Cocaine exposure is associated with subtle compromises of infants' and mothers' social-emotional behavior and dyadic features of their interaction in the face-to-face still-face paradigm.

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

Prenatal drug exposure and maternal and infant feeding behaviour.

OBJECTIVE: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. METHODS: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. RESULTS: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants' feeding problems. CONCLUSIONS: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

Effects of acute sleep restriction on behavior, sustained attention, and response inhibition in children.

This study examined the effects of acute sleep restriction on the day-time behavior and performance of healthy children and adolescents. 82 participants (8 to 15 years of age) completed 5 nights of baseline sleep and were randomly assigned to Optimized (10 hr.) or Restricted (4 hr.) sleep for an overnight lab visit. Behavior, performance, and sleepiness were assessed the following day. Sleep restriction was associated with shorter daytime sleep latency, increased subjective sleepiness, and increased sleepy and inattentive behaviors but was not associated with increased hyperactive-impulsive behavior or impaired performance on tests of response inhibition and sustained attention. Results are discussed in terms of current theories regarding effects of inadequate or disturbed sleep among children and adolescents.

Extended nights, sleep loss, and recovery sleep in adolescents.

In summary, this study of sleep in adolescents on an atypical schedule of 18-hour nights showed marked but not unanticipated differences in sleep as function of prior sleep deprivation. Unanticipated was the evidence of "recovery" sleep in adolescents who not only were not sleep deprived, but who had been on a sleep "optimizing" schedule and had been awake for only 10 hours. Extended sleep beginning about 4 hours in advance of entrained sleep onset phase was not associated with a return of SWS, a finding coinciding with predictions from studies in adults. Finally, this study provides an indication that the homeostatic sleep/wake process becomes less robust or sleep responsive during adolescent development, a phenomenon that may influence the delay of sleep common in adolescents.

Infant mental health and variability of parental depression symptoms.

OBJECTIVE: To examine the course of mothers' depression symptoms in association with child and family functioning beyond that explained by diagnostic status. METHOD: A longitudinal high-risk design with 16 months of course-of-illness follow-up was used. Structured clinical and family interviews, direct observation of child social-emotional competence, and parent reports of child behavior problems were included. RESULTS: Parameters of maternal symptom patterns across time were associated with child and family functioning. Most of these effects remained when presence/absence of major depression diagnosis was covaried. CONCLUSIONS: The trajectory of symptoms over time is important to consider in studies of children at risk and may also help to inform how illness in infancy and early childhood is conceptualized.

Interpreting research on prenatal substance exposure in the context of multiple confounding factors.

Fetal exposure to specific drugs often occurs in the context of polydrug use, medical complications, and social/environmental risks. Early reports of severe developmental consequences of fetal exposure to illicit drugs, for example, cocaine, have largely been unsupported by recent studies that take these factors into account. Using a database of published studies on cocaine exposure, this article examines how confounding factors are controlled by recruitment and statistical strategies. Rather than attempting to reduce the impact of these factors, it is suggested that multiple risks in children's lives should be included in models of developmental outcomes along with drug exposure. Understanding the complexity of multiple risks in the child's environment and the subtlety of drug exposure effects can guide the choice of clinical treatment and intervention.

Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures?

STUDY OBJECTIVES: This study provides estimates of reliability for aggregated values from 1 to 7 recording nights for five commonly used actigraphic measures of sleep patterns, reliability as a function of night type (weeknight or weekend night), and stability of measures over several months. DESIGN AND SETTING: Data are from three studies that obtained 7 nights of actigraph data (using Mini Motionlogger actigraphs and associated validated algorithms [ASA]) on children and adolescents living at home on self-selected sleep-wake schedules. PARTICIPANTS: Participants were 169 children aged 12-60 months, and 55 adolescents aged 11-16 years. MEASUREMENTS AND RESULTS: Up to 28% of weekly recordings may be unacceptable for analysis in young participants because of illness, technical problems, and participant noncompliance; studies aiming to collect 5 nights of actigraph data should record for at least 1 full week. Reliability estimates for values aggregated over any 5 nights were adequate (> or = .70) for sleep start time, wake minutes, and sleep efficiency. Measures of sleep minutes and sleep period were less reliable and may require 7 or more nights for estimates of stable individual differences. Reliability for 1- or 2-night aggregates were poor for all measures. We found significant and high correlations between summer and fall session measures for all five variables when weekend nights were included. CONCLUSIONS: Five or more nights of usable recordings are required to obtain reliable actigraph measures of sleep for children and adolescents.

Intrinsic circadian period of adolescent humans measured in conditions of forced desynchrony.

