Integrated, Family-based, Partial Hospital Treatment for Complex Pediatric Illness.

This paper describes a unique treatment program for complex pediatric illness. The Hasbro Children's Partial Hospital Program uses a family systems orientation, integrated care, and a partial hospital setting to treat children with a wide range of pediatric illnesses that have failed outpatient and inpatient treatments. We have treated more than 2000 children with at least 80 different ICD-9 diagnoses. The multidisciplinary treatment team functions as a meta-family for children and their families who present with illness and family beliefs that impede successful outcomes with standard care. The three features: family systems orientation, integrated care, and partial hospital setting, hopefully interact to create an environment that helps families expand and modify their explanatory models regarding participating in effective medical care. The goal of treatment is for both children and their parents to feel empowered to take control of the illness. Parents completing standardized measures at intake describe their children and families as experiencing significant emotional distress, low levels of general family functioning, and poor quality of life. Although the children are described as having distinct behavioral differences, the families are described as responding to the experience of a seriously ill child in similar ways. A treatment program that addresses the noncategorical aspects of how families respond to illness while addressing the specific diseases of the children can allow children and their families to respond favorably to treatment.

En este artículo se describe un programa de tratamiento único para las enfermedades pediátricas complejas. El programa hospitalario parcial de Hasbro Children's Hospital utiliza una orientación de sistemas familiares, atención integrada y un formato de hospital parcial para tratar a niños con una amplia variedad de enfermedades pediátricas a quienes los tratamientos ambulatorios y con internación no les han dado resultado. Hemos tratado a más de 2000 niños con, por lo menos, 80 diagnósticos diferentes de ICD-9. El equipo de tratamiento multidiscplinario funciona como una metafamilia para los niños y sus familiares que presentan una enfermedad y creencias familiares que impiden resultados favorables con la atención convencional. Las tres características: orientación de sistemas familiares, atención integrada y formato de hospital parcial interactuarían para crear un entorno que ayude a las familias a ampliar y modificar sus modelos explicativos con respecto a participar en una atención médica eficaz. El objetivo del tratamiento es que tanto los niños como sus padres se sientan facultados para tomar las riendas de la enfermedad. Los padres que se someten a evaluaciones estandarizadas en el ingreso explican que sus hijos y familias sufren distrés emocional considerable, niveles bajos de funcionamiento familiar general y una mala calidad de vida. Si bien se describe a los niños como personas con diferencias conductuales definidas, las familias se describen como personas que responden a la experiencia de un niño gravemente enfermo de formas similares. Un programa de tratamiento que aborde los aspectos no categóricos de las formas en las que las familias responden a la enfermedad y que, al mismo tiempo, aborde las enfermedades específicas de los niños puede permitir a los niños y a sus familias responder favorablemente al tratamiento.

Developmental Origins of Rumination in Middle Childhood: The Roles of Early Temperament and Positive Parenting.

Rumination, a thinking style characterized by a repetitive inward focus on negative cognitions, has been linked to internalizing disorders, particularly depression. Moreover, research suggests that rumination may be a cognitive vulnerability that predisposes individuals to psychopathology. Surprisingly little is known, however, about the etiology and development of rumination. The present study examined the role of specific components of child temperamental negative emotionality (sadness, fear, anger) and effortful control (inhibition), as well as parenting behaviors during early childhood on the development of rumination in middle childhood. Early childhood (age 3) temperament and parenting behaviors were assessed observationally and rumination was self-reported in middle childhood (age 9) in a large community sample (N = 425; 47.1% female). Two significant interactions emerged. First, temperamental anger interacted with inhibitory control (IC) such that high anger and low IC predicted higher levels of rumination, whereas low anger and low IC predicted lower levels of rumination. Second, IC interacted with parenting such that children with low IC and positive parenting had lower levels of rumination. In contrast, children with high IC reported similar levels of rumination regardless of parenting quality. Overall, these findings highlight the interplay of early IC with temperamental anger and positive parenting in the development of ruminative tendencies in middle childhood.

Early childhood cortisol reactivity moderates the effects of parent-child relationship quality on the development of children's temperament in early childhood.

