Are Infant-Toddler Social-Emotional and Behavioral

Problems Transient?
MARGARET J. BRIGGS-GOWAN, PH.D., ALICE S. CARTER, PH.D.,
JOAN BOSSON-HEENAN, B.A., AMANDA E. GUYER, PH.D., AND SARAH M. HORWITZ, PH.D.

ABSTRACT
Objective: To examine the persistence of parent-reported social-emotional and behavioral problems in infants and toddlers.
Method: The sample comprised 1,082 children ascertained from birth records. Children were 12 to 40 months old in year 1
(1998 Y 1999) and 23 to 48 months old in year 2 (1999 Y 2000). Eighty percent participated in year 1 and 91% were retained in
year 2. Social-emotional and behavioral problems were measured by high scores (Q90th percentile) on the Internalizing,
Externalizing, and/or Dysregulation domains of the Infant-Toddler Social and Emotional Assessment (ITSEA). Parents
reported on sociodemographic factors, family life impairment, parenting stress, and family functioning. Results: Among
children with any high ITSEA domain score in year 1, 49.9% had persistent psychopathology, as indicated by the continued
presence of a high score in year 2. In multivariate analyses, persistence was significantly more likely when parents reported
co-occurring problems (i.e., problems in multiple ITSEA domains), high family life disruption, and high parenting distress in
year 1. Homotypic persistence rates (i.e., same domain persistence) ranged from 38% to 50%. Only for dysregulation was
homotypic persistence greater when co-occurring problems were present than for dysregulation alone. Persistence patterns
were similar for boys and girls. Conclusion: Findings indicate that infant-toddler social-emotional/behavioral problems are
not transient and highlight the need for early identification, multidomain and family assessment, and effective early
intervention. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(7):849 Y 858. Key Words: infant-toddler, persistence, social-
emotional, behavioral problems.

Despite increasing consensus that psychopathology
exists in infancy and toddlerhood (National Center
for Toddlers and Families, 1994; Zeanah, 2000),
relatively little is known about the course and
persistence of early-emerging social-emotional and
behavioral problems. An understanding of the extent
to which these early-emerging problems persist over
time is essential to our understanding of their clinical
Accepted January 31, 2006.
Dr. Briggs-Gowan and Ms. Bosson-Heenan are with the Department of
Psychiatry, University of Connecticut Health Center, Farmington CT; Dr.
Carter is with the Psychology Department, University of Massachusetts, Boston;
Dr. Horwitz is with Case Western Reserve University, Cleveland; Dr. Guyer is
with the National Institute of Mental Health, Bethesda, MD.
This research was supported by National Institute of Mental Health grant
R01MH55278.
Correspondence to Dr. Margaret J. Briggs-Gowan, Department of Psychiatry,
University of Connecticut Health Center, 263 Farmington Avenue, Farmington,
CT, 06030; e-mail: Briggsgowan@psychiatry.uchc.edu.
0890-8567/06/4507 Y 0849Ó2006 by the American Academy of Child
and Adolescent Psychiatry.
DOI:10.1097/01.chi.0000220849.48650.59
significance and to the development of appropriate
intervention services for children with significant
psychopathology. Early childhood (birth to 3 years) is
characterized by rapid developmental change and
consequently many parents and professionals believe
that early social-emotional and behavioral problems are
developmentally transient (e.g., Bthe terrible twos[) and
likely to diminish as children grow older. This view
conflicts with a small but growing body of evidence that
some early-emerging social-emotional and behavioral
problems persist (Fischer et al., 1984; Keenan and
Wakschlag, 2000; Lavigne et al., 1998; Mathiesen and
Sanson, 2000) and may be a barrier preventing children
from receiving needed intervention services. In this
article, patterns of persistence of psychopathology,
measured by extreme social-emotional/behavioral prob-
lems, and factors related to persistence are examined in
a representative community sample of young children.
Psychopathology in young children is often concep-
tualized as falling along the three broad domains of

