Dysregulation in children: Origins and implications from age 5 to age 28

Assessment of affective dysregulation in children: development and evaluation of a semi-structured interview for parents and for children

BACKGROUND

Children with affective dysregulation (AD) show an excessive reactivity to emotionally positive or negative stimuli, typically manifesting in chronic irritability, severe temper tantrums, and sudden mood swings. AD shows a large overlap with externalizing and internalizing disorders. Given its transdiagnostic nature, AD cannot be reliably and validly captured only by diagnostic categories such as disruptive mood dysregulation disorder (DMDD). Therefore, this study aimed to evaluate two semi-structured clinical interviews-one for parents and one for children.

METHODS

Both interviews were developed based on existing measures that capture particular aspects of AD. We analyzed internal consistencies and interrater agreement to evaluate their reliability. Furthermore, we analyzed factor loadings in an exploratory factor analysis, differences in interview scores between children with and without co-occurring internalizing and externalizing disorders, and associations with other measures of AD and of AD-related constructs. The evaluation was performed in a screened community sample of children aged 8-12 years (n = 445). Interrater reliability was additionally analyzed in an outpatient sample of children aged 8-12 years (n = 27).

RESULTS

Overall, internal consistency was acceptable to good. In both samples, we found moderate to excellent interrater reliability on a dimensional level. Interrater agreement for the dichotomous diagnosis DMDD was substantial to perfect. In the exploratory factor analysis, almost all factor loadings were acceptable. Children with a diagnosis of disruptive disorder, attention-deficit/hyperactivity disorder, or any disorder (disruptive disorder, attention-deficit/hyperactivity disorder, and depressive disorder) showed higher scores on the DADYS interviews than children without these disorders. The correlation analyses revealed the strongest associations with other measures of AD and measures of AD-specific functional impairment. Moreover, we found moderate to very large associations with internalizing and externalizing symptoms and moderate to large associations with emotion regulation strategies and health-related quality of life.

CONCLUSIONS

The analyses of internal consistency and interrater agreement support the reliability of both clinical interviews. Furthermore, exploratory factor analysis, discriminant analyses, and correlation analyses support the interviews' factorial, discriminant, concurrent, convergent, and divergent validity. The interviews might thus contribute to the reliable and valid identification of children with AD and the assessment of treatment responses.

TRIAL REGISTRATION

ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963. Registered 27 June 2018.

Dysregulation profile in children of ethnoracially diverse at-risk families: Factor structure and longitudinal correlates

The present work sought to confirm the factor structure and examine longitudinal strengths-based and mental health correlates of the dysregulation profile (DP) in children of at-risk fragile families of diverse ethnoracial backgrounds. The data came from the Fragile Families and Child Wellbeing Study (N = 2125 families). Mothers (Mage = 25.3) were mostly unmarried (74.6%), and children (51.4% boys) were identified as Black (47.0%), Hispanic (21.4%), White (16.7%), or multiracial or other backgrounds. Childhood DP was constructed using mother reports of the Child Behavior Checklist at age 9. Mothers' in-home parent-child interactions and depressive symptoms were assessed at child age 5. At age 15, children responded about their own mental health, social skills, and other strengths-focused outcomes. A bifactor DP structure fit well to the data, with the DP factor representing difficulties in self-regulation. Using SEM, we found that mothers who were more depressed and used less warm parenting at child age 5 had children who presented with higher DP at age 9. DP was in turn associated with less social skills, perseverance, optimism, and more anxiety, depression, and impulsivity at adolescence. Childhood DP appears to be relevant and applicable for at-risk, diverse families, and may also impede on children's future positive functioning.

Systematic Review and Meta-Analysis: Early Irritability as a Transdiagnostic Neurodevelopmental Vulnerability to Later Mental Health Problems

OBJECTIVE

Irritability is a transdiagnostic indicator of child and adolescent internalizing and externalizing problems that is measurable from early life. The objective of this systematic review was to determine the strength of the association between irritability measured from 0 to 5 years and later internalizing and externalizing problems, to identify mediators and moderators of these relationships, and to explore whether the strength of the association varied according to irritability operationalization.

METHOD

Relevant studies published in peer-reviewed, English-language journals between the years 2000 and 2021 were sought from EMBASE, PsycINFO, MEDLINE, CINAHL, and ERIC. We synthesized studies that included a measure of irritability within the first 5 years of life and reported associations with later internalizing and/or externalizing problems. Methodological quality was assessed using the JBI-SUMARI Critical Appraisal Checklist.