Positive parenting has been related both to lower cortisol reactivity and more adaptive temperament traits in children, whereas elevated cortisol reactivity may be related to maladaptive temperament traits, such as higher negative emotionality (NE) and lower positive emotionality (PE). However, no studies have examined whether hypothalamic-pituitary-adrenal axis activity, as measured by cortisol reactivity, moderates the effect of the quality of the parent-child relationship on changes in temperament in early childhood. In this study, 126 3-year-olds were administered the Laboratory Temperament Assessment Battery (Lab-TAB; Goldsmith et al., 1995) as a measure of temperamental NE and PE. Salivary cortisol was collected from the child at 4 time points during this task. The primary parent and the child completed the Teaching Tasks battery (Egeland et al., 1995), from which the quality of the relationship was coded. At age 6, children completed the Lab-TAB again. From age 3 to 6, adjusting for age 3 PE or NE, a better quality relationship with their primary parent predicted decreases in NE for children with elevated cortisol reactivity and predicted increases in PE for children with low cortisol reactivity. Results have implications for our understanding of the interaction of biological stress systems and the parent-child relationship in the development of temperament in childhood.

Positive Parenting Interacts with Child Temperament and Negative Parenting to Predict Children's Socially Appropriate Behavior.

This study examined the effects of parents' positive and negative affect and behavior while interacting with their preschool child and the moderating role of child temperament in predicting children's subsequent difficulty with socially appropriate behavior around school-entry. Independent observational measures were used to assess child temperament (dysphoria; exuberance) and parenting at age 3, and multi-informant reports of child socially appropriate behavior were collected at age 6 (N = 219). Hierarchical multiple regression analyses revealed that children's temperamental dysphoria moderated the relationship between positive parenting and later socially appropriate behavior. High- and low-dysphoric children trended in opposite directions; highly dysphoric children experienced greater difficulty with socially appropriate behavior as levels of positive parenting increased, whereas low-dysphoric children experienced less difficulty with socially appropriate behavior with higher levels of positive parenting. There was also an interaction between positive and negative parenting, whereby the combination of elevated positive and negative parenting predicted children's later difficulty with socially appropriate behavior. The findings suggest that positive parenting interacts with early child temperament and negative parenting to impact the development of children's socially appropriate behavior.

Self-Reported and Observed Punitive Parenting Prospectively Predicts Increased Error-Related Brain Activity in Six-Year-Old Children.

The error-related negativity (ERN) is a negative deflection in the event-related potential (ERP) occurring approximately 50 ms after error commission at fronto-central electrode sites and is thought to reflect the activation of a generic error monitoring system. Several studies have reported an increased ERN in clinically anxious children, and suggest that anxious children are more sensitive to error commission--although the mechanisms underlying this association are not clear. We have previously found that punishing errors results in a larger ERN, an effect that persists after punishment ends. It is possible that learning-related experiences that impact sensitivity to errors may lead to an increased ERN. In particular, punitive parenting might sensitize children to errors and increase their ERN. We tested this possibility in the current study by prospectively examining the relationship between parenting style during early childhood and children's ERN approximately 3 years later. Initially, 295 parents and children (approximately 3 years old) participated in a structured observational measure of parenting behavior, and parents completed a self-report measure of parenting style. At a follow-up assessment approximately 3 years later, the ERN was elicited during a Go/No-Go task, and diagnostic interviews were completed with parents to assess child psychopathology. Results suggested that both observational measures of hostile parenting and self-report measures of authoritarian parenting style uniquely predicted a larger ERN in children 3 years later. We previously reported that children in this sample with anxiety disorders were characterized by an increased ERN. A mediation analysis indicated that ERN magnitude mediated the relationship between harsh parenting and child anxiety disorder. Results suggest that parenting may shape children's error processing through environmental conditioning and thereby risk for anxiety, although future work is needed to confirm this hypothesis.

Predictors of the onset of depression in young children: a multi-method, multi-informant longitudinal study from ages 3 to 6.

