Measures of Infant Behavioral and Physiological State Regulation Predict 54-Month Behavior Problems, 2011

A R T I C L E
MEASURES OF INFANT BEHAVIORAL AND

PHYSIOLOGICAL STATE REGULATION PREDICT 54-MONTH
BEHAVIOR PROBLEMS
LOURDES P. DALE, EMILY A. O’HARA, RACHEL SCHEIN, LORINN INSERRA,

JULIE KEEN, MARCI FLORES
University of Hartford
STEPHEN W. PORGES
University of Illinois at Chicago
ABSTRACT: This study investigated whether measures of infant temperament, regulatory disorders, and
physiological reactivity and concurrent measures of family environment were predictors of child behavior
problems at 54 months of age. The sample consisted of 23 children–mother dyads. The sample recruitment
strategy emphasized testing both typical and fussy/difficult infants at 9 months of age. Children were
categorized into low and high behavioral problem groups at 54 months of age. The children in the high
behavioral problem group were more likely at 9 months to have been temperamentally difficult, to have been
classified as regulatory disordered, and to have displayed respiratory sinus arrhythmia (RSA) regulation
difficulties. These children also were more likely to come from families described as less cohesive and
providing less focus on active/recreational activities when the children were 54 months old. A logistic
regression analysis, including only the 9-month infant measures (i.e., difficultness, regulatory disorders
classification, and RSA regulation), resulted in a significant model with 100.0% accurate classification into
high or low behavioral problem groups. Data suggest that infant measures of behavioral and physiological
state regulation may be early indicators of child behavior problems, especially internalizing problems.
* * *
During childhood, some children exhibit significant behavior problems such as aggres-
sion, social withdrawal, anxiety, depression, and somatic complaints. If behavior problems are
Research described in this article was supported, in part, by National Institute of Child Health and Human
Development Grants HD 22628 and HD 53570 and by Maternal and Child Health Bureau Grant MCH 240622
to Stephen W. Porges. Portions of this article were presented at the November 2007 21st annual Connecticut
Psychological Association Convention, Windsor, CT. This article is dedicated to the memory of Stanley I.
Greenspan, who together with Stephen W. Porges, began this research project on the development of infants with
regulatory disorders. We thank Jane A. Doussard-Roosevelt, Patricia E. Suess, Heidi Lee, and Dionne Dobbins
for help with data collection. We are grateful to the children and mothers whose continued cooperation made this
study possible.
Direct correspondence to: Lourdes P. Dale, Department of Psychology, East Hall 117B, University of Hartford,
200 Bloomfield Avenue, West Hartford, CT 06117; e-mail: dale@hartford.edu
INFANT MENTAL HEALTH JOURNAL, Vol. 32(4), 473–486 (2011)

C 2011 Michigan Association for Infant Mental Health
View this article online at wileyonlinelibrary.com.