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006 849

Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BRIGGS-GOWAN ET AL.
internalizing, externalizing, and dysregulation (National
Center for Toddlers and Families, 1994; Zeanah, 2000).
Information about clusters of social-emotional/behavioral
problems can be assessed in each domain and examined
dimensionally or by assigning cutpoints. Scores above the
cutpoints reflect the presence of multiple behaviors within
a given domain, which is used to indicate psychopa-
thology. Psychopathology also may be assessed using psy-
chiatric classification systems. However, young children
also may evidence social-emotional/behavioral problems
in the internalizing, externalizing, and/or dysregulation
domains that do not occur so frequently or intensely as to
be considered clinically significant psychopathology
(Carter and Briggs-Gowan, 2005). For the purpose of
clarity in this article, psychopathology is used to refer to
psychiatric disorders or high levels of social-emotional/
behavioral problems. Social-emotional/behavioral prob-
lems refer to dimensionally measured problem behaviors
that include both normal and atypical ranges of behavior.
In early childhood, internalizing problems include
difficulties with anxiety, depression/withdrawal, fears,
and shyness/inhibition. Externalizing problems include
aggression, overactivity, impulsivity, and inattention.
Recently, extreme problems in the regulation of state,
affect, and sensory processing have been addressed in the
regulatory disorders of the Diagnostic Classification
System for 0Y3 (National Center for Toddlers and
Families, 1994). Although conceptualizing extreme
regulatory problems as a form of psychopathology is
controversial, there is considerable evidence that children
with difficult temperament are vulnerable to developing
social-emotional/behavioral problems and psychiatric
disorders (Bates et al., 1985; Guerin et al., 1997; Keenan
et al., 1998; Prior et al., 1993; Shaw et al., 1996). This
suggests that difficulties with regulation may play a role
in the emergence or maintenance of psychopathology.
Therefore, it is important to examine the extent to which
extreme dysregulation persists and/or contributes to the
persistence of psychopathology in other areas.
Stability in Social-Emotional/Behavioral Problems
Most studies that have followed children beginning in
early childhood have employed dimensional measures to
assess aspects of internalizing and externalizing problems
and/or Bdifficult temperament.[ Longitudinal studies
that have examined the stability of social-emotional/
behavioral problems have varied considerably in sample
type, including community samples (Fischer et al., 1984;
850
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Mathiesen and Sanson, 2000), Bat-risk[ samples (Rose
et al., 1989; Shaw et al., 1998), and samples enriched for
psychopathology by overselection of children with high
scores on symptom checklists (Lavigne et al., 1998).
Despite methodological differences, these studies have
yielded fairly consistent evidence that parental reports of
infant-toddler internalizing and externalizing problems
correlate with later social-emotional/behavioral problems
(Briggs-Gowan and Carter, 1998; Fischer et al., 1984;
Mathiesen and Sanson, 2000; Mesman et al., 2001; Rose
et al., 1989; Shaw et al., 1998; Smith et al., 2004). Some
of these studies have suggested that stability may be more
consistent and stronger for externalizing problems than
for internalizing problems (Briggs-Gowan and Carter,
1998; Mesman and Koot, 2001l Mesman et al., 2001).
Many of these studies have focused on homotypic
stability, that is, the stability of behaviors within the
same domain over time. Within early childhood, several
studies suggest low to moderate homotypic stability in
early internalizing problems, with correlations from 0.23
to 0.52 (Briggs-Gowan and Carter, 1998; Fischer et al.,
1984; Mathiesen and Sanson, 2000). Early childhood
internalizing problems also have been linked with
school-age internalizing problems; however, results
have been inconsistent, with one study indicating greater
stability among boys (Mesman et al., 2001) and another
greater stability among girls (Fischer et al., 1984).
When examined dimensionally, externalizing prob-
lems demonstrate moderate to strong stability, with
longitudinal correlations from 0.31 to 0.70 (Briggs-
Gowan and Carter, 1998; Mathiesen and Sanson, 2000;
Mesman et al., 2001; Rose et al., 1989; Shaw et al.,
1998; Smith et al., 2004). Notably, toddler externalizing
behaviors have significantly predicted externalizing
disorders at age 5 (Keenan et al., 1998). Although two
studies found no sex differences in the stability of
externalizing problems (Fischer et al., 1984; Smith et al.,
2004), one study reported stronger longitudinal path-
ways for boys than girls (Mesman et al., 2001).
Categorical Persistence
Although the stability of early psychopathology is more
relevant to decisions about clinical intervention than the
stability of dimensional reports of social-emotional/
behavioral problems, few studies have examined the
persistence of psychopathology defined using symptom
cutpoints or diagnostic classifications. Mathiesen and
Sanson (2000) found that 37% of 18-month-olds with
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006