Circadian timing was assessed with forced desynchrony (FD) in 10 healthy adolescents (five boys, five girls; mean age 13.7 years). Following 10 days of entrainment to a fixed light-dark (LD) schedule at home, participants were studied under dim light (<20 lux) in the laboratory. A 28-h schedule (FD) was imposed for 12 x 28-h cycles. Saliva was collected at 30- or 60-min intervals throughout; core temperature was measured in constant routines (CR) before and after FD. Intrinsic circadian period was estimated by linear regression using temperature minimum from CRs and dim-light salivary melatonin onsets and offsets from FD. Average intrinsic circadian period for core temperature (n = 7) was 24.30+/-0.20, for melatonin onset was 24.33+/-0.21, and for melatonin offset was 24.35+/-0.21. Intrinsic circadian period in every adolescent was greater than 24 h.

Maternal interaction patterns and preschool competence in high-risk children.

BACKGROUND: The influence of specific maternal interaction patterns as compensatory mechanisms in promoting development of medically high-risk children has been understudied. OBJECTIVES: To investigate the association of three maternal interaction patterns, maternal responsivity, involvement, and control style, with preschool competency in a medically heterogeneous sample. METHOD: Children (N= 184) and their mothers participating in a prospective longitudinal study were assessed in a laboratory protocol and home visit. The methods of measurement were maternal self-report, global rating scales, interview, and nationally standardized instruments. RESULTS: Evidence of a maternal compensatory mechanism was exhibited in mothers' higher involvement with their children who were born at high medical risk (F(1,183) = 6.26, p = .01). Mothers of the most competent children demonstrated higher maternal responsivity, involvement, and more appropriate control than mothers of children who were not as competent. In hierarchical regression models, the three maternal interaction patterns were significant predictors after perinatal risk and maternal education were controlled explaining 29-37% of the variance in child competence scores. CONCLUSION: These findings imply that differential child outcomes are associated with specific maternal interaction patterns. It suggests that a combination of diverse information revealed in specific maternal interaction pattern is needed to predict cognitive, linguistic, and problem-solving competencies. Future research should consider individual differences in mother-child interaction patterns in order to isolate their significance for optimal child development.

Nutrition intervention for weight gain in cystic fibrosis: a meta analysis.

OBJECTIVES: A meta analysis of the literature on treatment approaches to malnutrition in cystic fibrosis (CF) was conducted to evaluate the effectiveness of oral supplementation, enteral nutrition, parenteral nutrition, and behavioral intervention on weight gain before and after treatment. STUDY DESIGN: Eighteen studies were reviewed: four behavioral, six supplement, five enteral nutrition, and three parenteral nutrition. RESULTS: The weighted effect size for weight gain was large for each intervention: 1.51 behavioral, 1.62 oral, 1.78 enteral, and 2.20 parenteral intervention. All interventions produced a large effect for weight gain in patients with CF. A univariate analysis of variance indicated no significant difference among the four interventions, F(3, 17) = 0.87, p > 0.05. Effect size for calorie intake was also evaluated when data were available (N = 7 studies), yielding a sample size of three behavioral, two enteral, and two oral supplement studies. Analysis of variance indicated a significant effect for treatment, F(2,4) = 13.34, p < 0.05, with post hoc analysis indicating that the behavioral intervention had a greater effect size for calorie intake than oral supplement. CONCLUSIONS: All interventions were effective in producing weight gain in patients with CF. Behavioral intervention appeared to be as effective in improving weight gain in patients with CF as more invasive medical procedures. These findings support continued research on nutrition intervention with patients with CF including controlled clinical trials of the interventions and long-term follow-up on the impact of nutrition on disease progression.

Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days.

STUDY OBJECTIVES: This study examined effects on adolescent sleep patterns, sleepiness, and circadian phase of a school transition requiring an earlier start. DESIGN AND SETTING: Adolescents were evaluated in 9th and 10th grades; school start time in 9th grade was 0825 and in 10th grade was 0720. Assessments at each point included 2 weeks of actigraphy and sleep diaries at home, followed by a 22-hour laboratory evaluation, including evening saliva samples every 30 minutes in dim light for determination of dim-light salivary melatonin onset phase (DLSMO), overnight sleep monitoring, and multiple sleep latency test (MSLT). PARTICIPANTS: Twenty-five females and 15 males, ages 14 to 16.2 were enrolled; 32 completed the study in 9th grade and 26 completed in 10th grade. INTERVENTIONS: Participants kept their own schedules, except that laboratory nights were scheduled based upon school-night sleep patterns. MEASUREMENTS AND RESULTS: According to actigraphy, students woke earlier on school days in 10th than in 9th grade, but they did not go to sleep earlier and they slept less. DLSMO phase was later in 10th grade (mean = 2102) than 9th grade (mean = 2024). Sleep latency on MSLT overall was shorter in 10th (mean = 8.5 minutes) than in 9th (mean = 11.4 minutes), particularly on the first test of the morning at 0830 (5.1 vs 10.9 minutes). Two REM episodes on MSLT occurred in 16% of participants in 10th grade; one REM episode occurred in 48%. When those with REM sleep on one or both morning MSLTs (n = 11) were compared to those without morning REM, significant differences included shorter sleep latency on the first test, less slow wave sleep the night before, and later DLSMO phase in those who had morning REM. CONCLUSIONS: Early start time was associated with significant sleep deprivation and daytime sleepiness. The occurrence of REM sleep on MSLT indicates that clinicians should exercise caution in interpreting MSLT REM sleep in adolescents evaluated on their "usual" schedules. Psychosocial influences and changes in bioregulatory systems controlling sleep may limit teenagers' capacities to make adequate adjustments to an early school schedule.