DOI: 10.1002/imhj.20306
473
474 • L.P. Dale et al.
expressed in the school environment, they may interfere with the child’s ability to deal with
both social and cognitive challenges. For example, Fish, Jacquet, and Frye (2002) found that
preschool children with fewer behavioral problems had better language skills. In addition to the
potential impact on school experiences, childhood behavioral problems also may interfere with
maternal relationships and negatively influence the home environment (Mullineaux, Deater-
Deckard, Petrill, & Thompson, 2009). Therefore, the early identification of children at risk for
behavior problems is critical in developing appropriate strategies to optimize social and cognitive
development.
Research has explored the relationship between later behavioral problems and temperament.
Thomas, Chess, and Birch (1968) asked parents to describe their infants’ behaviors and used
this information to categorize the children as easy babies, difficult babies, or slow-to-warm-up
babies. This categorization was helpful and clinically relevant since they found that difficult
temperament would be a determinant of later behavior problems (Thomas & Chess, 1982).
However, it was not always possible to categorize an infant within a temperament category
because each “temperament” required the expression of several specific behavioral dimensions.
For example, the difficult babies were described as irregular in their bodily functions and routines,
slow to adjust to new experiences, and more likely to react negatively and intensely to novel
events and stimuli. Given the range of dimensions in this and the other two categories, it is not
surprising that 35% of their original sample did not fit neatly into any of the three categories.
The parent-report measures of temperament that followed the groundbreaking work of
Thomas et al. (1968) assessed children along various dimensions of temperament, particu-
larly those related to the difficult child. For example, the Infant Characteristics Questionnaire
(ICQ) developed by Bates, Freeland, and Lounsbury (1979) focused on the four factors of
Fussy/Difficult, Unadaptable, Dull, and Unpredictable. The Infant Behavioral Questionnaire
(IBQ; Rothbart, 1981) also tapped the dimensions of temperament identified by Thomas et al.
(1968), along with other aspects of reactivity and self-regulation. Thus, the IBQ focused on the
child’s activity level, smiling and laughter, fear, distress to limitations, soothability, and duration
of orienting.
Research using the ICQ and the IBQ, as well as other measures, has been useful in es-
tablishing a relationship between temperament and the development of behavior problems. For
example, Putnam, Rothbart, and Garstein (2008) found that children who at 4 months dis-
played high levels of negative affect were more likely to later have difficulties with attention
and inhibitory control and to avoid interactions with peers their own age. Other research also
has linked early temperament and the development of behavioral problems (e.g., Andersson &
Sommerfelt, 1999; Guerin, Gottfried, & Thomas, 1997; Stams, Juffer, & van IJzendoom, 2002)
and more specifically, externalizing behaviors. For example, Bradley and Corwyn (2008) found
that children with difficult temperaments exhibited problematic externalizing behaviors in their
social and physical environments.
These findings are consistent with the results of longitudinal research that has suggested
that specific early temperamental qualities may relate to the development of later behavioral
problems. Children who at 3 years of age were characterized as having a lack of control of their
behaviors were likely to experience both internalizing problems as adolescents and externalizing
problems (e.g., hyperactivity and attentional problems) in late childhood and adolescence (Caspi,
Henry, McGee, Moffitt, & Silva, 1995). A follow-up of this sample (Caspi et al., 2003) found
that adults (age 26) who had been categorized as “undercontrolled” (i.e., impulsive, restless,
distractible, emotionally labile, and negativistic) as 3-year-olds were more likely to exhibit
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Early Indicators of Child Behavior Problems • 475
negative emotion, be intolerant, get easily upset, overreact to minor events, and feel mistreated or
betrayed by others whereas the adults who as 3-year-olds had been categorized as inhibited (i.e.,
socially reticent, fearful, and easily upset) were more likely to be nonassertive and overcontrolled
by others, and take little pleasure in life. These studies have suggested that early temperament
may predict the behaviors, thoughts, and feelings reported by adults.
Consistent with the definition of temperament provided by Rothbart and Bates (1998) as
“constitutionally based individual differences in emotional, motor, and attentional reactivity and
self-regulation” (p. 109), researchers have explored the relationship between temperament and
physiological measures such as respiratory sinus arrhythmia (RSA) as a measure of cardiac vagal
tone. The quantification RSA, a component of heart rate variability, provides an opportunity
to dynamically monitor the changing vagal regulation of the heart. RSA is characterized by
a rhythmic increase and decrease in heart rate associated with frequencies of spontaneous
breathing. Since respiration “gates” the vagal efferent influence to the heart by decreasing vagal
activity during inspiration and reinstating vagal activity during expiration, the amplitude of RSA
provides a functional estimate of cardiac vagal tone.
Early measures of baseline cardiac vagal tone have been reported to be related to concurrent
temperament (e.g., Porges, Doussard-Roosevelt, Portales, & Suess, 1994) and the expression
of behavior problems (e.g., Porges et al., 1994). For example, Eisenberg et al. (1995) reported
that children aged 3 to 4 years with higher vagal tone were more assertive in defending their
possessions and territory. In addition, El-Sheikh, Erath, and Keller (2007) found that children
(8–9 years) who exhibited lower vagal tone were at increased risk of developing externalizing
problems and depressive symptoms.
Consistent with the focus by Rothbart (1981) on exploring “individual differences in reac-
tivity and self-regulation” (p. 569), several studies have focused on the regulation of RSA. By
quantifying RSA prior to and during a mental development task, it is possible to monitor vagal
inhibition (i.e., regulation of the vagal brake). Optimally, during mental challenges, there is a
reduction of vagal inhibition on the heart that raises heart rate to support the metabolic demands
associated with the increased cognitive demands. Graziano, Keane, and Calkins (2007) studied
the relation between vagal regulation and children’s social competence including social skills,
peer status, and behavioral problems in children 5 to 6 years old. They reported that children who
exhibited greater RSA suppression during the cognitive tasks, consistent with the hypothesized
relation between regulation of the vagal brake and positive social behavior (Porges, Doussard-
Roosevelt, Portales, & Greenspan, 1996), were more likely to obtain higher social preference
and social skills scores and more likely to be nominated by peers as someone who “shares.”
In addition, males with higher levels of RSA suppression exhibited less behavior problems and
were more socially approachable.
Although removal of the vagal “brake” has been a marker of appropriate autonomic support
for various cognitive challenges, there have been reports that individuals at risk for behavioral
and psychiatric disorders may either suppress vagal regulation of the heart too much or not at
all. Atypical vagal regulation has been reported to affect the regulation of social behavior and
to be related to early temperamental difficulties and later behavioral problems (e.g., Calkins,
Graziano, & Keane, 2007; Hastings et al., 2008; Porges et al., 1996).
Regulatory disorders (RD), a diagnostic category for infants and toddlers (ZERO TO
THREE, 2005), have been associated with temperamental difficulties and cardiac vagal tone
(Dale, Keen, O’Hara, & Porges, 2011) and have been proposed as a precursor to behavioral
problems. The conceptualization of RD has evolved since it was initially proposed. DeGangi,