moderately high emotional/behavioral problems con-
tinued to have problems in the same area at 30 months.
Similarly, in the study of Lavigne et al. (1998), ap-
proximately half of 2-year-olds who met criteria for a
psychiatric disorder continued to meet criteria for a dis-
order 1 year later. Furthermore, toddlers extreme in be-
havioral inhibition have been found to be at increased risk
of later internalizing disorders (Biederman et al., 2001;
Schwartz et al., 1999). Most of these studies do not appear
to have examined sex differences in persistence rates.
However, Lavigne and colleagues (1998) reported that
internalizing disorders were more persistent among 2- and
3-year-old boys (50%) than among girls (29%), and that
there was no sex difference in the persistence of
externalizing disorders. Information concerning the het-
erotypic continuity of early social-emotional/behavioral
problems is limited. Although some studies have suggested
that internalizing problems may decrease the risk of
developing externalizing problems (Mesman et al., 2001;
Schwartz et al., 1999), others have found no link between
problems in one domain and risk of developing problems
in another (Lavigne et al., 1998; Mesman and Koot,
2001). A high level of co-occurrence across domains,
noted by Lavigne and colleagues (1998), may underlie
these conflicting results.
Contributing Factors
Some studies have indicated greater persistence
among children with higher levels of social-emotional/
behavioral problems (Lavigne et al., 1998; Mathiesen
and Sanson, 2000; Prior et al., 1992). This is not
surprising because the greater the number or severity of
problems, the greater the behavioral change needed for
difficulties to remit. Persistence also may be greater among
children whose difficulties interfere with their ability to
engage in age-appropriate activities and/or negatively affect
social relationships (i.e., impairment). Restricted exposure
to developmentally appropriate situations and activities
may constrain a child_s opportunities to learn to master
challenging tasks, such as learning to control aggressive
impulses when frustrated by peer interactions. Such
associations between impairment and persistence have
been identified in older children (Costello et al., 1999).
However, Lavigne and colleagues (1998) found that in
young children, persistence of externalizing disorders was
not related to a global measure of impairment. Given the
increased focus on impairment in current diagnostic
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
ARE INFANT-TODDLER PROBLEMS TRANSIENT?
systems, such as the DSM-IV (American Psychiatric
Association, 1994), addressing the role of impairment in
persistence is clearly important.
Although some studies have sought to identify risk
factors for persistent psychopathology, relatively few
factors have been identified. Mathiesen and Sanson
(2000) found that although many factors were associ-
ated with the onset of toddlers_ psychopathology, none
of a comprehensive array of risk factors, including
sociodemographic factors, maternal symptomatology,
social support, and life events, distinguished children
with stable versus remitting psychopathology. In
contrast, Mesman and Koot (2001) found that stressful
life events and physical health problems were associated
with risk of later disorder. Finally, Lavigne and
colleagues (1998) found that low family cohesiveness
was associated with persistence of early externalizing
disorders, but that negative maternal affect and child
cognitive level were not associated with persistence of
either internalizing or externalizing disorders.
An understanding of the persistence, or course, of
psychopathology in young children is critical to
improving identification and intervention efforts in
early childhood. Identifying those children whose
difficulties are particularly intransigent would aid
decision making regarding eligibility for targeted
prevention and intervention programs. In this work,
the persistence of high levels of parent-reported
internalizing, externalizing, and dysregulation problems
is examined in a sociodemographically diverse, repre-
sentative, community sample of children first studied at
approximately 1 to 3 years of age. Patterns of overall
persistence, homotypic persistence, and heterotypic
persistence are examined, with attention paid to the role
that having problems in multiple or co-occurring areas
may have on persistence. In addition, factors that may
contribute to persistence are examined, including child
sex, child age, problem severity, disruptions in family
routine attributed to child behavior, sociodemographic
risk, and potential risks and stressors within the family.
METHOD
Participants
The sample studied is an age- and sex-stratified healthy birth
cohort randomly selected from birth records at the State of
Connecticut Department of Public Health for children born in
a Standard Metropolitan Statistical Area of the 1990 Census
851
BRIGGS-GOWAN ET AL.
(Briggs-Gowan et al., 2001). Children likely to have developmental
delays caused by prematurity, low birth weight, or birth complica-
tions were excluded, as were parents unable to participate in English
and families that had moved out of the state. Of an eligible sample
of 1,605, 1,280 families participated (80% response rate) in year 1.
These participants were sociodemographically similar to families
living in the region (Briggs-Gowan et al., 2001). Of year 1
participants, 1,169 (91.3%) participated in the year 2 survey.
Seventeen children were subsequently deemed ineligible because of
significant developmental delays identified during the study (e.g.,
autism spectrum disorders).
Longitudinal analyses were restricted to children with complete
ITSEA data, the same respondent over time, and a minimum
interval of 6 months between the year 1 and year 2 surveys. Most of
the analyzed sample (89%) had a 9- to 15-month interval (mean
12.3 months; SD = 1.8 months); 5.5% had 6- to 8-month intervals,
and 5.8% had 15- to 22-month intervals. The final sample
included in analyses (N = 1,082) was similar to the sample (n = 178)
not available for analyses (because of nonparticipation, respondent
change, incomplete data, or time interval restrictions) with respect
to child sex, marital status, and poverty status, but differed
significantly (p G .05) on year 1 child age in months (mean 24.2,
SD = 7.0 versus mean 28.1, SD = 7.5, respectively), minority
ethnicity (36% versus 61%), and respondent educational attain-
ment of high school degree or less (27% versus 41%). Weights were
employed in all analyses to adjust for potential biases in the retained
sample. Weights accounted for unequal selection probabilities,
differential nonresponse in the initial study, and differential
attrition. Information from birth records concerning sociodemo-
graphic background (e.g., parental age, education and race) and
birth status (e.g., birth weight and gestational age) were used to
adjust for differential nonresponse and attrition in calculating final
sampling weights. Weighting resulted in nonwhole integers for cell
counts; these were rounded in the results to aid readability.
The majority of children ($97%) were within the target child age
ranges of 12 to 35 months in year 1 and 24 to 47 months in year 2.
The remaining children were slightly outside these age ranges
because of variability in the length of time needed to locate subjects
and obtain participation. In year 1, 547 were 12 to 23 months, 508
were 24 to 35 months, and 27 were 36 to 40 months. In year 2, 12
children were 23 months, 532 were 24 to 35 months, 513 were 36
to 47 months, and 25 were 48 months.
Boys and girls were equally represented (49.7% boys). Children
were ethnically diverse (64.1% white, 18.7% black, 4.7% Hispanic,
9.2% multiethnic minority, 2.0% Asian, and 1.3% other ethnicity).
Most respondents were mothers (97.7%) and married/cohabiting
with a partner (79.0%). Approximately 27% of respondents had
completed a high school education or less, 32% had some education
beyond high school, and 41% had a college degree or more. Median
annual income was $50,000, with 19.3% of families living on
incomes below the poverty line and 16.0% living in borderline
poverty (i.e., below 185% of poverty).
Measures
Sociodemographic Variables. Parents answered questions about
sociodemographic factors, such as child sex, age, ethnicity, parental
education, marital status, and household income.
Infant-Toddler Social and Emotional Assessment (ITSEA). The
Internalizing, Externalizing, and Dysregulation domains of the
ITSEA, a 166-item parent report measure of social-emotional/
behavioral problems and competencies in 12- to 48-month-olds, were
852
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
employed (Carter and Briggs-Gowan, 2005; Carter et al., 2003). The
Internalizing domain measures general anxiety, depression/withdraw-
al, inhibition to novelty/shyness, and separation distress. The
Externalizing domain measures aggression/defiance, peer aggression,
and activity/impulsivity. The Dysregulation domain measures
problems with regulation of state, affect, and sensory processes across
the areas of negative emotionality, eating, sleep, and sensory
sensitivities. Items are rated on a 3-point scale from not true/rarely
to very true/often. Across several studies, the ITSEA has demonstrated
acceptable internal consistency, test-retest reliability, and validity
relative to other parent report checklists and independent behavioral
observations (Carter and Briggs-Gowan, 2005). Domain cutpoints
are set at the 90th percentile. A Total ITSEA Problems T score was
calculated as the sum of the three domain scores standardized within
6-month age bands and sex.
Family Life Impairment Scale (FLIS). The 21-item FLIS assesses
the extent to which the parent views the young child_s behavior,
personality, or special needs as limiting the child_s participation in
activities that are typical for families with young children (e.g., visiting
family, dining at family restaurants, going grocery shopping) or as
negatively affecting the parent (e.g., by placing restrictions on the
parent_s socialization with friends or intimate time with her partner).
The FLIS was developed for this study as a brief measure that would be
appropriate for a normative sample of children, most of whom would
not have disabilities or chronic health problems.
Worry About Child. Parents rated their level of worry about their
child_s behavior, social development, and emotional development
on a 5-point scale (1 = not at all worried to 5 = extremely worried).
Parenting Stress Index Short Form. The Parent Distress (PD) and
Parent-Child Dysfunctional Interaction (PCDI) scales were
employed (Abidin, 1990). PD addresses general stress and
dissatisfaction in the parenting role. PCDI measures whether the
child meets parental expectations and reinforces the parent. These
scales have acceptable reliability and validity. Clinical cutpoints
available from the author (Abidin) were employed.
Center for Epidemiologic Studies Depression Inventory. The 20-
item Center for Epidemiologic Studies Depression Inventory self-
report checklist assesses adult depressive symptoms. It has
demonstrated high internal consistency (coefficient ! from .84 to
.90) and modest test-retest reliability (r = 0.51 to 0.67; Radloff,
1977). A clinical cutpoint of 16 was employed.
Beck Anxiety Inventory. This self-report measure consists of
statements that describe common symptoms of anxiety (Beck et al.,
1988). Symptoms are rated on a 4-point scale from Bnot at all
bothered[ to Bseverely bothered.[ Psychometric properties are
adequate. A clinical cutpoint of 16 was employed.
Family Environment Scale (FES). The FES Expressiveness and
Conflict subscales were employed (Moos and Moos, 1983). These
subscales have acceptable reliability and validity in measuring
disruptions in family functioning. Cutpoints indicating Conflict
scores in the upper 80th percentile and Expressiveness scores in the
lowest 20th percentile were employed.
Life Events. The child stressful life events measure, developed as a
companion to the ITSEA, comprises 14 items that children may
have experienced in their lifetime (e.g., hospitalization, injury,
separation from parent, violence). The parent life events comprises
38 items selected from the Life Events Inventory (Cochrane and
Robertson, 1973), based on having the highest severity weights and
greatest applicability to young families.
Social support was measured with the Tangible and Emotional
Informational Support measures of the Medical Outcomes Study
(Sherbourne and Stewart, 1991). The scales comprise 12 items and
have demonstrated adequate psychometric properties.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006
 ARE INFANT-TODDLER PROBLEMS TRANSIENT?