RESULTS

Of 29,818 identified studies, 98 met inclusion criteria, with a total number of 932,229 participants. Meta-analysis was conducted on 70 studies (n = 831,913). Small, pooled associations were observed between infant irritability (0-12 months) and later internalizing (r = 0.14, 95% CI = 0.09, 0.20) and externalizing symptoms (r = 0.16, 95% CI = 0.11, 0.21) symptoms. For toddler/preschool irritability (13-60 months), small-to-moderate pooled associations were observed for internalizing (r = 0.21, 95% CI = 0.14, 0.28) and externalizing (r = 0.24, 95% CI = 0.18, 0.29) symptoms. These associations were not moderated by the lag between irritability and outcome assessment, although the strength of the associations varied according to irritability operationalization.

CONCLUSION

Early irritability is a consistent transdiagnostic predictor of internalizing and externalizing symptoms in childhood and adolescence. More work is required to understand how to accurately characterize irritability across this developmental period, and to understand mechanisms underlying the relationship between early irritability and later mental health problems.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as living with a disability. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

STUDY PREREGISTRATION INFORMATION

Early irritability as a transdiagnostic neurodevelopmental vulnerability to early onset mental health problems: A systematic review; https://www.crd.york.ac.uk/prospero/; CRD42020214658.

Screening for affective dysregulation in school-aged children: relationship with comprehensive measures of affective dysregulation and related mental disorders

Affective dysregulation (AD) is characterized by irritability, severe temper outbursts, anger, and unpredictable mood swings, and is typically classified as a transdiagnostic entity. A reliable and valid measure is needed to adequately identify children at risk of AD. This study sought to validate a parent-rated screening questionnaire, which is part of the comprehensive Diagnostic Tool for Affective Dysregulation in Children (DADYS-Screen), by analyzing relationships with comprehensive measures of AD and related mental disorders in a community sample of children with and without AD. The sample comprised 1114 children aged 8-12 years and their parents. We used clinical, parent, and child ratings for our analyses. Across all raters, the DADYS-Screen showed large correlations with comprehensive measures of AD. As expected, correlations were stronger for measures of externalizing symptoms than for measures of internalizing symptoms. Moreover, we found negative associations with emotion regulation strategies and health-related quality of life. In receiver operating characteristic (ROC) analyses, the DADYS-Screen adequately identified children with AD and provided an optimal cut-off. We conclude that the DADYS-Screen appears to be a reliable and valid measure to identify school-aged children at risk of AD.

Perinatal Factors and Emotional, Cognitive, and Behavioral Dysregulation in Childhood and Adolescence

OBJECTIVE

This cohort study assessed perinatal factors known to be related to maternal and neonatal inflammation and hypothesized that several would be associated with emotional, cognitive, and behavioral dysregulation in youth.

METHOD

The Environmental influences on Child Health Outcomes (ECHO) is a research consortium of 69 pediatric longitudinal cohorts. A subset of 18 cohorts that had both Child Behavior Checklist (CBCL) data on children (6-18 years) and information on perinatal exposures including maternal prenatal infections was used. Children were classified as having the CBCL-Dysregulation Profile (CBCL-DP) if the sum of their T scores for 3 CBCL subscales (attention, anxious/depressed, and aggression) was ≥180. Primary exposures were perinatal factors associated with maternal and/or neonatal inflammation, and associations between these and outcome were assessed.

RESULTS

Approximately 13.4% of 4,595 youth met criteria for CBCL-DP. Boys were affected more than girls (15.1% vs 11.5%). More youth with CBCL-DP (35%) were born to mothers with prenatal infections compared with 28% of youth without CBCL-DP. Adjusted odds ratios indicated the following were significantly associated with dysregulation: having a first-degree relative with a psychiatric disorder; being born to a mother with lower educational attainment, who was obese, had any prenatal infection, and/or who smoked tobacco during pregnancy.

CONCLUSION

In this large study, a few modifiable maternal risk factors with established roles in inflammation (maternal lower education, obesity, prenatal infections, and smoking) were strongly associated with CBCL-DP and could be targets for interventions to improve behavioral outcomes of offspring.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Social Needs and Acculturation as Predictors of Emotional Problems and Perceived Stress Among Latinx Mothers with Low Income

Associations between household social needs, acculturation, and emotional health remain understudied, particularly among Latinx mothers. We analyzed baseline survey data from 455 Latinx mothers in a previous study. Using multinomial regression, we examined whether emotional problems and perceived stress were associated with household social needs and acculturation. Almost half the sample reported four or more household social needs. Social needs cumulatively and independently predicted increased odds of frequent emotional problems or perceived stress. Lower acculturation predicted lower odds of frequent emotional problems. There is increased risk for emotional problems and stress in low-income Latinx mothers who experience high social need. Integrated social service and mental health care models may be one way to improve health outcomes. More research is needed to understand how clinical settings can leverage unique cultural protective factors to address the social and emotional health needs of Latinx mothers.