DiPietro, Greenspan, and Porges (1991) postulated that infants with RD needed to meet at least
two diagnostic criteria that include difficulties with sleeping, consoling, feeding, and hyper-
arousal. The ZERO TO THREE diagnostic classification system (1994) proposed that clinical
criteria for RD include behavioral patterns (i.e., sleep and feeding problems) as well as difficulty
with sensory, sensorimotor, and organizational processing that greatly impact the child’s func-
tioning. While this version of the ZERO TO THREE diagnostic system has suggested that there
were various subtypes of RD, the more recent version of ZERO TO THREE diagnostic system
(2005) does not include criteria for RD subtypes because of lack of supporting research.
Additional research (DeGangi, Breinbauer, Doussard-Roosevelt, Porges, & Greenspan,
2000) has suggested that since sleep difficulties usually resolve in infancy for most children, they
should be excluded from the diagnostic criteria. This suggestion is consistent with literature that
has indicated that only a small percentage of children with infant-onset sleep difficulties continue
to have sleep difficulties in later childhood. For example, a longitudinal study assessing sleep
problems during first year of life up until 4 years found that the majority of children reported
to have a sleeping problem during the first year of life were reported as nonproblematic over
the course of the study (Gaylor, Burnham, Goodlin-Jones, & Anders, 2005). Although sleep
difficulties may be conceptualized as being separate from RD, Lam, Hiscock, and Wake (2003).
suggested that children (not diagnosed with RD) with persistent or recurrent sleep difficulties
from infancy to the preschool years may be at increased risk of developing child behavioral
problems. While both persistent sleep difficulties and RD may relate to the development of
behavioral problems, this article focuses on RD as a potential negative factor.
Previous research on RD (DeGangi, Porges, Sickel, & Greenspan, 1993) comparing the
developmental outcome of infants with and without RD has found that 8 of 9 infants with RD had
emotional and behavioral, sensorimotor, and developmental deficits when they were evaluated
at 4 years of age. Within the RD group, the infants rated as more temperamentally difficult and
who exhibited higher baseline cardiac vagal tone were more likely to have behavioral difficulties
at 4 years. DeGangi et al. (2000) supported the relationship between early regulatory difficulties
during infancy and later outcome. Specifically, they reported that children with early regulatory
difficulties were at risk of developing later emotional/behavioral, language, perceptual, and
sensory integrative difficulties in the preschool years. These studies have suggested that it is
important to consider the important potential covariation between temperamental qualities that
characterize behavioral regulation (e.g., difficultness) and physiological regulation (e.g., cardiac
vagal tone) when investigating the developmental outcome of infants diagnosed with RD.
From a family systems perspective (Haley, 1976; Minuchin, 1974), the functioning of the
child and development of behavior problems are dependent on how well the child fits within a
particular environment. The appropriateness of a child’s social behavior may either impact on or
be modified by the family environment. Family environment features, as evaluated by the Family
Environment Scale (FES; Moos & Moos, 1986), have been found to be related to child referral
for school behavior problems (Searight, Searight, & Scott, 1987). Families with children having
school behavior problems are described as emphasizing more morality/religion, organization,
and control, and less intellectual/cultural and social/recreational activities. Whiteside-Mansell,
Bradley, Casey, Fussell, and Conners-Burrow (2009), in a longitudinal study, found that child
temperament moderates the impact of family discord and externalizing behaviors.
The research described earlier has suggested that various infant qualities such as diffi-
cultness, physiological regulation, and family environment independently contribute to the
development of behavior problems; however, we are unaware of any study that incorporates
all three qualities into one study to determine their relative and shared impact on behavioral
development. The current study, which was conducted in response to this gap in the literature,
includes mother–child dyads that were part of a longitudinal study in which children were eval-
uated at 9, 20, 36, and 54 months of age. The study represents secondary analyses of data from
the 54-month follow-up and data from earlier stages of development that have been previously
reported. For example, Porges et al. (1996) indicated that children with behavioral problems at
3 years of age were likely to have had difficulty with 9-month regulation of RSA. Interestingly,
in this study, 9-month child difficultness was not predictive of 3-year behavioral problems.
In the current article, data were analyzed to determine whether children who had more
behavior problems at 54 months differed on the 9-month assessments of RD as currently con-
ceptualized. Thus, previously collected data were recoded to determine which children met the
criteria for RD. This variable along with infant temperament (i.e., difficultness and unadaptabil-
ity) and regulation of RSA were entered in regression analyses as predictors of 54-month child
behavior problems. Given that research by Pevalin, Wade, and Brannigan (2003) has suggested
that family environment may begin to play a greater role at 4 years of age, information regarding
the 54-month family environment also was entered into the analyses. Analyses were structured
to test the hypothesis that the children with the most behavioral problems at 54 months would
have poorer 9-month assessments (i.e., characterized by higher difficultness scores, less RSA
regulation, and more likely to be classified as RD). In addition, given the findings by Searight,
Searight, and Scott (1987), it was hypothesized that families who included children with the
most behavioral problems would emphasize more morality/religion, organization, and control,
and less social/recreational activities. Based on our clinical insights, we suspected that these
families also would place less emphasis on cohesion and expressiveness.
METHOD
Participants
The participants evaluated in this study were part of a longitudinal investigation that assessed
development at 9, 20, 36, and 54 months of age. Participants described in the current study were
the 23 children (12 males, 11 females) and their parents who returned completed questionnaires
when their children were 54 months. All infants were born full-term without a major medical
complication and with an average birth weight of 3,462 grams (SD = 486). The sample consisted
of 10 children who were firstborn. The majority of participants were Caucasian.
Procedures
Participants were recruited from the metropolitan Washington, DC area via advertisements in
local doctors’ offices and newspapers inviting mothers of 7- to 9-month-old infants to participate
in the research project. Separate advertisements recruited mothers with difficult infants and
mothers with typical nondifficult infants to ensure a broad range of infant behavior.
At 9 months of age, the infants were evaluated with the Mental Development Index (MDI)
and Motor Development Index (PDI) of the Bayley Scales of Infant Development (Bayley,
1969). Scores ranged from 91 to 150 (M = 122.6, SD = 18.3) on the MDI and from 69 to 144
(M = 107.5, SD = 18.6) on the PDI. At the time of the 9-month laboratory session, the mothers
were between 22 and 39 years of age (M = 32.61, SD = 4.24) and had an average of 16.30
years of education (SD = 1.89). Fathers were between 23 and 44 years of age (M = 33.74,
SD = 5.058) and had an average education of 16.96 years (SD = 2.53).
During the 9-month session, after informed consent was obtained, electrodes were placed on
the child, and heart rate data were collected during a baseline period (i.e., child sat on mother’s
lap while watching a video) and during the Bayley MDI. The 54-month data were obtained via
questionnaires that were sent to the parents’ homes, completed, and mailed back.
Behavioral Constructs and Measures