Procedure Dysregulation, 39.7% versus 37.7%, respectively (p > .05).

Parents were invited to participate via mail and telephone. In addition, there were no significant difference between
Most parents answered the questions as self-report question- younger and older children in rates of homotypic
naires. Less than 5% of parents were read questions verbatim by persistence of Internalizing (35.8% versus 39.9%),
research staff. Informed consent procedures were followed. All of
the procedures were approved by the institutional human subjects Externalizing (55.7% versus 43.4%), or Dysregulation
review board. Parents who declined participation were not (38.8% versus 38.7%) problems.
contacted further. Parents received $25 for participating. Similar Heterotypic persistence was defined as the presence of
procedures were used in both years.
problem(s) in different areas over time. Of the 110
children with persistent problems, only 11.8% (n = 13)
RESULTS
had problems solely in a new area in year 2. All shifts
were from one pure group to another pure group and
Initial Problems
most (12/13) involved Dysregulation (4 Dysregulation
In the overall sample, 20.3% of children were reported to Internalizing, 3 Dysregulation to Externalizing, 5
to have any ITSEA problem, defined as one or more Externalizing to Dysregulation, and 1 Internalizing to
Internalizing, Externalizing, and/or Dysregulation score Externalizing).
above the 90th percentile based on the sex of the child Rates of Persistence in Pure and Co-occurring Groupings.
and 6-month age bands (Table 1). Approximately 14.2% As a first step in examining the possible influence of co-
of children had a single high domain score (i.e., Bpure[ occurring problems (present in 30.1% of children with
problems) and 6.1% had multiple high domain scores Any Problem), mutually exclusive groups were formed
(i.e., Bco-occurring[ problems in two or three do-
mains). Notably, 30.1% of children with Any Problem
TABLE 1
had co-occurring problems. Rates of problems were Rates of Initial Problems and Overall Persistence
similar for boys and girls across all pure and co- (Weighted) (N = 1,082)
occurring groups. In year 2, similar rates of problems Any ITSEA
were reported across these groupings. Year 1 Problem Year
ITSEA 2 (Overall
Persistence Problem(s) Persistence)
NY2
Overall Problem Persistence. The rate of overall Year 1 ITSEA Domains NY1(%) (% NY2/NY1)
problem persistence, defined as the presence of Any
Any internalizing problem 105 (9.7) 55 (52.0)
ITSEA Problem in year 2 among children with any
Any externalizing problem 101 (9.4) 64 (63.3)
ITSEA problem year 1, was 49.9% (Table 1) and Any dysregulation problem 105 (9.7) 61 (58.0)
was similar for boys (47.6%) and girls (52.6%). Simi- Any problem (Internalizing, 220 (20.3) 110 (49.9)
lar rates of persistence were obtained among younger Externalizing, and/or
children (12Y23 months: 54.5%) and older children Dysregulation domain)
(24Y40 months: 45.3%), # 2 = 1.62, not significant. No problem 862 (79.7) 120 (14.0)
Mutually exclusive groupings
Although not a focus of this article, the incidence of Internalizing only 57 (5.3) 19 (33.5)A
any ITSEA problem in year 2 among children with no Externalizing only 51 (4.7) 26 (51.1)A,B
year 1 problem was 14.0%. Dysregulation only 45 (4.2) 15 (33.6)A
Homotypic and Heterotypic Persistence. Homotypic Internalizing and 7 (0.6) 4 (55.2)A,C
persistence was defined as the presence of a high score in Externalizing
Internalizing and 15 (1.4) 11 (73.2)B,C
the same domain over time, regardless of the presence of
Dysregulation
co-occurring problems in other domain(s). Homotypic Externalizing and 18 (1.7) 14 (78.2)B,C
persistence rates were 37.8% for the Internalizing domain, Dysregulation
49.9% for the Externalizing domain, and 38.7% for the Internalizing, 26 (2.4) 21 (79.2)C
Dysregulation domain, with no significant differences in Externalizing, and Dysregulation
rates across the domains. Rates of homotypic persistence Note: Cells that do not share a common superscript letter differ
were comparable for boys and girls: Internalizing, 30.4% significantly, p G .01. ITSEA = Infant-Toddler Social and
versus 46.1%; Externalizing, 47.4% versus 52.7%; and Emotional Assessment; Y1 = year 1; Y2 = year 2.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006 853

Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BRIGGS-GOWAN ET AL.

based on the combination of problems in year 1 (Table 1).
Across the pure groups, overall persistence rates ranged
from 33.5% for Internalizing only to 51.1% for
Externalizing only, with no significant differences in
rates across the pure groups. In the co-occurring groups,
persistence rates ranged from 55.2% for Internalizing/
Externalizing to 79.2% for Internalizing/Externalizing/
Dysregulation, with no significant differences in persis-
tence across the co-occurring groups. The co-occurring
groups tended to be significantly more persistent than the
pure groups. However, Externalizing only and Internal-
izing/Externalizing were exceptions to this pattern: the
Externalizing only group differed only from the Internal-
izing/Externalizing/Dysregulation group and the Internal-
izing/Externalizing group did not differ from any other
group. When children with co-occurring problems were
compared with children with pure problems, those
with co-occurring problems were approximately 4.7
times more likely to have Any Problem in year 2, #2 =
22.09, p G .0001, relative risk ratio (RR) = 4.65, 95%
confidence interval (CI) = 2.43Y8.86.
Bivariate analyses were employed to examine whether,
for each domain separately, the presence of co-occurring
problems significantly increased the likelihood of (1)
overall problem persistence and (2) homotypic persis-
tence within that domain (Table 2). For all domains,
overall persistence was significantly more likely in the co-
occurring group than in the pure group, with increased
RR ranging from approximately 2.9 for Externalizing to
6.7 for Dysregulation. However, the impact of co-
occurring problems on homotypic persistence varied
with domain. For Dysregulation, homotypic persis-
tence was approximately 4.5 times more likely in the
co-occurring group (53.5%) than in the pure group
(20.1%). Yet, co-occurring problems had no signifi-
cant effect on the homotypic persistence of Inter-
nalizing or Externalizing problems.
Severity. Because the impact of co-occurrence on
persistence may be related to overall problem severity,
an analysis of variance (ANOVA) was examined in
which the Total ITSEA Problems T score was the
dependent variable and overall persistence status and
child sex were independent variables. The overall model
was significant, F3,216 = 9.10, p G .0001, as was the
effect of persistence status, F1,216 = 26.84, p G .0001,
with higher Total Problems in the persistent group
(mean = 66.83, SD = 8.91) than in the remitting group
(mean = 61.07, SD = 7.61). There was no significant
sex effect (F1,216 = 0.01) nor was there a significant
interaction between sex and persistence status (F1,216 =
0.88; data not shown).
Factors Related to Overall Problem Persistence. As a
first step in identifying sociodemographic and parent/
family functioning factors associated with increased risk

TABLE 2
Effect of Co-occurrence on Rates of Overall and Homotypic Persistence Among Children With Any Problem, Year 1
Year 2 ITSEA Status
Overall Problem Homotypic
Persistence NY2 Persistence NY2
Year 1 ITSEA Status NY1 (%)a (%)a
Internalizing
Pure Internalizing 57 19 (33.5) 18 (31.9)
Co-occurring Internalizing 48 35 (74.0) 21 (44.9)
Relative risk (95% CI) 5.63 (2.42 Y 13.17) 1.74 (0.78 Y 3.85)
Externalizing
Pure Externalizing 51 26 (51.1) 21 (41.4)
Co-occurring Externalizing 50 38 (75.7) 29 (58.4)
Relative risk (95% CI) 2.98 (1.28 Y 6.94) 1.99 (0.90 Y 4.38)
Dysregulation
Pure Dysregulation 45 15 (33.6) 9 (20.1)
Co-occurring Dysregulation 59 46 (77.3) 32 (53.5)
Relative risk (95% CI) 6.74 (2.83 Y 16.04) 4.57 (1.88 Y 11.12)
Note: Relative risks shown in bold are statistically significant (i.e., confidence intervals exclude 1.0). ITSEA =
Infant-Toddler Social and Emotional Assessment; Y1 = year 1; Y2 = year 2 ; CI = confidence interval.
a
% = NY1/NY2.

854 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006

Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
 ARE INFANT-TODDLER PROBLEMS TRANSIENT?

