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

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

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

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

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

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

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

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

A relational perspective on PTSD in early childhood.

This paper describes the clinical and research evidence for the importance of the relational context of posttraumatic stress disorder in young children. We review 17 studies that simultaneously assessed parental and child functioning following trauma. In many studies, despite limitations, an association between undesirable parental/family variables and maladaptive child outcomes has been consistently found. We present a model of the parental/family variables as moderators and vicarious traumatic agents for symptoms in young children. Also, a Compound Model is proposed, with three distinctive patterns of the parent-child relationship that impact on posttraumatic symptomatology in young children. Implications for clinical practice and research directions are discussed.

Disturbances of attachment in young children adopted from institutions.

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

Attachment and developmental psychopathology.

This article describes the case of an 8-year-old boy who was first brought to clinical attention at age 2 1/2. He was followed by several clinicians over a 6-year period and was assigned a wide variety of diagnoses. From the first assessment to hospitalization at age 8, a pattern of mother-child relationship disturbance is evident. The use of principles and recent research derived from attachment theory provides a useful basis for formulation in this complex case. This report focuses on the relationship between the patient's mother's internal working models of attachment and his behavior in infancy and early childhood.

Clinical disturbances of attachment in infancy and early childhood.

The development of the attachment behavioral system in infancy has been the focus of a wide range of research in the past 30 years. The clinical significance of disturbances in this area of development is currently a major focus for this research. Research on patterns of attachment in infancy has informed understanding of the development of psychopathology in later childhood; insecure-disorganized attachment is recognized as an important risk factor in this regard. The clinical features of reactive attachment disorder in early childhood are also becoming more clear. Finally, knowledge about the intersection between attachment and various risk conditions is growing and should inform clinical judgement about infants and young children requiring intervention. Primary care physicians can use these findings to identify children in need of intervention.

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

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

Intensive intervention for maltreated infants and toddlers in foster care.

We have described a program that integrates clinical approaches of infant mental health to infants and toddlers in foster care. The juxtaposition of a mental health program in a forensic setting creates a number of special features that we have highlighted. Unique from the clinical perspective, the team is explicitly relationship-focused, attempting to understand all of the young child's caregiving relationships as they affect development. We strive to enhance the quality of all of relationships in which infants participate, fostering healthy attachments and development. Also unique is the emphasis on system liaison, and making programmatic efforts to affect various systems involved in making custody determinations about infants and toddlers. Unique from the forensic perspective, we offer multidisciplinary expertise about an especially high-risk population, a comprehensive service delivery system in which we provide or coordinate and monitor all intervention efforts for a given family, a prevention orientation, and clinical follow-up with infants for as long as they are in care. The goals of the program include expediting permanency planning decisions, increasing continuity in high-quality foster care placements, increasing court satisfaction with mental health consultation, decreasing the number of court-ordered evaluations for adjudicated families, and increasing CPS satisfaction with available treatment and continuity of care. We believe that this approach integrates delivery of services to the youngest and most vulnerable victims of maltreatment and expedites permanency planning.

Mothers' representations of their infants assessed prenatally: stability and association with infants' attachment classifications.

The stability and predictive validity of classifications of mothers' representations of their infants as determined by the Working Model of the Child Interview (WMCI) were examined. Concordance between mothers' representations of their infants assessed prenatally and again one year later and infant Strange Situation (SS) attachment classifications at 12 months was also examined. WMCI classifications were stable over 12 months in 80% of mothers, compared to 51% expected by chance alone. Pregnancy WMCIs predicted infant SS classifications in 74% of cases, compared to 54% expected by chance. Concordance between 11-month WMCI and 12-months SS classifications was 73% (vs. 55% expected by chance). Problems with the skewed distribution of the sample, the low concordance between pregnancy and 11 months for one of the three classifications, and future directions for research are discussed.

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

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

Psychopathology in infancy.

The first three years of life present unique challenges to the study of psychopathology. We highlight four of the issues in a selective review of the developmental psychopathology of early childhood, including lack of specificity of risk and outcome variables, measurement difficulties, rapid developmental changes and the centrality of the relationship context in early childhood. We also highlight issues relevant to conceptualizations of disorders of infancy, emphasizing especially the need for efforts to validate clinical disorders. We consider two major domains of infant development that we believe are especially relevant to a discussion of psychopathology, namely, regulation of emotion and infant-caregiver attachment. Discussions of these two domains of infant development and their psychopathological extremes allow us to consider conceptualizations of psychopathology from the dual perspectives of developmental psychopathology and clinical disorders. We conclude by suggesting a number of strategies to build upon previous research.

Beyond insecurity: a reconceptualization of attachment disorders of infancy.

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

Traumatic loss in a one-year-old girl.

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

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

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

Parenting styles and risks in the vulnerable infant.

Risk factors for infant development are considered in three areas: infant temperament, postpartum depression, and prenatal cocaine exposure. Investigations of all three areas indicate that contextual characteristics of infant development must be incorporated into models attempting to link early risk factors with later behavioral adaptation.

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

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

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

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