Long-term effects of pre-adoptive risk on emotional and behavioral functioning in children adopted from foster care

BACKGROUND

Children adopted from foster care are at heightened risk for emotional and behavioral challenges, potentially due to early trauma exposure and related risk factors. Research has demonstrated that adoptees with greater pre-adoptive risk exhibit higher rates of internalizing and externalizing problems across childhood and into adulthood. However, these studies have been limited by their use of individual risk factors or sum scores of cumulative risk and their measurement of internalizing and externalizing behaviors separately.

OBJECTIVE

The current study aimed to examine effects of pre-adoptive risk on long-term functioning in children adopted from foster care.

METHOD

In a longitudinally-followed sample of 82 adoptees, we utilized latent growth curve modeling to examine effects of two latent indices of pre-adoptive risk, postnatal (i.e., trauma-related) risk and prenatal risk (not including prenatal substance exposure, since it was nearly ubiquitous in this sample), on adoptee internalizing, externalizing, and latent scores of dysregulation across childhood. Additionally, in three separate models, we tested whether baseline levels and change across childhood in internalizing, externalizing, and dysregulation mediated effects of prenatal and postnatal risk on adolescent/young-adult functioning.

RESULTS

Greater postnatal risk, but not prenatal risk, predicted higher levels of internalizing and dysregulation across childhood. However, only dysregulation mediated the effect of postnatal risk on adolescent/young-adult functioning.

CONCLUSIONS

These results are consistent with prior research evidencing long-term effects of postnatal pre-adoptive risk, but not prenatal risk, in adoptees. Furthermore, they suggest that trauma exposure in this population may result in a profile of broad dysregulation that increases risk for maladjustment into adulthood.

Emotional Dysregulation in Adults from 10 World Societies: An Epidemiological Latent Class Analysis of the Adult-Self-Report

Background/Objective

Method

Results

Conclusions

Parenting practices and dysregulation profile in a sample of Italian children

BACKGROUND

emotional dysregulation is a transdiagnostic factor linked to a heightened risk for psychopathology. A dysregulation profile (DP) derived from the Strenght and Difficulties Questionnaire (SDQ) is often used to indirectly assess emotional dysregulation in children and adolescents. Theoretical models account for parenting as a causal and maintaining factor for emotional dysregulation. Notwithstanding, empirical data are scant.

METHODS

547 students (47.5% males) aged between 9 and 11 years of age (mean age = 9.66, SD = 0.64) were assessed with the SDQ-DP (teacher and parent-reported) and their parents self-reported on their own parenting practices with the Alabama Parenting Questionnaire.

RESULTS

as expected, SDQ-DP teacher-rated was positively associated with maternal and paternal negative parenting practices; SDQ-DP mother and father-rated were both negatively associated with maternal and paternal positive parenting and positively associated with maternal and paternal negative parenting practices.

LIMITATION

the age range is limited to pre-adolescents. The cross-sectional nature of the study precludes inferences on causality.

CONCLUSIONS

youth's emotional dysregulation is linked to parenting practices. These findings support the need to include families in the intervention for emotionally dysregulated youths.

Cognitive performance in children and adolescents with psychopathology traits: A cross-sectional multicohort study in the general population

Psychopathology and cognitive development are closely related. Assessing the relationship between multiple domains of psychopathology and cognitive performance can elucidate which cognitive tasks are related to specific domains of psychopathology. This can help build theory and improve clinical decision-making in the future. In this study, we included 13,841 children and adolescents drawn from two large population-based samples (Generation R and ABCD studies). We assessed the cross-sectional relationship between three psychopathology domains (internalizing, externalizing, dysregulation profile (DP)) and four cognitive domains (vocabulary, fluid reasoning, working memory, and processing speed) and the full-scale intelligence quotient. Lastly, differential associations between symptoms of psychopathology and cognitive performance by sex were assessed. Results indicated that internalizing symptoms were related to worse performance in working memory and processing speed, but better performance in the verbal domain. Externalizing and DP symptoms were related to poorer global cognitive performance. Notably, those in the DP subgroup had a 5.0 point lower IQ than those without behavioral problems. Cognitive performance was more heavily affected in boys than in girls given comparable levels of psychopathology. Taken together, we provide evidence for globally worse cognitive performance in children and adolescents with externalizing and DP symptoms, with those in the DP subgroup being most heavily affected.