TABLE 3
Bivariate Analysis of Factors Related to Persistence Among Children With Any Problem in Year 1
Factor Remit NFactor/NRemit(%) Persist (Any Problem) NFactor/NPersist(%)
Child factors
Sex (male) 58/103 (56.2) 50/100 (50.4)
Age group (24 Y 40 mo) 58/103 (56.8) 46/100 (46.1)
Co-occurring problems 15/103 (14.8) 43/100 (43.5)y
Sociodemographics
Resp. educ. e high school 36/103 (34.7) 38/109 (38.3)
Poor/borderline poor 44/103 (43.2) 52/99 (53.1)
Single parent 31/103 (30.5) 36/100 (35.6)
Minority ethnicity 48/103 (46.8) 55/100 (55.5)
Parenting stress
Parent worry about child 36/103 (34.5) 45/100 (44.7)
Family life impairment 43/103 (41.4) 67/100 (66.9)***
PSI/parenting distress 7/103 (6.7) 26/100 (25.6)***
PSI/P-C dysfunction 7/103 (6.6) 15/100 (15.1)*
Parent/family factors
Depressive symptoms 24/103 (23.5) 36/100 (36.2)*
Anxiety symptoms 3/103 (3.0) 14/100 (14.4)**
FES expressiveness 20/100 (20.2) 14/99 (13.8)
FES conflict 17/97 (17.2) 22/99 (22.0)
Parent stressful events 9/103 (8.8) 14/100 (14.5)
Child stressful events 8/103 (7.6) 11/100 (10.5)
Low social support 22/101 (21.5) 27/98 (28.1)
Note: Sample size reduced due to elimination of 17 subjects with missing covariate data.
Significance evaluated with continuity adjusted #2. Resp. educ. e high school = respondent
educational attainment of less than or equal to a high school degree; PSI = Parenting Stress Index; PSI/
P-C = Parent-Child Dysfunctional Interaction; FES = Family Environment Scale.
* p G .10; ** p G .01; *** p G .001; y p G .0001.

of overall persistence (persist versus remit), bivariate # 2 in which Total ITSEA Problems and Co-occurring
tests were employed (Table 3). Persistence was signifi- Problems were entered in the first model step indicated
cantly more likely in the presence of high year 1 comparable model fit (likelihood ratio = 40.82, p G .0001)
parental anxiety, parenting distress, and FLIS disrup-
tion in family life than when each of these factors was
not high. Persistence status was not significantly TABLE 4
associated with any other factor tested. Multivariate Logistic Regression Examining Factors Related to
Overall Problem Persistence Among Children With Any Problem
A multivariate stepwise logistic regression model was
in Year 1 (n = 203)
employed to further examine these associations. The
Estimate SE RR 95% CI
model included all variables that met a significance level of
p G .10 in the bivariate analyses, thus restricting the Intercept Y 1.01 0.25 V V
Co-occurring 1.36 0.36 3.89*** 1.93 Y 7.85
number of variables in the model, as was necessary because problems
of power constraints. Overall problem persistence was PSI/parenting 1.38 0.48 3.96** 1.55 Y 10.13
significantly more likely when co-occurring problems distress
were present (RR = 3.89), with high parenting distress High family life 0.75 0.31 2.11* 1.14 Y 3.92
(RR = 3.96) and with high FLIS disruption (RR = 2.11) impairment
Likelihood ratio (5,203) = 39.13, p G .0001
(Table 4). Parental depressive symptoms, anxiety symp-
toms, and PSI-PC did not remain in the final model. No Note: PSI = Parenting Stress Index.
significant interactions were present. A competing model * p G .05; ** p G .01; *** p G .001.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006 855

Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BRIGGS-GOWAN ET AL.
and the same pattern of significant effects. Results
indicated shared variance between Total Problems and
Co-occurrence; although Total Problems was not signifi-
cant (p G .20), co-occurrence had smaller RR than in the
first model (RR = 2.56, 95% CI 1.00Y6.53, p G .05).
DISCUSSION
A primary aim of this work was to document the
persistence of parent-reported psychopathology in
infants and toddlers in a representative healthy birth
cohort. Our findings indicate that even at this young
age, elevations in social-emotional and behavioral
problems are not transient. Approximately half of the
infants and toddlers who were reported to have high
social-emotional and behavioral problems continued to
have such problems approximately 1 year later.
Furthermore, rates were comparable for younger and
older children. This level of persistence is consistent
with findings reported by others who have studied this
phenomenon in early childhood (Fischer et al., 1984;
Lavigne et al., 1998; Mathiesen and Sanson, 2000) and
parallels rates of persistence documented in school-age
children (Briggs-Gowan et al., 2003). Furthermore,
although many studies have examined homotypic
stability using symptom counts, fewer have examined
homotypic persistence using cutpoints or diagnostic
status (Lavigne et al., 1998; Mathiesen and Sanson,
2000). Our findings indicate substantial homotypic
stability in cutpoint status, with rates of 38% for
Internalizing, 39% for Dysregulation, and 50% for
Externalizing. These early, stable, and distinctive
manifestations of psychopathology support the pres-
ence of early differentiation in psychopathological
behaviors that may be signs of later disorders or
represent the presence of early childhood disorders.
In addition to contributing to our understanding of
the unfolding of early psychopathology, these findings
have implications for identifying children whose social-
emotional/behavioral problems are most likely to
persist and who are likely to have the greatest need of
intervention. Remarkably, persistent social-emotional/
behavioral problems were reported in approximately
75% of children with co-occurring problems. Children
with co-occurring problems represented 30% of
children with any initial problem and nearly half of
children whose problems persisted. These children were
approximately 4.7 times more likely to have persistent
856
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
problems than children with pure problems, and 3.9
times more likely after controlling for parenting distress
and family disruption. Thus, comprehensive assessment
tools capable of identifying problems in multiple
domains may aid efforts to identify children at par-
ticular risk of persistent problems.
There may be several explanations for the link
between co-occurrence and overall persistence. For
example, when problem behaviors are of greater
number or severity, it is simply less probable that all
problems will drop below cutpoint thresholds. It also is
possible that difficulty with emotion regulation man-
ifests across multiple areas, such as aggression/defiance,
separation distress, and sleep problems. Co-occurring
problems also may indicate a greater progression of
psychopathology, in which problems that began in one
area become more pervasive and affect functioning in
another area. For example, oppositionality first
expressed as defiance may develop an aggressive
component and come to be expressed as power struggles
at mealtime or bedtime. Our multivariate findings
indicated that total problems and co-occurrence shared
variance; thus, persistence is likely related to both
severity and pervasiveness across domains.
Furthermore, co-occurring problems were associated
with increased homotypic persistence of dysregulation
problems (co-occurring 54%, pure 20%), but not with
increased persistence of internalizing or externalizing
problems. The presence of problem behaviors in other
domains may make it more challenging for parents to
help their children to develop more appropriate
regulatory skills. Furthermore, the relatively low
stability of dysregulation when not accompanied by
problems in other areas suggests that the dysregulation
construct measured does not have a strong tempera-
mental component.
Factors other than co-occurrence also affect persis-
tence, as evidenced by the fact that approximately half of
children with persistent problems had initial pure
problems. Controlling for co-occurrence, persistence
was more likely when parents reported high levels of
parenting distress and/or disruption in family life because
of their child_s behavior. This is consistent with studies of
older children that have linked greater parental burden
with symptom severity, impairment, and service use
(Angold et al., 1998). Although there are likely
bidirectional influences between child psychopathology
and parenting distress and family disruption, these
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006