BACKGROUND: Despite growing interest in depression in young children, little is known about which variables predict the onset of depression in early childhood. We examined a range of predictors of the onset of depression diagnoses in a multi-method, multi-informant longitudinal study of a large community sample of young children from ages 3 to 6. METHODS: Predictors of the onset of depression at age 6 were drawn from five domains assessed when children were 3 years old: child psychopathology (assessed using a parent diagnostic interview), observed child temperament, teacher ratings of peer functioning, parental psychopathology (assessed using a diagnostic interview), and psychosocial environment (observed parental hostility, parent-reported family stressors, parental education). RESULTS: A number of variables predicted the onset of depression by age 6, including child history of anxiety disorders, child temperamental low inhibitory control, poor peer functioning, parental history of mood, anxiety, and substance use disorders, early and recent stressful life events, and less parental education. CONCLUSIONS: Predictors of the onset of depression in early childhood tend to be similar to those identified in older youth and adults, and support the feasibility of identifying children in greatest need for early intervention.

Effortful control and parenting: associations with HPA axis reactivity in early childhood.

While activation of the hypothalamic-pituitary-adrenal (HPA) axis is an adaptive response to stress, excessive HPA axis reactivity may be an important marker of childhood vulnerability to psychopathology. Parenting, including parent affect during parent-child interactions, may play an important role in shaping the developing HPA system; however, the association of parent affect may be moderated by child factors, especially children's emerging self-regulatory skills. We therefore tested the relationship between parent affectivity and 160 preschoolers' cortisol reactivity during a laboratory visit, examining children's effortful control (EC) as a moderator. Greater parent negative affectivity was related to greater initial and increasing cortisol over time, but only when children were low in EC. Higher parent positive affectivity was related to a higher baseline cortisol for children with low EC and lower baseline cortisol for children with high EC. Results indicate that children's EC moderates the extent to which parent affect shapes stress reactive systems in early childhood.

Child dopamine active transporter 1 genotype and parenting: evidence for evocative gene-environment correlations.

The dopamine active transporter 1 (DAT1) gene is implicated in psychopathology risk. Although the processes by which this gene exerts its effects on risk are poorly understood, a small body of research suggests that the DAT1 gene influences early emerging negative emotionality, a marker of children's psychopathology risk. As child negative emotionality evokes negative parenting practices, the DAT1 gene may also play a role in gene-environment correlations. To test this model, children (N = 365) were genotyped for the DAT1 gene and participated in standardized parent-child interaction tasks with their primary caregiver. The DAT1 gene 9-repeat variant was associated with child negative affect expressed toward the parent during parent-child interactions, and parents of children with a 9-repeat allele exhibited more hostility and lower guidance/engagement than parents of children without a 9-repeat allele. These gene-environment associations were partially mediated by child negative affect toward the parent. The findings implicate a specific polymorphism in eliciting negative parenting, suggesting that evocative associations play a role in elevating children's risk for emotional trajectories toward psychopathology risk.

Parenting and Child DRD4 Genotype Interact to Predict Children's Early Emerging Effortful Control.

Effortful control (EC), or the trait-like capacity to regulate dominant responses, has important implications for children's development. Although genetic factors and parenting likely influence EC, few studies have examined whether they interact to predict its development. This study examined whether the DRD4 exon III variable number tandem repeat polymorphism moderated the relation between parenting and children's EC. Three hundred and eighty-two 3-year-olds and primary caregivers completed behavioral tasks assessing children's EC and parenting. Children's DRD4 genotypes moderated the relation between parenting and EC: Children with at least one 7-repeat allele displayed lower EC in the context of negative parenting than children without this allele. These findings suggest opportunities for modifying early risk for low EC.

Correlates of the CBCL-dysregulation profile in preschool-aged children.

BACKGROUND: A growing literature indicates that the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) identifies youths with heightened risk for severe psychopathology, comorbidity, and impairment. However, this work has focused on school-age children and adolescents; no studies have examined whether preschool-aged children with the CBCL-DP exhibit a similar constellation of problems. METHOD: Using a community sample of preschoolers, we compared children with (N = 61) and without (N = 488) the CBCL-DP on a broad range of variables assessed using multiple methods. RESULTS: Univariate analyses revealed numerous differences between children with the CBCL-DP and their peers on psychiatric symptomatology, temperament, parenting behavior, and parental personality, psychopathology, and marital functioning. In multivariate analyses, children with the CBCL-DP exhibited greater temperamental negative affectivity and lower effortful control. They also had more depressive and oppositional defiant symptoms, as well as greater functional impairment. Parents of CBCL-DP children reported engaging in more punitive, controlling parenting behavior than parents of non-profile children. CONCLUSIONS: In a non-clinical sample of preschoolers, the CBCL-DP is associated with extensive emotional and behavioral dysregulation and maladaptive parenting.

