Evidence-based intervention for young children born premature: preliminary evidence for associated changes in physiological regulation

A Pilot Trial of a Home-Based Parenting Intervention for High-Risk Infants: Effects on and Moderating Role of Effortful Control

Despite the important developmental outcomes associated with effortful control (EC), there is limited research demonstrating the efficacy of early interventions for improving EC and assessing the extent to which a child's level of baseline EC impacts the outcome of intervention on externalizing problems. This study aims to fill these gaps in the literature by assessing the efficacy of the Infant Behavior Program (IBP), a parenting intervention for infants with elevated levels of behavior problems, in improving infant EC and the moderating effect of baseline infant EC on intervention outcomes. Participants included 60 high-risk 12- to 15-month-old infants and their mothers. Families were randomized to receive the IBP or standard pediatric primary care. Parent-report measures of infant behavior and compliance were examined at baseline, post-intervention, and 3- and 6-month follow-up assessments. Results showed infants who received the IBP displayed significantly higher levels of EC at the post-intervention assessment compared to infants in the control group. Additionally, moderation analyses showed initial levels of EC moderated the effect of the IBP on externalizing problems and compliance, such that infants with higher levels of baseline EC displayed greater decreases in externalizing problems at post-intervention and greater increases in compliance at the 6-month follow-up. While these findings did not survive a false discovery rate correction, they offer preliminary support for the efficacy of the IBP in improving infants' EC and highlight the importance of considering EC as a factor associated with early intervention outcomes for externalizing problems.

Efficacy of parent-child interaction therapy for children born premature

BACKGROUND

Premature children are known to be at a high risk of developing behavioral problems. This study examined the effectiveness of parent-child interaction therapy (PCIT) in reducing behavioral problems in young children born premature.

METHODS

The study included 18 child-parent pairs with children born at less than 35 weeks of gestation (range: 23-34 weeks, median: 31.0 weeks) and aged 27-52 months (median: 38.0 months). They were assigned to either the PCIT group (n = 7) or the non-PCIT group (n = 11) based on maternal desire for treatment. The study was designed to examine the effects of PCIT. Specifically, the Eyberg Child Behavior Inventory (ECBI) intensity score, ECBI problem score, and Parenting Stress Index Short Form (PSI-SF) scores were compared before treatment and after 6 months.

RESULTS

In the PCIT group, the mean ECBI intensity score was 135.7 (SD = 13.5; T-score = 64) at baseline and 90.1 (SD = 15.5; T-score = 46) at post-assessment, the mean ECBI problem score was 9.8 (SD = 1.9; T-score = 54) at baseline and 4.4 (SD = 3.1; T-score = 44) at post-assessment, the mean PSI-SF total score was 60.1 (SD = 4.8; 95%tile) at baseline and 49.6 (SD = 5.6; 85%tile) at post-assessment, showing a significant improvement (ECBI intensity scores: p < 0.001, d = 2.03; ECBI problem scores: p < 0.001, d = 1.94; PSI-SF total scores: p = 0.004, d = 0.86). On the other hand, none of the scores showed significant change in the non-PCIT group.

CONCLUSIONS

The PCIT can be considered as a potential treatment option for behavioral problems in young children born premature.

PCIT engagement and persistence among child welfare-involved families: Associations with harsh parenting, physiological reactivity, and social cognitive processes at intake

Parent-Child interaction therapy (PCIT) has been shown to improve positive, responsive parenting and lower risk for child maltreatment (CM), including among families who are already involved in the child welfare system. However, higher risk families show higher rates of treatment attrition, limiting effectiveness. In N = 120 child welfare families randomized to PCIT, we tested behavioral and physiological markers of parent self-regulation and socio-cognitive processes assessed at pre-intervention as predictors of retention in PCIT. Results of multinomial logistic regressions indicate that parents who declined treatment displayed more negative parenting, greater perceptions of child responsibility and control in adult-child transactions, respiratory sinus arrhythmia (RSA) increases to a positive dyadic interaction task, and RSA withdrawal to a challenging, dyadic toy clean-up task. Increased odds of dropout during PCIT's child-directed interaction phase were associated with greater parent attentional bias to angry facial cues on an emotional go/no-go task. Hostile attributions about one's child predicted risk for dropout during the parent-directed interaction phase, and readiness for change scores predicted higher odds of treatment completion. Implications for intervening with child welfare-involved families are discussed along with study limitations.

