early interventions for young, inhibited children.

Comparison of behaviorally inhibited and typically developing children's play behaviors in the preschool classroom.

Introduction: Behavioral inhibition (BI) is a temperamental trait characterized by a bias to respond with patterns of fearful or anxious behavior when faced with unfamiliar situations, objects, or people. It has been suggested that children who are inhibited may experience early peer difficulties. However, researchers have yet to systematically compare BI versus typically developing children's observed asocial and social behavior in familiar, naturalistic settings. Method: We compared the in-school behaviors of 130 (M = 54 months, 52% female) highly inhibited preschoolers (identified using the parent-reported Behavioral Inhibition Questionnaire) to 145 (M = 53 months, 52% female) typically developing preschoolers. Both samples were observed on at least two different days for approximately 60 min. Observers used the Play Observation Scale to code children's behavior in 10-s blocks during free play. Teachers completed two measures of children's behavior in the classroom. Results: Regression models with robust standard errors controlling for child sex, age, and weekly hours in school revealed that preschoolers identified as BI engaged in significantly more observed reticent and solitary behavior, and less social play and teacher interaction than the typically developing sample. Children with BI also initiated social interaction with their peers and teachers less often than their counterparts who were not inhibited. Teachers reported that children identified as BI were more asocial and less prosocial than their non-BI counterparts. Discussion: Significantly, the findings indicated that inhibited children displayed more solitude in the context of familiar peers. Previous observational studies have indicated behavioral differences between BI and unfamiliar typical age-mates in novel laboratory settings. Children identified as BI did not receive fewer bids for social interaction than their typically developing peers, thereby suggesting that children who are inhibited have difficulty capitalizing on opportunities to engage in social interaction with familiar peers. These findings highlight the need for early intervention for children with BI to promote social engagement, given that the frequent expression of solitude in preschool has predicted such negative outcomes as peer rejection, negative self-regard, and anxiety during the elementary and middle school years.

Screening for parent and child ADHD in urban pediatric primary care: pilot implementation and stakeholder perspectives.

BACKGROUND: ADHD commonly co-occurs in children and parents. When ADHD is untreated in parents, it contributes to negative child developmental and treatment outcomes. Screening for parent and child ADHD co-occurrence in pediatric primary care may be an effective strategy for early identification and treatment. There is no data on whether this screening model can be implemented successfully and there exists limited guidance on how to effectively approach parents about their own ADHD in pediatric settings. Even greater sensitivity may be required when engaging with families living in urban, low SES communities due to systemic inequities, mistrust, and stigma. METHODS: The current pilot study described the first 6 months of implementation of a parent and child ADHD screening protocol in urban pediatric primary care clinics serving a large population of families insured through Medicaid. Parents and children were screened for ADHD symptoms at annual well-child visits in pediatric primary care clinics as part of standard behavioral health screening. Independent stakeholder group meetings were held to gather feedback on factors influencing the implementation of the screening and treatment strategies. Mixed methods were used to examine initial screening completion rates and stakeholder perspectives (i.e., parents, primary care office staff, pediatricians, and behavioral health providers) on challenges of implementing the screening protocol within urban pediatric primary care. RESULTS: Screening completion rates were low (19.28%) during the initial 6-month implementation period. Thematic analysis of stakeholder meetings provided elaboration on the low screening completion rates. Identified themes included: 1) divergence between provider enthusiasm and parent hesitation; 2) parent preference versus logistic reality of providers; 3) centering the experiences of people with marginalized identities; and 4) sensitivity when discussing parent mental health and medication. CONCLUSIONS: Findings highlight the importance of developing flexible approaches to screening parent and child ADHD in urban pediatric health settings and emphasize the importance of cultural sensitivity when working with marginalized and under-resourced families. TRIAL REGISTRATION: NCT04240756 (27/01/2020).

Examining the Relations Between Children's Vagal Flexibility Across Social Stressor Tasks and Parent- and Clinician-Rated Anxiety Using Baseline Data from an Early Intervention for Inhibited Preschoolers.