Hypothalamic-pituitary-adrenal axis reactivity in the preschool-age offspring of depressed parents: moderation by early parenting.

The hypothalamic-pituitary-adrenal axis is thought to play a role in the pathogenesis of depression. In the study reported here, we tested the hypothesis that parenting behavior moderates the relation between parents' lifetime history of depression and their offspring's cortisol reactivity to a psychosocial stressor. We exposed 160 preschool-age children to stress-inducing laboratory tasks, during which we obtained four salivary cortisol samples. Parents completed clinical interviews and an observational parent-child interaction task. The results confirmed our hypothesis: The offspring who evidenced high and increasing cortisol levels were those whose parents had a history of depression and demonstrated hostility toward their child. This moderating effect was specific to offspring who were exposed to maternal depression during the first few years of life. As do findings in animals, results of this study underscore the importance of the early rearing environment in the intergenerational transmission of stress sensitivity.

The dopamine D2 receptor gene and depressive and anxious symptoms in childhood: associations and evidence for gene-environment correlation and gene-environment interaction.

OBJECTIVES: Research implicates the A1 allele of the dopamine D2 receptor gene (DRD2) Taq1A polymorphism in the development of depression and anxiety. Furthermore, recent papers suggest that children with A1 allele of this gene may receive less positive parenting, and that the effects of this gene on child symptoms may be moderated by parenting. We sought to replicate and extend these findings using behavioral measures in a nonclinical sample of young children. METHODS: In a sample of 473 preschool-aged children and their mothers, structured clinical interview measures and maternal reports of child symptoms were collected, and standardized observations of parent-child interactions were conducted. RESULTS: An association was detected between the DRD2 A1 allele and symptoms of depression and anxiety indexed using interview and parent report methods. As found in previous reports, children with the DRD2 A1 allele received less supportive parenting and displayed higher levels of negative emotionality during parent-child interactions. Tests of mediation and moderation were conducted. CONCLUSION: We found associations between the DRD2 A1 allele and early-emerging anxious and depressive symptoms in a community sample of preschool-aged children, and evidence of a gene-environment correlation and moderation of the main effect of child genotype on child symptoms by parenting.

Low Positive Affectivity and Behavioral Inhibition in Preschool-Age Children: A Replication and Extension of Previous Findings.

The present report replicates and extends our previous study using a laboratory assessment of child temperament and behavior to distinguish the affective component, low positive affect (PA), of the broader positive emotionality construct from behavioral inhibition (BI) in a larger, independent sample. Additionally, we examined whether laboratory-assessed traits could be distinguished on parent/teacher reports of related constructs. Low positive emotionality and BI share the core feature of low approach/engagement and are often not distinguished in the literature, despite presumed differences in underlying motivation. We examined these traits in novel and non-novel laboratory contexts. Similar to previous findings, we found that in novel situations, children with low PA and children with high BI exhibited similar levels of approach, and both groups exhibited lower approach than controls. In contrast, in non-novel situations, children with low PA exhibited significantly lower levels of approach than children with high BI and controls. Finally, we also found external evidence for the distinction between laboratory-defined low PA and high BI on parent and teacher reports of child temperament.

Differentiation Between Low Positive Affectivity and Behavioral Inhibition in Preschool-Age Children: A Comparison of Behavioral Approach in Novel and Non-Novel Contexts.

The temperament constructs of low positive affectivity (PA) and high behavioral inhibition (BI) overlap and are often not differentiated in the research literature. In particular, both constructs are characterized by low approach and engagement. However, current theoretical conceptualizations of these constructs suggest that low PA should be associated with low approach across most contexts, whereas BI should be associated with low approach only in novel situations. The present study used laboratory measures of child temperament and behavior to test these hypotheses in a sample of 100 preschool-age children. Results indicated that in novel situations, both lower positive affect and higher BI predicted low behavioral approach. However, in non-novel situations, only lower levels of positive affect predicted lower levels of approach; BI was not related to approach behavior in more familiar contexts. In conclusion, this study indicates that the overlap between the temperament traits of low PA and high BI is limited to novel contexts and that these constructs are distinguished by behavior in non-novel situations.