associations highlight the need to include both children
and parents in assessment and intervention.
The lack of sex differences is notable and contrasts
with some prior evidence of sex differences in problem
persistence and stability. This difference may reflect in
part that the ITSEA employs age- and sex-based
cutpoints. Thus, although there are sex differences in
some ITSEA subscales (Carter et al., 2003), when
compared within age and sex bands, patterns of co-
occurrence, overall persistence, and homotypic conti-
nuity did not differ for boys and girls.
Limitations
The reliance on parental reports without corrobora-
tion from direct observation or another informant
constrains our ability to establish the clinical signifi-
cance of the problem behaviors studied. Reporting
biases or individual differences in thresholds applied
when reporting problems behaviors may affect parental
reports. Nevertheless, parental perceptions of extreme
social-emotional/behavioral problems, even if not
initially clinically significant, may become so when
maintained over a period of years. Additional research is
warranted to examine the contributions of tempera-
ment, emotion regulation, and symptom clusters to the
developmental course of psychopathology. Ideally, this
future research would incorporate observational methods
and newly available structured diagnostic interviews
(Del Carmen-Wiggins and Carter, 2004) to allow careful
characterization of temperament, emotional regulation,
and psychopathology.
Clinical Implications
Most broadly, the high rates of persistence observed
contrast with a view of early problems as developmen-
tally transient. Early social-emotional/behavioral pro-
blems appear to be especially intransigent when
problems are present in multiple domains and when
parents report high distress in parenting and disruption
in family routines. Results also indicate that many
parents who reported persistent psychopathology were
not worried about their child_s behavior, thus empha-
sizing the need for systematic early identification
strategies, such as screening with normed instruments.
Finally, evidence that persistence was related to both co-
occurrence of problems across domains and disrupted/
distressed parenting suggests that child psycho-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
ARE INFANT-TODDLER PROBLEMS TRANSIENT?
pathology and disrupted/distressed parenting may be
mutually maintaining, thus emphasizing the need for
parentYchild interventions.
Disclosure: The Infant-Toddler Social and Emotional Assessment
(ITSEA) is licensed for publication with Harcourt Assessment. Drs.
Carter and Briggs-Gowan will receive royalties from its publication.
The other authors have no financial relationships to disclose.
REFERENCES
Abidin RR (1990), Parenting Stress Short-Test Manual. Charlottesville, VA:
Pediatric Psychology Press
American Psychiatric Association (1994), Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition (DSM-IV). Washington, DC: American
Psychiatric Association
Angold A, Messer SC, Stangl D, Farmer EM, Costello EJ, Burns BJ (1998),
Perceived parental burden and service use for child and adolescent
psychiatric disorders. Am J Public Health 88:75 Y 80
Bates JE, Maslin CA, Frankel KA (1985), Attachment security mother-child
interaction, and temperament as predictors of behavior-problem ratings
at age three years. Monogr Soc Res Child Dev 50:167x Y 193x
Beck AT, Epstein N, Brown G, Steer RA (1988), An inventory for
measuring clinical anxiety: psychometric properties. J Consult Clin
Psychol 56:893 Y 897
Biederman J, Hirshfeld-Becker DR, Rosenbaum JF et al. (2001), Further
evidence of association between behavioral inhibition and social anxiety
in children. Am J Psychol 158:1673 Y 1679
Briggs-Gowan MJ, Carter AS (1998), Preliminary acceptability and
psychometrics of the Infant-Toddler Social and Emotional Assessment
(ITSEA): a new adult report questionnaire. Infant Ment Health J
19:422 Y 445
Briggs-Gowan MJ, Carter AS, Skuban EM, Horwitz SM (2001), Prevalence of
social-emotional and behavioral problems in a community sample of 1-
and 2-year-old children. J Am Acad Child Adolesc Psychiatry 40:811 Y 819
Briggs-Gowan MJ, Owens PL, Schwab-Stone ME, Leventhal JM, Leaf PJ,
Horwitz SM (2003), Persistence of psychiatric disorders in pediatric
settings. J Am Acad Child Adolesc Psychiatry 42:1360 Y 1369
Carter AS, Briggs-Gowan MJ (2005), Infant Toddler and Brief Infant
Toddler Social Emotional Assessment (ITSEA) (BITSEA) Manual. San
Antonio, TX: Harcourt Assessment
Carter AS, Briggs-Gowan MJ, Jones SM, Little TD (2003), The Infant-
Toddler Social and Emotional Assessment (ITSEA): factor structure,
reliability, and validity. J Abnorm Child Psychol 31:495 Y 514
Cochrane R, Robertson A (1973), The life events inventory: a measure
of the relative severity of psycho-social stressors. J Psychosom Res
17:135 Y 139
Costello EJ, Angold A, Keeler GP (1999), Adolescent outcomes of
childhood disorders: the consequences of severity and impairment.
J Am Acad Child Adolesc Psychiatry 38:121 Y 128
Del Carmen-Wiggins R, Carter AS, eds. (2004), Handbook of Infant and
Toddler Mental Health Assessment. New York: Oxford University Press
Fischer M, Rolf JE, Hasazi JE, Cummings L (1984), Follow-up of a
preschool epidemiological sample: cross-age continuities and predictions
of later adjustment with internalizing and externalizing dimensions of
behavior. Child Dev 55:137 Y 150
Guerin DW, Gottfried AW, Thomas CW (1997), Difficult temperament
and behaviour problems: a longitudinal study from 1.5 to 12 years. Int J
Behav Dev 21:71 Y 90
Keenan K, Shaw D, Delliquadri E, Giovannelli J, Walsh B (1998), Evidence
for the continuity of early problem behaviors: application of a
developmental model. J Abnorm Child Psychol 26:441 Y 452
Keenan K, Wakschlag LS (2000), More than the terrible twos: the nature
and severity of behavior problems in clinic-referred preschool children.
J Abnorm Child Psychol 28:33 Y 46
857
BRIGGS-GOWAN ET AL.