The 54-month measures. The 54-month child behavior problems were assessed with the Child
Behavior Checklist/4–18 (CBCL/4–18; Achenbach, 1991). The CBCL/4–18 is an 89-item in-
strument completed by the parent, who rates the child’s behavior on a Likert scale of 0 (not true),
1 (somewhat or sometimes true), and 2 (very true or often true). Achenbach (1991) reported high
reliability and validity (test-retest reliability = 0.87–0.89; interparent agreement = 0.74–0.78;
construct validity = 0.59–0.88). In the current study, since there were no a priori hypotheses
regarding internalizing and externalizing problems, analyses were conducted using only total
behavioral problems scale as the outcome variable. Higher scores on the Total Behavior Prob-
lems scale indicate greater behavioral difficulties. As recommended by the scale developers,
statistical analyses were conducted on the raw scores, and T scores were used to provide a
clinical interpretation of the raw scores.
Family environment was assessed via the Family Environment Scale (FES; Moos & Moos,
1986). The FES includes 10 subscales organized according to three general dimensions of
relationship, personal growth, and system maintenance. Given the age of the children, only the
subscales viewed as age relevant were included. Specifically, the current study focused on the
Cohesion, Expressiveness, and Conflict subscales of the relationship dimension, the Active-
Recreational Orientation and Moral-Religious subscales of the personal growth dimension, and
the Organization and Control subscales of the system maintenance dimension as reported by
parents. Reliability has been found to range from 0.61 to 0.78 (Moos & Moos, 1986).
The 9-month measures. Infant temperament (i.e., difficultness and unadaptability) was assessed
with the 6-month version of the Infant Characteristics Questionnaire (ICQ; Bates et al., 1979).
For the ICQ, higher scale scores indicate more problematic characteristics.
Each infant was evaluated at 9 months for RD. RD was evaluated with the Regulatory
Disorders Checklist (RDC; Dale, Keen, & Porges, 2009), a diagnostic checklist that assesses
RD characteristics in infants and young children. The RDC defines RD consistent with the
features described by DeGangi et al. (2000). The RDC is completed by researchers in re-
sponse to information provided by each child’s parents. The RDC evaluates each child on the
two primary domains that define RD: (a) the infant’s ability to self-regulate body states and
(b) the infant’s ability to organize and to cope with environmental stimuli. In addition, the RDC
includes information about other developmental difficulties such as hyperactivity, attentional
difficulty, sleep disturbance, poor muscle tone, motor delays, language delays, and mental de-
velopment delays. In the current study, the RDC used the 9-month infant assessments to partition
the sample into two groups: RD or non-regulatory-disordered (NRD).
Quantification of 9-month heart rate and RSA. The ECG was monitored via three Ag-AgCl
placed on the infant’s chest. The output of the ECG amplifier was stored on a Vetter C-4 FM tape
recorder (A.R. Vetter; Rebersburg, PA). Data were quantified offline by replaying the tapes into
the Vagal Tone Monitor (Delta-Biometrics, Bethesda, MD). The vagal tone monitor detected the
peak of the R-wave with 1-ms accuracy and timed sequential heart periods to the nearest ms.
The sequential heart periods were stored in a file on a computer. The amplitude of RSA was
assessed to provide an accurate description of impact on beat-to-beat heart rate by the nucleus
ambiguus branch of the vagus nerve (Porges, 1985, 1995).
MXedit software (Delta-Biometrics) was used to visually display the heart period data, edit
outliers, and quantify the heart period and the amplitude of RSA. MXedit incorporates the Porges
(1985) method of calculating the amplitude of RSA. This method contains a detrending algorithm
to remove from the heart rate pattern the variance associated with the complex aperiodic baseline
and oscillations slower than RSA. The detrending algorithm requires heart period values (i.e.,
the time between successive heart beats) to be measured with ms accuracy and includes the
resampling of the heart period data every 250 ms, removal of trend and slow oscillations with
a moving polynomial filter (3rd order 21-point), and the extraction of RSA with a band-pass
filter (.24–1.04 Hz). The analysis represents the variance of RSA reported in natural logarithmic
units. In this study, each heart rate parameter (i.e., heart period and RSA) was calculated for
sequential 30-second epochs within each condition (i.e., 3 min during the baseline condition and
7 min during the Baley MDI assessment). The mean of the epochs was used in the data analyses.
Heart rate parameters were assessed only during the 9-month session.
RESULTS
Comparison of Outcome Groups
Raw scores on the 54-month CBCL Total Behavioral Problems scale ranged from 0 to 43
(M = 19.28, SD = 13.63). As evident in Figure 1, the scores formed a binomial distribution, with
14 participants categorized as a low behavioral problems group (scores of 0–19; 6 males,
8 females) and 9 participants categorized as a high behavioral problems group (scores of 28–
43). The split in the two groups corresponded with a t value of 50, the mean for the normative
sample. Within the high behavioral problems group, t scores identified 1 male child in the clinical
range and 2 female children in the borderline range. The groups did not differ on gender, χ 2 (1,
n = 23) = .35, p = .68. Of note, in this small sample, the high behavioral problems group was
almost evenly split in terms of gender (i.e., 5 males, 4 females) and birth order (i.e., 4 of the 9
were firstborn).
Although no a priori hypotheses were proposed, the high behavioral problem group was
further investigated to determine if any of the children within this group were in the clinical
or borderline range for internalizing and/or externalizing problems. Inspection of the high
behavioral problem group identified that all 9 children (5 males, 4 females) were in the borderline
or clinical range for internalizing problems, and 4 children (2 males, 2 females) in the borderline
or clinical range for externalizing problems. In contrast, in the low behavioral problem group,
only 1 child was in the borderline range for internalizing problems, and no child was in the
borderline or clinical range for externalizing problems.
Table 1 illustrates statistical contrasts for the 9-month infant and 54-month family variables
between the low and high behavioral problem groups. Although the groups did not differ
on the unadaptability dimension, the high behavioral problem group had significantly higher
difficultness scores, t(1, 20) = −2.21, p < .05. The 95% confidence intervals for the two groups
were 18.32 to 29.24 for high scorers and 13.85 to 20.72 for low scorers. Consistent with these
findings, effect size calculations indicated that this was a large effect (η2 = .19). In addition, the
FIGURE 1. The frequency of total behavioral problem scores for participants in the study display a binomial distribution.
high behavioral problem group included all 3 children (all firstborn males) who met the criteria
for RD at 9 months of age, χ 2 (1, n = 21) = 5.37, p < .05. The groups did not differ on the
Bayley Scales.
Although the groups did not differ on baseline RSA or magnitude of RSA reactivity, there
was a trend suggesting that the high behavioral problem group was more likely to increase RSA
during the 9-month MDI, χ 2 (1, n = 17) = 2.84, p = .09. Of the children in the high behavioral
problem group, only 2 of the 7 with complete RSA data exhibited the expected suppression of
RSA during the MDI. Post hoc analyses indicated that only 2 of the 8 children in the borderline or
clinical range of internalizing problems exhibited RSA suppression, χ 2 (1, n = 17) = 4.74, p <
.05. Although not statistically significant, χ 2 (1, n = 17) = 2.55, p = .11, note that neither of the 2
children in the borderline or clinical range of externalizing problems exhibited RSA suppression
and that none of the 9 children who exhibited RSA suppression were in the borderline or clinical
range of externalizing problems.
The high and low behavioral problem groups differed with regard to family environment.
Specifically, the high behavior problem group scored lower on the Family Cohesion scale, t(1,
21) = 2.07, p = .05. The 95% confidence intervals for the two groups were 6.33 to 8.78 for
the high group and 8.14 to 9.01 for the low group. Consistent with these findings, effect size
calculations indicated that this was a large effect (η2 = .17). In addition, the high problem group
TABLE 1. T-test Comparison of the 54-Month Behavior Problem Groups with Regard to 9-Month Child
Characteristics and 54-Month Family Environment
Low Scorers High Scorers