Ten-year stability of depressive personality disorder in depressed outpatients.

OBJECTIVE: The purpose of this study was to examine the long-term stability of depressive personality disorder. METHOD: The subjects included 142 outpatients with axis I depressive disorders at study entry; 73 had depressive personality disorder. The patients were assessed by using semistructured diagnostic interviews at baseline and in four follow-up evaluations at 2.5-year intervals over 10.0 years. Follow-up data were available for 127 (89.4%) of the patients. RESULTS: The 10.0-year stability of the diagnoses of depressive personality disorder was fair, and the rate of depressive personality disorder declined over time. The dimensional score was moderately stable over 10.0 years. Growth curve analyses revealed a sharp decline in the level of depressive personality disorder traits between the baseline and 2.5-year assessments, followed by a gradual linear decrease. Reductions in depressive personality disorder traits were associated with remission of the axis I depressive disorders. Finally, depressive personality disorder at baseline predicted the trajectory of depressive symptoms over time in patients with dysthymic disorder. CONCLUSIONS: Depressive personality disorder is moderately stable, particularly when assessed with a dimensional approach. However, the diagnosis rate and traits of depressive personality disorder tend to decline over time. The degree of stability for depressive personality disorder is comparable to that for the axis II disorders in the main text of DSM-IV. Finally, depressive personality disorder has prognostic implications for the course of axis I mood disorders, such as dysthymic disorder.

Predictors of response to treatment in children and adolescents with mood disorders.

Depression and bipolar disorder are frequently chronic disorders, with onset often beginning in childhood. Mood disorders are becoming more recognized in children and adolescents, and treatment of these disorders has received much attention, particularly in the past 10 years. Recent studies have demonstrated efficacy of antidepressant medications (particularly SSRIs) and specific psychotherapies (primarily CBT). Rates of remission (little or no symptoms) in these studies, however, have remained quite low (35% to 40% in most acute studies). Furthermore, recurrence is common in this population, and affects 40% to 50%. Early onset mood disorders are also associated with increased risk of developing other psychiatric disorders, substance abuse, and suicide, and having poor academic, work, and social functioning. The lifelong implications are serious. Identifying factors that may predict response to treatment, both in general and to specific treatments, may lead to improved outcomes for these patients. Unfortunately, studies have typically been inconsistent. Most studies do not identify demographic variables as predictive of outcome, although older age has been associated with poor prognosis in several studies. Psychosocial factors have yielded some results, particularly with regard to family environments. Generally, intact families with positive interaction styles and less dysfunction have been associated with better outcomes. Psychiatric disorders among parents not only predicts the development of the disorder, but is also associated with poorer prognosis. Finally, several clinical factors have been linked to poorer outcome in children and adolescents with mood disorders. More frequent episodes, increased severity (particularly suicidality and psychosis), and comorbid disorders are likely to lead to fewer recoveries, longer episodes, and increased rate of recurrence. Recent attention has focused on mediators and moderators of outcomes to treatment. In general, the theory is that enumerable factors contribute to the course of an individual's mood disorder, but that by identifying some of the variables that have more impact may allow for more specific or modified treatments to improve outcome. Many of the predictive factors explored in this article are examples of mediators and moderators that affect outcome. Each one alone may not provide definitive answers for predicting response to treatment, but each must be taken into account at the outset of treatment. It is clear that treatments must be individualized for each patient. Furthermore, selecting only one treatment exclusively for patients may hinder progress. The first step is to attempt to identify some of the underlying causes and the consequences of the disorder itself (i.e., decreased social interaction). The next step in successful treatment is to address both the causes and consequences of the disorder, through medication, psychotherapy, skills training, family intervention, or any other methods needed to assist the child to begin functioning better in all domains (social, academic, work, family, and so forth). Such a biopsychosocial approach to treatment of these disorders will likely improve overall outcome.