Lavigne JV, Arend R, Rosenbaum D, Binns HJ, Christoffel KK, Gibbons
RD (1998), Psychiatric disorders with onset in the preschool years: I.
Stability of diagnoses. J Am Acad Child Adolesc Psychiatry 37:
1246 Y 1254
Mathiesen KS, Sanson A (2000), Dimensions of early childhood behavior
problems: stability and predictors of change from 18 to 30 months.
J Abnorm Child Psychol 28:15 Y 31
Mesman J, Bongers IL, Koot HM (2001), Preschool developmental
pathways to preadolescent internalizing and externalizing problems.
J Child Psychol Psychiatry 42:679 Y 689
Mesman J, Koot HM (2001), Early preschool predictors of preadolescent
internalizing and externalizing DSM-IV diagnoses. J Am Acad Child
Adolesc Psychiatry 40:1029 Y 1036
Moos RH, Moos BM (1983), Family Environment Scale. In: Family Health
and Neighborhood Questions. Palo Alto, CA: Consulting Psychologists
Press
National Center for Toddlers and Families (1994), Diagnostic Classification:
0-3. Diagnostic Classification of Mental Health and Developmental
Disorders of Infancy and Early Childhood. Washington, DC: National
Center for Toddlers and Families
Prior M, Smart D, Sanson A, Oberklaid F et al. (1993), Sex differences in
psychological adjustment from infancy to 8 years. J Am Acad Child
Adolesc Psychiatry 32:291 Y 304
Prior M, Smart D, Sanson A, Pedlow R, Oberklaid F (1992), Transient
versus stable behavior problems in a normative sample: infancy to school
age. J Pediatr Psychol 17:423 Y 443
Radloff LS (1977), The CES-D scale: a self report depression scale for
research in the general population. Appl Psychol Meas 1:385 Y 401
Rose SL, Rose SA, Feldman JF (1989), Stability of behavior problems in very
young children. Dev Psychopathol 1:5 Y 19
Schwartz CE, Snidman N, Kagan J (1999), Adolescent social anxiety as an
outcome of inhibited temperament in childhood. J Am Acad Child
Adolesc Psychiatry 38:1008 Y 1015
Shaw DS, Owens EB, Vondra JI, Keenan K, Winslow EB (1996), Early risk
factors and pathways in the development of early disruptive behavior
problems. Dev Psychopathol 8:679 Y 699
Shaw DS, Winslow EB, Owens EB, Vondra JI, Cohn JF, Bell RQ (1998),
The development of early externalizing problems among children from
low-income families: a transformational perspective. J Abnorm Psychol
26:95 Y 107
Sherbourne CD, Stewart AL (1991), The MOS Social Support Survey. Soc
Sci Med 32:705 Y 714
Smith L, Calkins SD, Keane SP, Anastopoulos AD, Shelton TL (2004),
Predicting stability and change in toddler behavior problems:
contributions of maternal behavior and child gender. Dev Psychol
40:29 Y 42
Zeanah CHJ (2000), Handbook of Infant Mental Health, 2nd ed. New York:
The Guilford Press

Comparison of Complementary and Alternative Medicine Use: Reasons and Motivations Between Two Tertiary
Children_s Hospitals D.R. Cincotta, N.W. Crawford, A. Lim, N.E. Cranswick, S. Skull, M. South, C.V.E. Powell

Aims: To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and
alternative medicine (CAM) use between two tertiary children_s hospitals. Methodology: A study, using a face-to-face questionnaire, of
500 children attending the University Hospital of Wales, Cardiff, UK, was compared to an identical study of 503 children
attending the Royal Children_s Hospital, Melbourne, Australia. Results: One year CAM use in Cardiff was lower than Melbourne
(41% v 51%; OR = 0.67, 95% CI 0.52j0.85), reflected in non-medicinal use (OR = 0.41, 95% CI 0.29 Y 0.58), and general
paediatric outpatients (OR = 0.38,95% CI 0.21 Y 0.67). Compared to Melbourne, factors associated with lower CAM use
in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44 Y 0.77) or nontertiary educated parents (mother: OR =
0.54, 95% CI 0.38 Y 0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18 Y 0.51) and herbs (OR = 0.49, 95%
CI 0.34 Y 0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06 Y 0.37), and naturopaths (OR = 0.08, 95% CI 0.02 Y 0.33),
but saw more reflexologists (OR = 3.33, 95% CI 1.08 Y 10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92,
95% CI 1.03 Y 3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27 Y 0.73). Most CAM was self-initiated (by parent) in
Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31 Y 0.68). Non-
disclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent
medicinal CAM use in inpatient notes (0/21 v 2/22). Conclusions: The differences in CAM use may reflect variation in
sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor
communication highlights the importance of local policy development. Archives of Disease in Childhood 2006;91:153 Y 158.

858 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:7, JULY 2006

Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.