(n = 14) (n = 9)
M (SD) M (SD) t
9-month Characteristics
Difficultness 17.29 (5.95) 23.78 (7.10) −2.37∗
Unadaptability 10.50 (3.67) 12.89 (4.49) −1.40
Mental development 123.29 (20.89) 121.56 (14.40) 0.22
Motor development 106.57 (20.03) 108.89 (17.23) −0.29
Baseline RSA 4.08 (1.05) 3.93 (1.11) 0.77
RSA Reactivity −.27 (0.60) .23 (1.12) 0.24
Baseline HP 444.45 (40.63) 451.70 (25.45) 0.68
HP Reactivity 19.38 (24.91) 13.44 (33.05) 0.68
54-Month Family Environment
Cohesion 8.57 (0.76) 7.56 (1.59) 2.07†
Expressiveness 6.93 (1.77) 6.22 (1.39) 1.01
Conflict 4.00 (1.66) 3.22 (1.39) 1.16
Active-Recreational 6.64 (1.22) 4.78 (1.64) 3.13∗∗
Moral Religious 5.36 (2.90) 5.11 (2.42) 0.21
Organization 5.93 (2.30) 5.11 (2.52) 0.80
Control 4.50 (2.31) 4.22 (2.05) 0.29
RSA = respiratory sinus arrhythmia; HP = heart period.