Interpretation biases and depressive symptoms among anxiety-disordered children: The role of individual differences in respiratory sinus arrhythmia

Individual differences in interpretation biases-the tendency to interpret ambiguous stimuli as threatening-partially explain the presence of comorbid depressive symptoms among anxious youth. Increasing efforts have examined physiological processes that influence the association between interpretation biases and depressive symptoms in this population, and potential gender differences in this relationship. This study examined the moderating role of respiratory sinus arrhythmia (RSA) suppression (i.e., decrease from baseline)-an index of parasympathetic nervous system reactivity-in the association between interpretation biases and depressive symptoms in clinically anxious youth. One-hundred-and-five clinically anxious children (Mage  = 10.09 years, SD = 1.22; 56.7% female; 61.9% racial/ethnic minority) completed measures of self-reported and behaviorally indexed interpretation biases, reported anxiety/depression symptom severity, and participated in a speech task. RSA suppression during the task moderated the association between interpretation biases and depressive symptom severity in the total sample. Separate exploratory moderation analyses were conducted among girls and boys. Among girls, RSA suppression moderated the association between behaviorally indexed interpretation biases and depressive symptoms, and marginally moderated (p = .067) the association between self-reported interpretation biases and depressive symptoms. Among boys, RSA suppression was not a significant moderator. These findings may help identify clinically anxious youth most at-risk for comorbid depressive symptoms.

Parent–Child Interaction Therapy for children with autism spectrum disorder and a matched case-control sample

Parent–Child Interaction Therapy is an empirically based, behavioral parent training program for young children exhibiting disruptive behaviors. Parent–Child Interaction Therapy shows promise for treating disruptive behaviors in children with autism spectrum disorder. Treatment processes (i.e. treatment length and homework compliance), parenting skills, parenting stress, and behavioral outcomes (i.e. disruptive and externalizing behaviors and executive functioning) were compared in 16 children with autism spectrum disorder and 16 children without autism spectrum disorder matched on gender, age, and initial intensity of disruptive behaviors. Samples were statistically similar in terms of child receptive language, child race and ethnicity, parent age, gender and education, and number of two-parent families in treatment. Families received standard, mastery-based Parent–Child Interaction Therapy. Both groups demonstrated significant and clinically meaningful improvements in child disruptive and externalizing behavior and executive functioning, parenting skills, and parenting stress. Length of treatment, homework compliance, and parent and child outcomes did not differ significantly between groups. A subset of children with autism spectrum disorder also showed significant improvements in social responsiveness, adaptive skills, and restricted/repetitive behaviors. This study replicates and extends prior research by demonstrating that children with and without autism spectrum disorder experience similar benefits following Parent–Child Interaction Therapy. Findings may expand the availability and dissemination of time-limited, evidence-based interventions for autism spectrum disorder and comorbid disruptive behaviors.

Vagal Tone as a Putative Mechanism for Pragmatic Competence: An Investigation of Carriers of the FMR1 Premutation

Pragmatic language skills exist across a continuum in typical and clinical populations, and are impaired in many neurodevelopmental disorders, most notably autism. The mechanisms underlying pragmatic impairment are poorly understood, although theory suggests dampened vagal tone plays a role. This study investigated the FMR1 premutation as a genetic model that may lend insight into the relationship between vagal function and pragmatic ability. Participants included 38 women with the FMR1 premutation and 23 controls. Vagal tone accounted for significant variance in pragmatics across both groups and statistically mediated the effect of FMR1 premutation status on pragmatic ability. Results support vagal tone as a biophysiological correlate of pragmatic ability, which informs potential mechanistic underpinnings and could have implications for targeted treatment.

An intervention that increases parental sensitivity in families referred to Child Protective Services also changes toddlers' parasympathetic regulation

Experiencing maltreatment in early childhood predicts poor parasympathetic regulation, characterized by low baseline parasympathetic activity and strong withdrawal of parasympathetic influence in response to tasks. The Promoting First Relationships® (PFR) program improves parental sensitivity toward young children in families identified as maltreating. Using a subsample from a randomized control trial, we examined whether parental participation in PFR had lasting effects on toddlers' parasympathetic regulation, as measured by respiratory sinus arrhythmia (RSA), relative to a resource and referral control condition. In addition, we examined whether parental sensitive and responsive behavior mediated or moderated associations between parent treatment group and children's RSA. More than 6 months after completing treatment, 29 families in the PFR condition and 30 families in the control condition were visited at home, and toddlers' RSA was assessed at baseline and during five moderately challenging tasks. Groups did not differ in baseline RSA, but differed in RSA reactivity to the tasks. Across tasks, toddlers of parents in the control condition manifested significantly larger RSA decreases than toddlers of parents in the PFR condition. Parental behavior showed divergent associations with RSA change for toddlers of parents in the PFR versus control condition, with PFR treatment predicting RSA change ranging from small decreases to increases in toddlers of parents who showed the most sensitive, responsive behavior in the 6 months following treatment. This preliminary study showed that the same intervention that improved parenting also improved toddlers' parasympathetic regulation in response to everyday activities, warranting further experimental investigation.