Early behavioral inhibition (BI) is a known risk factor for later anxiety disorder. Variability in children's parasympathetic nervous system (PNS) functioning may provide insight into the substantial heterogeneity in anxiety outcomes for children high in BI. However, gaps persist due to an over-reliance on static measures of functioning, which limits our ability to leverage PNS functioning to identify risk for anxiety. We address these gaps using baseline data from an early intervention study of inhibited preschoolers by characterizing vagal flexibility (VF), an index of non-linear change in PNS functioning, across social stressor tasks and by examining the associations between VF and anxiety. One hundred and fifty-one parents and their 3.5- to 5-year-old children were selected on the basis of BI to participate in an early intervention program (ClinicalTrials.gov registration: NCT02308826). A structural equation modeling framework was used to model children's VF across tasks designed to mimic exposure to novel social interactions and to test the predictive links between VF and anxiety. Children who showed less VF, characterized by less suppression and flatter recovery, were rated by both parents and clinicians as more anxious. Moreover, a multiple group model showed that children meeting diagnostic criteria for social anxiety disorder demonstrated significantly less VF across social stressor tasks. Among inhibited youth, reduced VF is a risk factor for anxiety and may reflect an individual's reduced capacity to actively cope with external demands. Study results contribute to our understanding of the regulatory processes underlying risk for anxiety in early childhood.

Early intervention for inhibited young children: a randomized controlled trial comparing the Turtle Program and Cool Little Kids.

BACKGROUND: Children classified as behaviorally inhibited (BI) are at risk for social anxiety. Risk for anxiety is moderated by both parental behavior and social-emotional competence. Grounded in developmental-transactional theory, the Turtle Program involves both parent and child treatment components delivered within the peer context. Our pilot work demonstrated beneficial effects of the Turtle Program ('Turtle') over a waitlist control group. Herein, we report results of a rigorous randomized controlled trial (RCT) comparing Turtle to the best available treatment for young children high in BI, Cool Little Kids (CLK). METHODS: One hundred and fifty-one parents and their 3.5- to 5-year-old children selected on the basis of BI were randomly assigned to Turtle or CLK, delivered in group format over 8 weeks. Effects on child anxiety, life interference, BI, and observed parenting were examined at post-treatment and 1-year follow-up. ClinicalTrials.gov registration: NCT02308826. RESULTS: No significant main effect differences were found between Turtle and CLK on child anxiety; children in both programs evidenced significant improvements in BI, anxiety severity, family accommodation, and child impairment. However, Turtle yielded increased observed warm/engaged parenting and decreased observed negative control, compared with CLK. Parental social anxiety moderated effects; parents with higher anxiety demonstrated diminished improvements in child impairment, and parent accommodation in CLK, but not in Turtle. Children of parents with higher anxiety demonstrated more improvements in child BI in Turtle, but not in CLK. CONCLUSIONS: Turtle and CLK are both effective early interventions for young children with BI. Turtle is more effective in improving parenting behaviors associated with the development and maintenance of child anxiety. Turtle also proved to be more effective than CLK for parents with social anxiety. Results suggest that Turtle should be recommended when parents have social anxiety; however, in the absence of parent anxiety, CLK may offer a more efficient treatment model.

Predictors and Moderators of Parent Engagement in Early Interventions for Behaviorally Inhibited Preschool-Aged Children.