Heterotypic continuity of inhibitory control in early childhood: Evidence from four widely used measures

Inhibitory control has been widely studied in association with social and academic adjustment. However, prior studies have generally overlooked the potential heterotypic continuity of inhibitory control and how this could affect assessment and understanding of its development. In the present study, we systematically considered heterotypic continuity in four well-established measures of inhibitory control, testing two competing hypotheses: (a) the manifestation of inhibitory control coheres within and across time in consistent, relatively simple ways, consistent with homotypic continuity. Alternatively, (b) with developmental growth, inhibitory control manifests in more complex ways with changes across development, consistent with heterotypic continuity. We also explored differences in inhibitory control as a function of the child's sex, language ability, and the family's socioeconomic status. Children (N = 513) were studied longitudinally at 30, 36, and 42 months of age. Changes in the patterns of associations within and among inhibitory control measures across ages suggest that the measures' meanings change with age, the construct manifests differently across development, and, therefore, that the construct shows heterotypic continuity. We argue that the heterotypic continuity of inhibitory control motivates the use of different combinations of inhibitory control indexes at different points in development in future research to improve validity. Confirmatory factors and growth curves also suggest that individual differences in inhibitory control endure, with convergence among inhibitory control measures by 36 months of age. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sustained attention across toddlerhood: The roles of language and sleep

The present study examined individual differences in the development of sustained attention across toddlerhood, as well as how these individual differences related to the development of language and sleep. Toddlers (N = 314; 54% male) were assessed at 30, 36, and 42 months using multiple measures of attention, a standardized language assessment, and actigraphic measures of sleep. Toddlers were 80% White. Family socioeconomic status (SES) was calculated using the Hollingshead Four Factor Index and ranged from 13 to 66 (M = 47.59, SD = 14.13). Aims were (a) to examine associations between measures of attention across situations, informants, and time; (b) to consider the independent and interactive effects of language and sleep on attention; and (c) to test potential bidirectional associations between sleep and attention. Findings showed attention measures were stable across time but were only weakly linked with each other at 42 months. Attention was consistently linked with language. More variable sleep and longer naps were associated with less growth in sustained attention across time. Nighttime sleep duration interacted with language in that sleep duration was positively associated with attention scores among toddlers with less advanced language, even when SES was controlled. The findings describe an understudied aspect of how sustained attention develops, involving the main effect of consistent sleep schedules and the interaction effect of amount of sleep and child language development. These findings are relevant to understanding early childhood risk for developing attention problems and to exploring a potential prevention target in family sleep practices. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trajectories of Dysregulation in Children with Autism Spectrum Disorder

Objective: This study determined whether child and family environment factors are associated with differences in developmental trajectories of emotional and behavioral dysregulation in children with autism spectrum disorder (ASD).Method: Participants included 186 families of a child with ASD (5-12 years old at baseline; 86% male; 83% non-Hispanic Caucasian; 35% comorbid intellectual disability). At each of the four time points (each spaced 12 months apart), mothers and fathers within each family completed well-validated measures on their own mental health, their child's dysregulation, their parent-child relationship, and their parent couple relationship. Longitudinal multi-level modeling was used to describe trajectories of dysregulation across 3 years and test whether parent depression, closeness in the parent-child relationship, and positive parent dyadic coping were associated with differences in child trajectories.Results: On average, child dysregulation decreased across time. Closer mother-child and father-child relationship quality was associated with lower baseline dysregulation. More severe child restricted and repetitive behaviors, fewer maternal depression symptoms, and more positive parent dyadic coping were associated with declines in child dysregulation over time.Conclusions: On average, children with ASD become less dysregulated across time. However, there is important variability in dysregulation trajectories of children with ASD. Children with ASD who have a high (versus low) severity of restricted and repetitive behaviors appear to be at risk for greater dysregulation. The family environment, and specifically a closer parent-child relationship, better maternal mental health, and more positive couple coping, may contribute to a pattern of improved child regulation across time in ASD.

Sleep and self-regulation in early childhood

What is the role of sleep in children's behavioral, emotional, and cognitive regulation? This chapter considers theoretical and conceptual links between sleep and self-regulation, with special attention to sleep and self-regulation in early childhood. We selectively review the growing body of research on associations between sleep and self-regulation, mentioning some methodological issues. We also consider how child characteristics and sociocontextual factors may interact with sleep in the development of self-regulation in early childhood. We provide some relevant empirical examples from our own research.