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.

Improvements in Negative Parenting Mediate Changes in Children's Autonomic Responding Following a Preschool Intervention for ADHD

Abnormal patterns of sympathetic- and parasympathetic- linked cardiac activity and reactivity are observed among externalizing children, and mark deficiencies in central nervous system regulation of behavior and emotion. Although changes in these biomarkers have been observed following treatment, mechanisms remain unexplored. We used MEMORE-a new approach to analyzing intervening variable effects-to evaluate improvements in parenting as mediators of changes in SNS- and PNS-linked cardiac activity and reactivity among 99 preschoolers with attention-deficit hyperactivity disorder who were treated using an empirically supported intervention. Decreases in negative parenting (criticism, negative commands, physical intrusions) were associated with increases in resting RSA and PEP reactivity to incentives from pre- to post-intervention. Increases in positive parenting were not associated with changes in autonomic function. These findings suggest socially-induced plasticity in peripheral biomarkers of behavior and emotion regulation, and underscore the importance of reducing aversive interactions between parents and children when treating externalizing behavior.

Parent-Child Interaction Therapy: current perspectives

Parent-Child Interaction Therapy (PCIT) is an empirically supported intervention originally developed to treat disruptive behavior problems in children between the ages of 2 and 7 years. Since its creation over 40 years ago, PCIT has been studied internationally with various populations and has been found to be an effective intervention for numerous behavioral and emotional issues. This article summarizes progress in the PCIT literature over the past decade (2006-2017) and outlines future directions for this important work. Recent PCIT research related to treatment effectiveness, treatment components, adaptations for specific populations (age groups, cultural groups, military families, individuals diagnosed with specific disorders, trauma survivors, and the hearing-impaired), format changes (group and home-based), teacher-child interaction training (TCIT), intensive PCIT (I-PCIT), treatment as prevention (for externalizing problems, child maltreatment, and developmental delays), and implementation are discussed.

Parasympathetic reactivity and disruptive behavior problems in young children during interactions with their mothers and other adults: A preliminary investigation

Parasympathetic nervous system influences on cardiac functions-commonly indexed via respiratory sinus arrhythmia (RSA)-are central to self-regulation. RSA suppression during challenging emotional and cognitive tasks is often associated with better emotional and behavioral functioning in preschoolers. However, the links between RSA suppression and child behavior across various challenging interpersonal contexts remains unclear. The present study experimentally evaluated the relationship between child RSA reactivity to adult (mother vs. study staff) direction and disruptive behavior problems in children ages 3-8 with varying levels of disruptive behavior problems (N = 43). Reduced RSA suppression in the context of mothers' play-based direction was associated with more severe child behavior problems. In contrast, RSA suppression in the context of staff play-based direction was not associated with behavior problems. Findings suggest that the association between RSA suppression and child behavior problems may vary by social context (i.e., mother vs. other adult direction-givers). Findings are discussed in regard to RSA as an indicator of autonomic self-regulation that has relevance to child disruptive behavior problems.

Intersections between cardiac physiology, emotion regulation and interpersonal warmth in preschoolers: Implications for drug abuse prevention from translational neuroscience

BACKGROUND

Early childhood is characterized by dramatic gains in emotion regulation skills that support social adjustment and mental health. Understanding the physiological substrates of healthy emotion regulation may offer new directions for altering trajectories toward initiation and escalation of substance abuse. Here, we describe the intersections between parasympathetic and sympathetic tone, emotion regulation and prosocial behavior in a high-risk sample of preschoolers.

METHOD

Fifty-two 3-6 year old children completed an assessment of attention regulation in response to affective stimuli. Cardiac respiratory sinus arrhythmia, an index of parasympathetic tone, and pre-ejection period, a marker of sympathetic activation, were recorded at rest and while children engaged in social interactions with their mothers and an unfamiliar research assistant. Mothers reported on children's emotional reactivity and prosocial behavior.