∗ p < .05. ∗∗ p < .01. † p = .05.
scored lower on the Active-Recreational subscale, t(1, 21) = 2.65, p < .01. The 95% confidence
intervals for the two groups were 3.52 to 6.04 for high group and 5.94 to 7.35 for low group.
Consistent with these findings, effect size calculations indicated that this was a large effect
(η2 = .25). Thus, these findings suggest that parents of children with more behavioral prob-
lems may describe their family environments as being less cohesive and as emphasizing less
active/recreational recreational activities.
Post hoc analyses indicated that the families who placed less emphasis on active/recreational
activities were less likely to be cohesive, r(23) = .43, p < .05. In turn, families who were less
cohesive and placed less emphasis on active/recreational activities were more likely to include
children who were difficult at 9 months of age, r(23) = −.37, p = .08, and r(23) = −.54,
p < .01, respectively. Similarly, families who were less cohesive and placed less emphasis
on active/recreational activities were more likely to include children classified as regulatory
disordered at 9 months, r(23) = −.485, p < .05, and r(23) = −.379, p =.08, respectively,
although difficultness and the regulatory classification were not significantly correlated.
Predicting Behavioral Problems

Given that the grouping of children into behavioral problem groups was dichotomous, logistic
regression analyses evaluated models that predict group classification (i.e., low or high behav-
ioral problems groups) from the 9-month infant characteristics (i.e., infant difficultness, RD,
and RSA regulation) and 54-month family environment variables (i.e., Family Cohesion and
TABLE 2. Classification of Children into Behavioral Groups
Predicted
Regression Variables Low Scorer High Scorer %Correct
1 Difficultness, Observed Low Scorer 13 1 92.9

Regulatory High Scorer 3 6 66.7
Disorder,
Cohesion, Active/ χ 2 (4, n = 23) = 12.35, p < .05; with 82.6% accurate classification
Recreational
Activities

Regulatory
Disorder, High Scorer 0 7 100.0
Cohesion, Active/
Recreational χ 2 (5, n = 17) = 23.05, p < .001, with 100.0% accurate classification
Activities, RSA
Regulation