Behavioral inhibition (BI) is a temperamental style that poses risk for later anxiety. Efficacious interventions have been developed for inhibited children, but their success depends on parent engagement. However, little is known regarding predictors of parent engagement in early interventions for BI. This study examined parent-, child- and treatment-level (i.e., parent-only or parent-child) factors as independent and interactive predictors of parent engagement (attendance, and parent-reported homework completion and treatment satisfaction) in a randomized-controlled trial comparing two interventions for inhibited preschoolers: Cool Little Kids (CLK) and the Turtle Program ("Turtle"). We also explored predictors of co-parent (CP) attendance. The sample comprised 151 primary parents (PPs) and their 45-64-month-old children. Attendance was greater in Turtle and homework completion was slightly greater in CLK, with no group difference in satisfaction. In Turtle, child anxiety predicted greater PP attendance and PP depression predicted lower satisfaction. In CLK, the interaction between child and PP anxiety significantly predicted satisfaction. Across groups, child anxiety predicted greater homework completion and CP anxiety predicted greater CP attendance. Results suggest that child anxiety may motivate parent engagement, particularly when children receive concurrent treatment and/or in-vivo coaching. However, intensive treatment may be too burdensome for depressed parents, whereas less intensive treatments may be more acceptable to non-anxious parents of anxious children. These findings can inform approaches to improve parent engagement in early interventions targeting BI.

Generalization of an Early Intervention for Inhibited Preschoolers to the Classroom Setting.

Considerable evidence has accumulated supporting transactional influences between early childhood behavioral inhibition (BI), parent-child and child-peer relationships, and the development of anxiety disorders in adolescence and adulthood. Drawing from this literature, the Turtle Program was designed to treat children high in BI by intervening at the level of both parents and peers. In this pilot study, we sought to determine whether benefits of participating in the Turtle Program extended to children's classrooms in the form of increased positive social interactions with peers. Forty inhibited children (42-60 months) and their parent(s) were randomized to either the Turtle Program (n = 18) or a waitlist control group (WLC; n = 22). The Turtle Program involved 8 weeks of concurrent parent and child treatment. Trained research assistants, blind to treatment condition, coded participants' social interactions with peers during free play at each child's preschool at the beginning and end of treatment. Teachers unaware of group assignment also provided reports of social behaviors at these time points. Reliable change index scores revealed that both Turtle Program and WLC participants experienced relatively high rates of reliable increases in observed peer play interactions from pre- to post-treatment (73.3% and 42.1% respectively). Additionally, Turtle Program participants experienced high rates of reliable increase in observed initiations to peers (73.3%) as well as a moderate degree of reliable decrease in teacher-reported displays of fear/anxiety (33.3%). These data provide preliminary, but promising, evidence that increases in children's social behaviors as a result of participation in the Turtle Program generalize to their preschool classrooms.

Future Directions for Research on Early Intervention for Young Children at Risk for Social Anxiety.

Anxiety disorders are common among young children, with earlier onset typically associated with greater severity and persistence. A stable behaviorally inhibited (BI) temperament and subsequent shyness and social withdrawal (SW) place children at increased risk of developing anxiety disorders, particularly social anxiety. In this Future Directions article, we briefly review developmental and clinical research and theory that point to parenting and peer interactions as key moderators of both the stability of BI/SW and risk for later anxiety, and we describe existing interventions that address early BI/SW and/or anxiety disorders in young children. We recommend that future research on early intervention to disrupt the trajectory of anxiety in children at risk (a) be informed by both developmental science and clinical research, (b) incorporate multiple levels of analysis (including both individual and contextual factors), (c) examine mediators that move us closer to understanding how and why treatments work, (d) be developed with the end goal of dissemination, (e) examine moderators of outcome toward the goal of treatment efficiency, (f) consider transdiagnostic or modular approaches, (g) integrate technology, and (h) consider cultural norms regarding BI/SW/anxiety and parenting.

Maternal depression and the learning-promoting effects of infant-directed speech: Roles of maternal sensitivity, depression diagnosis, and speech acoustic cues.

The hypothesis that the associative learning-promoting effects of infant-directed speech (IDS) depend on infants' social experience was tested in a conditioned-attention paradigm with a cumulative sample of 4- to 14-month-old infants. Following six forward pairings of a brief IDS segment and a photographic slide of a smiling female face, infants of clinically depressed mothers exhibited evidence of having acquired significantly weaker voice-face associations than infants of non-depressed mothers. Regression analyses revealed that maternal depression was significantly related to infant learning even after demographic correlates of depression, antidepressant medication use, and extent of pitch modulation in maternal IDS had been taken into account. However, after maternal depression had been accounted for, maternal emotional availability, coded by blind raters from separate play interactions, accounted for significant further increments in the proportion of variance accounted for in infant learning scores. Both maternal depression and maternal insensitivity negatively, and additively, predicted poor learning.