RESULTS

Controlling for age and psychosocial risk, higher parasympathetic tone predicted better attention regulation in response to angry emotion and higher levels of prosocial behavior, whereas a reciprocal pattern of higher parasympathetic tone and lower sympathetic arousal predicted better attention in response to positive emotion and lower emotional reactivity. Children exposed to fewer risk factors and higher levels of maternal warmth were more able to sustain a high level of parasympathetic tone during interaction episodes.

CONCLUSIONS

Findings suggest that autonomic measures represent biomarkers for socio-emotional competence in young children. They also point to the importance of early experiences in the establishment of physiological regulation and the promise of family-based intervention to promote healthy emotion regulation and prevent substance dependence in high-risk populations.

Cardiac autonomic regulation in autism and Fragile X syndrome: a review

Despite the significance of efforts to understand the biological basis of autism, progress in this area has been hindered, in part, by the considerable heterogeneity in the disorder. Fragile X syndrome (FXS), a monogenic condition associated with high risk for autism, may pave the way for the dissection of biological heterogeneity within idiopathic autism. This article adopts a cross-syndrome biomarker approach to evaluate potentially overlapping profiles of cardiac arousal dysregulation (and broader autonomic dysfunction) in autism and FXS. Approaches such as this, aimed at delineating shared mechanisms across genetic syndromes, hold great potential for improving diagnostic precision, promoting earlier identification, and uncovering key systems that can be targeted in pharmaceutical/behavioral interventions. Biomarker approaches may be vital to deconstructing complex psychiatric disorders and are currently promoted as such by major research initiatives such as the NIMH Research Domain Criteria (RDoC). Evidence reviewed here supports physiological dysregulation in a subset of individuals with autism, as evidenced by patterns of hyperarousal and dampened parasympathetic vagal tone that overlap with the well-documented physiological profile of FXS. Moreover, there is growing support for a link between aberrant cardiac activity and core deficits associated with autism, such as communication and social impairment. The delineation of physiological mechanisms common to autism and FXS could lend insight into relationships between genetic etiology and behavioral endstates, highlighting FMR1 as a potential candidate gene. Research gaps and potential pitfalls are discussed to inform timely, well-controlled biomarker research that will ultimately promote better diagnosis and treatment of autism and associated conditions.

Feasibility of intensive parent-child interaction therapy (I-PCIT): Results from an open trial

OBJECTIVE

The current pilot study examined the feasibility, acceptability, and initial outcome of an intensive and more condensed version of Parent-Child Interaction Therapy (90 minute sessions for 5 days/week over the course of 2 weeks).

METHOD

Using an open trial design, 11 children (M child age = 5.01 years) and their mothers completed a baseline period of 2 weeks, a treatment period of 2 weeks, and a post-treatment evaluation. A follow-up evaluation was also conducted 4 months following treatment completion. Across all assessments, mothers completed measures of child behavior and parenting stress, and observational data was collected during three 5-minute standard situations that vary in the degree of parental control (child-led play, parent-led play, & clean-up).

RESULTS

All 11 families completed the intervention with extremely high attendance and reported high satisfaction. Results across both mother report and observations showed that: a) externalizing behavior problems were stable during the baseline period; b) treatment was effective in reducing externalizing behavior problems (ds = 1.67-2.50), improving parenting skills (ds = 1.93-6.04), and decreasing parenting stress (d = .91); and c) treatment gains were maintained at follow-up (ds = .53-3.50).

CONCLUSIONS

Overall, preliminary data suggest that a brief and intensive format of a parent-training intervention is a feasible and effective treatment for young children with externalizing behavior problems with clinical implications for improving children's behavioral impairment in a very brief period of time.

Cardiac vagal control and children's adaptive functioning: a meta-analysis

Polyvagal theory has influenced research on the role of cardiac vagal control, indexed by respiratory sinus arrhythmia withdrawal (RSA-W) during challenging states, in children's self-regulation. However, it remains unclear how well RSA-W predicts adaptive functioning (AF) outcomes and whether certain caveats of measuring RSA (e.g., respiration) significantly impact these associations. A meta-analysis of 44 studies (n=4996 children) revealed small effect sizes such that greater levels of RSA-W were related to fewer externalizing, internalizing, and cognitive/academic problems. In contrast, RSA-W was differentially related to children's social problems according to sample type (community vs. clinical/at-risk). The relations between RSA-W and children's AF outcomes were stronger among studies that co-varied baseline RSA and in Caucasian children (no effect was found for respiration). Children from clinical/at-risk samples displayed lower levels of baseline RSA and RSA-W compared to children from community samples. Theoretical/practical implications for the study of cardiac vagal control are discussed.