Predictors and outcomes of self-reported dysregulation profiles in youth from age 11 to 21 years

Understanding the dysregulation profile (DP) consisting of high scores in aggression, attention problems, and anxious/depressed problems is still limited. The aims of the present study were threefold: (a) to analyze developmental trajectories of DP (b) to identify predictors of these trajectories, and (c) to study the outcome of DP in terms of mental disorders and criminal offenses in young adulthood. A sample of 402 individuals aged 11-14 years at baseline was followed up during adolescence and young adulthood. Latent class growth analysis was used to identify DP based on the youth self-report and the young adult self-report. Self-related cognitions, perceived parental behavior, life events and coping served as predictors, psychiatric diagnoses and criminal convictions in young adulthood as outcomes. There were three developmental trajectories representing high, moderate, and low DP subgroups with 9.2% of participants represented by the high DP subgroup. Among predictors, self-esteem (negative), self-awareness (positive), and high numbers of life events had the most consistent effect on high DP. Affective and anxiety disorders and any mental disorder were significant outcomes of the high DP subgroup in both sexes at the time of young adulthood. This first report on DP based on longitudinal self-reports shows that DP is stable for a sizeable proportion of youth during adolescence and young adulthood. The predictors for DP share some similarity with those predicting psychopathology in general. However, so far there seems to be no heightened risk for the development of crime in the concerned individuals.

Sympathetic arousal in children with oppositional defiant disorder and its relation to emotional dysregulation

BACKGROUND

Emotional dysregulation (ED) is a trans-nosographical condition characterized by mood instability, severe irritability, aggression, temper outburst, and hyper-arousal. Pathophysiology of emotional dysregulation and its potential biomarkers are an emerging field of interest. A Child Behaviour Checklist (CBCL) profile, defined as Dysregulation Profile (DP), has been correlated to ED in youth. We examined the association between the CBCL-DP and indices of sympathetic arousal in children with Oppositional Defiant Disorder (ODD) and healthy controls.

METHOD

The current study sought to compare the arousal level measured via electrodermal activity in response to emotional stimuli in three non-overlapping groups of children: (1) ODD+CBCL-DP (n = 28), (2) ODD without CBCL-DP (n = 35), and (3) typically developing controls (n = 25).

RESULTS

Analyses revealed a distinct electrodermal activity profile in the three groups. Specifically, children with ODD+CBCL-DP presented higher levels of sympathetic arousal for anger and sadness stimuli compared to the other two groups.

LIMITATIONS

The relatively small sample and the lack of assessing causality limit the generalizability of this study which results need to be replicated in larger, different samples.

CONCLUSION

The CBCL-DP was associated to higher levels of arousal for negative emotions, consistently with previous reports in individuals with depression and anxiety. Further work may identify potential longitudinal relationships between this profile and clinical outcomes.

Clinical utility of the CBCL Dysregulation Profile in children with disruptive behavior

BACKGROUND

Children who are severely dysregulated experience a range of concurrent and long-term impairments and psychopathology and are particularly at-risk for mood and anxiety disorders. The Child Behavior Checklist Dysregulation Profile (CBCL-DP) may be useful in identifying children who are highly dysregulated, which could facilitate early intervention.

METHODS

We examined the prevalence, gender differences, parent-teacher agreement, and concurrent validity of two categorical definitions of the CBCL-DP in 348 children ages 6-12 who were clinic-referred for assessment and treatment because of disruptive behavior.

RESULTS

Rates of the CBCL-DP were 3 times higher when a less stringent versus a more stringent definition of the CBCL-DP was used (46.8% vs. 15.2%). Girls were more likely than boys to meet criteria for the CBCL-DP when the more stringent definition was used. Parent-teacher agreement was low, particularly when the more stringent definition of the CBCL-DP was used. Children with the CBCL-DP were rated by their parents, but not their teachers, as more impaired than other children, regardless of the definition of the CBCL-DP used, and even when compared to children with clinically elevated scores on other CBCL subscales.

LIMITATIONS

Our cross-sectional data did not allow us to examine the predictive validity of the CBCL-DP, informant effects may have inflated associations between CBCL-DP and parent-rated impairment, and teacher ratings were missing for many children.

CONCLUSIONS

Our findings support other reports that provide evidence that the CBCL-DP may identify a particularly symptomatic and impaired group of children with disruptive behavior, as rated by their parents.