Maternal depression and expressive communication in one-year-old infants.

To separate effects of maternal depression on infant cognitive versus language development, 1-year-olds were assessed using the revised Bayley Scales of Infant and Toddler Development (BSID-III). Percentile scores on the Bayley Expressive Communication (EC) subscale were significantly negatively correlated with maternal self-report scores on the Beck Depression Inventory (BDI-II). However, mothers' BDI-II scores did not correlate with infant percentile scores on the general cognitive (COG) or receptive communication (RC) subscales. Boys had significantly lower percentile scores than girls on the RC and EC scales, but did not differ on the Cog scale. Gender and maternal depression did not significantly interact on any of the scales. These findings suggest problems with expressive communication precede, and may at least partially account for, apparent deficits in general cognitive development.

A developmental decline in the learning-promoting effects of infant-directed speech for infants of mothers with chronically elevated symptoms of depression.

Infants of mothers who varied in symptoms of depression were tested at 4 and 12 months of age for their ability to associate a segment of an unfamiliar non-depressed mother's infant-directed speech (IDS) with a face. At 4 months, all infants learned the voice-face association. At 12 months, despite the fact that none of the mothers were still clinically depressed, infants of mothers with chronically elevated self-reported depressive symptoms, and infants of mothers with elevated self-reported depressive symptoms at 4 months but not 12 months, on average did not learn the association. For infants of mothers diagnosed with depression in remission, learning at 12 months was negatively correlated with the postpartum duration of the mother's depressive episode. At neither age did extent of pitch modulation in the IDS segments correlate with infant learning. However, learning scores at 12 months correlated significantly with concurrent maternal reports of infant receptive language development. The roles of the duration and timing of maternal depressive symptoms are discussed.

An associative learning deficit in 1-year-old infants of depressed mothers: role of depression duration.

The effectiveness of infant-directed speech (IDS) produced by non-depressed mothers for promoting the acquisition of voice-face associations was investigated in 1-year-old children of depressed mothers in a conditioned-attention paradigm. Prior research suggested that infants of mothers with comparatively longer-duration depressive episodes exhibit poorer learning in response to non-depressed mothers' IDS, but duration of depression was confounded with infant age. In the current study, 1-year-old infants of currently depressed mothers with relatively longer-duration depressive episodes (i.e., perinatal onset) showed significantly poorer learning than 1-year-olds of currently depressed mothers with relatively shorter duration depressive episodes (non-perinatal onset). This was true despite the fact that there were no measurable differences in the severity of depression, level of social functioning, or antidepressant medication use between the two groups. These findings add support to the hypothesis that there is an experience-based change in responsiveness to female IDS in infants of depressed mothers during the first year of life.

A Privileged Status for Male Infant-Directed Speech in Infants of Depressed Mothers? Role of Father Involvement.

Prior research showed that 5- to 13-month-old infants of chronically depressed mothers did not learn to associate a segment of infant-directed speech produced by their own mothers or an unfamiliar nondepressed mother with a smiling female face, but showed better-than-normal learning when a segment of infant-directed speech produced by an unfamiliar nondepressed father signaled the face. Here, learning in response to an unfamiliar nondepressed father's infant-directed speech was studied as a function both of the mother's depression and marital status, a proxy measure of father involvement. Infants of unmarried mothers on average did not show significant learning in response to the unfamiliar nondepressed father's infant-directed speech. Infants of married mothers showed significant learning in response to male infant-directed speech, and infants of depressed, married mothers showed significantly stronger learning in response to that stimulus than did infants of nondepressed, married mothers. Several ways in which father involvement may positively or negatively affect infant responsiveness to male infant-directed speech are discussed.