Regulatory High Scorer 0 7 100.0
Disorder, RSA
Regulation χ 2 (3, n = 17) = 23.04, p < .001, with 100.0% accurate classification
RSA = respiratory sinus arrhythmia.
Active/Recreational Activities subscales). Since 9-month physiological data were not available
for all children, three logistic regression analyses were run; the classification results from these
analyses are reported in Table 2.
The first analysis maximized the number of participants by including only the behavioral
variables (i.e., 9-month difficultness and RD classification and the 54-month variables of family
cohesion and focus on active/recreational activities). This analysis resulted in a significant model,
χ 2 (4, n = 23) = 12.35, p < .05, with 82.6% accurate classification. The second regression
restricted the sample to the 17 participants with complete data (i.e., RSA regulation and the
behavioral indicators used in the aforementioned analysis) resulted in a significant model, χ 2 (5,
n = 17) = 23.05, p < .001, with 100.0% accurate classification. A final regression, which only
included the 9-month infant data of difficultness, RD classification, and RSA regulation, resulted
in a significant model, χ 2 (3, n = 17) = 23.04, p < .001, with 100.0% accurate classification.
DISCUSSION
This longitudinal study investigated the potential impact of early child characteristics and con-
current family factors on the development of child behavior problems. We focused on identifying
subgroups of fussy/difficult and nondifficult infants. We were able to evaluate at 9 months of age
a nonrandom sample of infants with difficult temperaments. Infants who remain fussy/difficult
at 9 months represent a small percentage of normal births. The literature has reported that, at
3 months’ postpartum, approximately 20% of normal births fit this category (von Kries, Kalies,
& Papousek, 2006; Wurmser, Laubereau, Hermann, Papousek, & von Kries, 2001), with most of
these infants resolving fussiness by 6 months of age (Schmitt, 1981, 1986). Via our recruitment
strategy, we were able to identify infants who at 9 months of age had fussy/difficult features and
met the criteria for RD and at 54 months of age could be separated into low and high behavioral
problem groups based on their CBCL Total Behavioral Problem scores.
In the current study, both early parent perceptions of infant behavior and infant physiological
reactivity were indicators of a developmental progression leading to behavioral difficulties.
Consistent with the 36-month follow-up (Porges et al., 1996), children with poorer behavioral
outcomes at 54 months of age were less likely to have suppressed RSA during the MDI at
9 months. Of children in the high behavior problem group, only 2 exhibited at 9 months of age
the expected suppression of RSA during the MDI. Instead, most of the infants within this group
increased RSA, a response strategy that hypothetically would not physiologically support the
attentional demands required by the MDI. The optimal response during an attentional task is a
reduction in RSA, followed by a recovery to baseline. This withdrawal of vagal tone supports
the metabolic needs related to mental processing and provides a preparatory physiological state
associated with vigilance that enables physical movement if necessary.
Moreover, all 9 infants in the high behavior problem group were rated as being in the
borderline or clinical range on the Internalizing scale of the CBCL, and only 2 of the 8 children
in the borderline or clinical range of internalizing problems (with complete RSA data) exhibited
RSA suppression. These findings support hypotheses relating early developmental difficulties
in autonomic regulation to internalizing disorders and are consistent with findings suggesting
that atypical modulation of the “vagal brake” characterizes clinically vulnerable groups (Calkins
et al., 2007; Hastings et al., 2008).
Consistent with the observed deficit in vagal regulation during early childhood and per-
haps as an antecedent index of future psychiatric vulnerabilities, vagal regulation deficits have
been reported in adult psychiatric disorders such as depression (Rottenberg, Solomon, Gross,
& Gotlib, 2005) and borderline personality disorder (Austin, Riniolo, & Porges, 2007). For
example, Fonagy and Bateman (2008) conceptualized the vulnerability and development of bor-
derline personality disorder using neurobiology, attachment, emotional and cognitive processing,
and family constructs. Our current study supports the addition of vagal regulation deficits as
vulnerability and the inclusion of family constructs.
Consistent with research by Searight et al. (1987), families of children with more behavioral
problems were less likely to emphasize social and recreational activities. The families in our
study also reported less cohesion. Taken together, these findings suggest that temperamentally
difficult children may influence the level of cohesion and focus on active/recreational activities,
which in turn, rather than ameliorating the child’s disruptive behaviors, may provide greater
opportunities for the child to express behavioral problems. Alternatively, families who are less
cohesive and engage in fewer active/recreational activities may create environments that are less
supportive of the temperamental needs of the child and thus are more likely to have children
with behavioral problems. The importance of considering the bidirectional interaction between
temperament and family environment is consistent with research by Ramos, Guerin, Gottfried,
Bathurst, and Oliver (2005), which focused on family factors related to childhood behavioral
problems.
This study is not without limitations. The sample sizes, regardless of the attempt to spread the
range of individual differences during infancy, resulted in a design that may be underpowered. In
addition, although the recruitment strategy emphasized both difficult and nondifficult infants, we
know little about the stability of difficultness in behavioral and physiological regulation during
early infancy. Thus, we do not know if 9 months of age is the optimal time to identify stable
features that may lead to poor outcome. Finally, since these data represent the final follow-up
of a multiple-assessment longitudinal project, not all participants were available for follow-up,
and not all measures were available for all participants who were tested.
The second major limitation relates to the behavioral measures. The behavioral information
was obtained through parental report, which may be influenced by the parent’s perception of
appropriate behavior and well-being. For example, parents who are experiencing more stress
may be more likely to view their child’s temperament and behaviors as problematic. To address
this concern, future studies should supplement the parent reports with both direct interviews
with the parents and direct behavior observations of the children.
Results of this study are important for researchers and clinicians working with young
children and their families in the discipline of infant mental health. This study suggests that
children with early emotional and behavioral difficulties should be provided with more extensive
evaluations to assess temperamental characteristics, physiological regulation, and the presence of
RD. The obtained biobehavioral information should be discussed with the parents and integrated
into the treatment plan to help the parents to provide the family environment that may be the
most supportive of the child’s individual needs.
REFERENCES
Achenbach, T.M. (1991). Manual for the Child Behavior Checklists/4–18 and 1991 profile. Burlington:
University of Vermont, Department of Psychiatry.
Andersson, H.W., & Sommerfelt, K. (1999). Infant temperamental factors as predictors of problem behavior
and IQ at age 5 years: Interactional effects of biological and social risk factors. Child Study Journal,
29(3), 207–226.
Austin, M.A., Riniolo, T.C., & Porges, S.W. (2007). Borderline personality disorder and emotion regulation:
Insights from the polyvagal theory. Brain and Cognition, 65(1), 69–76.
Bates, J.E., Freeland, C.A., & Lounsbury, M.L. (1979). Measurement of infant difficultness. Child Devel-
opment, 50, 794–803.
Bayley, N. (1969). Bayley Scales of Infant Development: Birth to two years. New York: Psychological
Corporation.
Bradley, R.H., & Corwyn, R.F. (2008). Infant temperament, parenting, and externalizing behavior in first
grade: A test of the differential susceptibility hypothesis. Journal of Child Psychology and Psychiatry,
49(2), 124–131.
Calkins, S.D., Graziano, P.A., & Keane, S.P. (2007). Cardiac vagal regulation differentiates among children
at risk of behavior problems. Biological Psychology, 74(2), 144–153.
Caspi, A., Harrington, H., Milne, B., Amell, J.W., Theodore, R.F., & Moffitt, T.E. (2003). Children’s
behavioral styles at age 3 are linked to their adult personality traits at age 26. Journal of Personality,
71(4), 495–513.
Caspi, A., Henry, B., McGee, R.O., Moffitt, T.E., & Silva, P.A. (1995). Temperamental origins of child and
adolescent behavior problems: From age three to age fifteen. Child Development, 66, 55–68.
Dale, L.P., Keen, J., O’Hara, E.A., & Porges, S.W. (2011). Infant regulatory disorders: Temperamental,
physiological, and behavioral features. Journal of Developmental and Behavioral Pediatrics, 32(3),
216–224.
Dale, L.P., Keen, J., & Porges, S.W. (2009). Regulatory Disorders Checklist. Unpublished instrument.
DeGangi, G.A., Breinbauer, C., Doussard-Roosevelt, J., Porges, S., & Greenspan, S. (2000). Prediction
of childhood problems at three years in children experiencing disorders of regulation during infancy.
Infant Mental Health Journal, 21(3), 156–175.
DeGangi, G.A., DiPietro, J.A., Greenspan, S.I., & Porges, S.W. (1991). Psychophysiological characteristics
of the regulatory disordered. Infant Behavior & Development, 14, 37–50.
DeGangi, G.A., Porges, S.W., Sickel, R.Z., & Greenspan, S.I. (1993). Four-year follow-up of a sample of
regulatory disordered infants. Infant Mental Health Journal, 14(4), 330–343.
Eisenberg, N., Fabes, R.A., Murphy, B., Maszk, P., Smith, M., Karbon, M. (1995). The role of emotionality
and regulation in children’s social functioning: A longitudinal study. Child Development, 66(5),
1360–1384.
El-Sheikh, M., Erath, S.A., & Keller, P.S. (2007). Children’s sleep and adjustment: The moderating role
of vagal regulation. Journal of Sleep Research, 16, 396–405.
Fish, M., Jacquet, E., & Frye, H. (2002). Early development of low-income rural Appalachian children.
Rural Health Monograph, 2(1), 3–11.
Fonagy, P., & Bateman, A. (2008). The development of borderline personality disorder—A mentalizing
model. Journal of Personality Disorders, 22(1), 4–21.
Gaylor, E.E., Burnham, M.M., Goodlin-Jones, B.L., & Anders, T.F. (2005). A longitudinal follow-up
study of young children’s sleep patterns using a developmental classification system. Behavioral
Sleep Medicine, 3(1), 44–61.
Graziano, P.A., Keane, S.P., & Calkins, S.D. (2007). Cardiac vagal regulation and early peer status. Child
Development, 78(1), 264–278.
Guerin, D.W., Gottfried, A.W., & Thomas, C.W. (1997). Difficult temperament and behaviour problems:
A longitudinal study from 1.5 to 12 years. International Journal of Behavioral Development, 21(1),
71–90.
Haley, J. (1976). Problem-solving therapy. San Francisco: Jossey-Bass.
Hastings, P.D., Nuselovici, J.N., Utendale, W.T., Coutya, J., McShane, K.E., & Sullivan, C. (2008).
Applying the polyvagal theory to children’s emotion regulation: Social context, socialization, and
adjustment. Biological Psychology, 79(3), 299–306.
Lam, P., Hiscock, H., & Wake, M. (2003). Outcomes of infant sleep problems: A longitudinal study of
sleep, behavior, and maternal well-being. Pediatrics, 111(3), 203–207.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Moos, R.H., & Moos, B.S. (1986). Family Environment Scale Manual. Palo Alto, CA: Consulting
Psychologists Press.
Mullineaux, P.Y., Deater-Deckard, K., Petrill, S.A., & Thompson, L.A. (2009). Parenting and child be-
haviour problems: A longitudinal analysis of non-shared environment. Infant & Child Development,
18(2), 133–148.
Pevalin, D.J., Wade, T.J., & Brannigan, A. (2003). Parental assessment of early childhood development:
Biological and social covariates. Infant & Child Development, 12, 167–175.
Porges, S.W. (1985). Methods and apparatus for evaluating rhythmic oscillations in aperiodic physio-
logical response systems. U.S. Patent No. 4520944. Washington, DC: U.S. Patent and Trademark
Office.
Porges, S.W. (1995). Orienting a defensive world: Mammalian modifications of our evolution-
ary heritage. A polyvagal theory [Presidential Address 1994]. Psychophysiology, 32, 301–
318.
Porges, S.W., Doussard-Roosevelt, J.A., Portales, A.L., & Greenspan, S.I. (1996). Infant regulation of
the vagal “brake” predicts child behavior problems: A psychobiological model of social behavior.
Developmental Psychobiology, 29(8), 697–712.
Porges, S.W., Doussard-Roosevelt, J.A., Portales, A.L., & Suess, P.E. (1994). Cardiac vagal tone: Stability
and relation to difficultness in infants and 3-year olds. Developmental Psychobiology, 27(5), 289–300.
Putnam, S.P., Rothbart, M.K., & Garstein, M.A. (2008). Homotypic and heterotypic continuity of fine
grain temperament during infancy, toddlerhood, and early childhood. Infant & Child Development,
17(4), 387–405.
Ramos, M.C., Guerin, D.W., Gottfried, A.W., Bathurst, K., & Oliver, P.H. (2005). Family conflict and
children’s behavior problems: The moderating role of child temperament. Structural Equation
Modeling, 12(2), 278–298.
Rothbart, M.K. (1981). Measurement of temperament in infancy. Child Development, 52, 569–578.
Rothbart, M.K., & Bates, J.E. (1998). Temperament. In W. Damon & R.M. Lerner (Series Eds.) & N.
Eisenberg (Vol. Ed.), Handbook of child psychology: Vol. 3. Social, emotional, and personality
development (6th ed., pp. 99–166). New York: Wiley.
Rottenberg, J., Solomon, K., Gross, J.J., & Gotlib, I.H. (2005). Vagal withdrawal to a sad film predicts
subsequent recovery from depression. Psychophysiology, 42, 277–281.
Schmitt, B.D. (1981). Infants who do not sleep through the night. Developmental & Behavioral Pediatrics,
2(1), 20–23.
Schmitt, B.D. (1986). The prevention of sleep problems and colic. Pediatric Clinics of North America,
33(4), 763–774.
Searight, H.R., Searight, P.P., & Scott, E. (1987). Family environment of children with school behavior
problems. Psychological Reports, 60, 1263–1266.
Stams, J.M., Juffer, F., & van IJzendoom, M.H. (2002). Maternal sensitivity, infant attachment, and
temperament in early childhood predict adjustment in middle childhood: The case of adopted children
and their biologically unrelated parents. Developmental Psychology, 38(5), 806–821.
Thomas, A., & Chess, S. (1982). Temperament and follow-up to adulthood. In R. Porter & G.M. Collins
(Eds.), Temperamental differences in infants and young children. Symposium conducted at the
meeting of the CIBA Foundation, 89168-75. London: Pittman.
Thomas, A., Chess, S., & Birch, H.G. (1968). Temperament and behavior disorders in children. New York:
New York University Press.
von Kries, R., Kalies, H., & Papousek, M. (2006). Excessive crying beyond 3 months may herald other fea-
tures of multiple regulatory problems. Archives of Pediatric and Adolescent Medicine, 160, 508–511.
Whiteside-Mansell, L., Bradley, R.H., Casey, P.H., Fussell, J.J., & Conners-Burrow, N.A. (2009). Triple
risk: Do difficult temperament and family conflict increase the likelihood of behavioral maladjustment
in children born low birth weight and preterm? Journal of Pediatric Psychology, 34(4), 396–405.
Wurmser, H., Laubereau, B., Hermann, M., Papousek, M., & von Kries, R. (2001). Excessive infant
crying: Often not confined to the first 3 months of age. Early Human Development, 64, 1–6.
ZERO TO THREE/National Center for Clinical Infant Programs. (1994). Diagnostic Classification
0–3: Diagnostic Classification of Mental Health and Developmental Disorders in Infancy and Early
Childhood. Arlington, VA: Author.
ZERO TO THREE. (2005). Diagnostic Classification 0–3: Diagnostic Classification of Mental Health and
Developmental Disorders in Infancy and Early Childhood (Rev. ed.). Washington, DC: ZERO TO
THREE Press.

Measures of Infant Behavioral and Physiological State Regulation Predict 54-Month Behavior Problems, 2011

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Measures of Infant Behavioral and Physiological State Regulation Predict 54-Month Behavior Problems, 2011

Uploaded by

Copyright:

Available Formats

A R T I C L E

MEASURES OF INFANT BEHAVIORAL AND

LOURDES P. DALE, EMILY A. O’HARA, RACHEL SCHEIN, LORINN INSERRA,

INFANT MENTAL HEALTH JOURNAL, Vol. 32(4), 473–486 (2011)

View this article online at wileyonlinelibrary.com.

Behavioral Constructs and Measures

Low Scorers High Scorers

RSA = respiratory sinus arrhythmia; HP = heart period.

Predicting Behavioral Problems

TABLE 2. Classification of Children into Behavioral Groups

Regression Variables Low Scorer High Scorer %Correct

1 Difficultness, Observed Low Scorer 13 1 92.9

2 Difficultness, Observed Low Scorer 10 0 100.0

3 Difficultness, Observed Low Scorer 10 0 100.0

RSA = respiratory sinus arrhythmia.

You might also like