An approach to studying circadian rhythms of adolescent humans.

The "long nights" protocol was designed to evaluate sleep processes and circadian rhythm parameters in young humans. A total of 19 children (10 boys, ages 11.2 to 14.1 years [mean = 12.7 +/- 1.0], and 9 girls, ages 12.2 to 14.4 years [mean = 13.1 +/- 0.7]) took part in the study. Sleep/wake initially was assessed at home using actigraphy and diary for 1 week on each child's self-selected schedule followed by an 8-night fixed light-dark (LD) condition, while sleeping from 22:00 to 08:00 h and wearing an eye mask to exclude as much light as possible. Phase measurements included 4-night mean actigraphically estimated sleep onset and offset as well as 1-night dim light salivary melatonin onset (DLSMO) phase at the end of each condition. Subjects then lived in the laboratory for 6 consecutive cycles: Day 1 LD = 14:10 h, lights out 22:00 to 08:00 h; Days 2-4 LD = 6:18 h, lights out 18:00 to 12:00 h; Days 5-6 = constant routine in continuous dim light (about 20 lux); Night 6 = 14 h recovery sleep. Phase markers (sleep onset, sleep offset, DLSMO) were significantly less dispersed after the fixed LD as compared to the self-selected condition, indicating efficacy of the LD protocol. Phase markers were correlated at the self-selected assessment (sleep onset vs. sleep offset r = .72; DLSMO vs. sleep onset r = .82; DLSMO vs. sleep offset r = .76) but not on the fixed schedule, probably due to restricted range. The constant routine provided additional phase markers, melatonin offset and midphase. Offset phase of melatonin secretion was significantly correlated with age (r = .62) and Tanner stage (r = .62). In conclusion, these preliminary data indicate a relationship between adolescent development and circadian phase. Thus, the long nights protocol is a feasible way in which to assess circadian parameters in young humans as well as to examine intrinsic sleep processes.

Physical and sexual abuse and their relation to psychiatric disorder and suicidal behavior among adolescents who are psychiatrically hospitalized.

Adolescents who were psychiatrically hospitalized (N = 105) were classified as sexually abused, physically abused, both sexually and physically abused, or not abused, and studied to determine the prevalence of suicidal behavior and psychiatric disorders. Self-reports of hopelessness, depression, coping, and self-concept were also examined. No difference in suicidal behavior or psychiatric disorder, based on abuse history, was found, with one exception. Adolescents who were sexually abused, particularly those who experienced the most severe sexual abuse, used negative coping strategies more often than those not sexually abused. Findings suggest that symptomatology of adolescents who are psychiatrically hospitalized does not differ markedly based on history of abuse.

Behavioral intervention and post-natal growth in full-term intrauterine growth retarded (IUGR) infants.

The purpose of this study was twofold: (1) to describe the patterns of post-natal growth in full-term infants as a function of IUGR and (2) to assess the impact of an individualized behavioral feeding intervention with the mothers on these patterns of infant growth. Eighty-eight (88) full-term infants, including 54 with IUGR, half of whom received behavioral intervention were included. Weight, length, skinfold thickness, head circumference and Ponderal Index were measured at birth and at 1, 4, 8, 12, and 18 months. Results show positive intervention effects between birth and 1 month in weight, length, skinfold thickness, and Ponderal Index. However, there were no intervention effects at subsequent ages. No evidence was found for catch-up growth in full-term IUGR infants in weight, length, and head circumference. We conclude that an individualized behavioral feeding intervention can accelerate early growth in IUGR infants, but the positive effects on growth are only seen while the intervention lasts (between birth and 1 month). On most parameters of physical growth, there is no lasting catch-up growth over the first 18 months in IUGR full-term infants.

Conceptual and methodologic issues in quantifying perceptual accuracy in childhood asthma.

Delineated methodologic issues in the study of symptom perception in childhood asthma. A review of past and recent psychophysiological and clinical studies of both adults and children presents the methodologic and analytic approaches that have been applied to quantify perceptual accuracy. Peak expiratory flow rate, forced expiratory volume in the first second, and force expiratory flow can serve as objective measures of asthma. A visual analog scale, a numerical guess, and a categorical description as subjective measures all have clear strengths and weaknesses. Correlational analysis of subjective-objective data, arithmetic differences between subjective guess and objective value, and an error grid categorization can each be applied to calculate an accuracy index on an individual subject. Illustrative examples reveal that the same data lead to different indices depending on the method chosen. Empirical research is needed to standardize various methodologic approaches. Given the increasing prevalence, severity, and morbidity of pediatric asthma, the study of symptom perception may be a critical component in our understanding of asthma management, and will likely lead to useful clinical interventions.

Prediction of adolescent affective disorder: effects of prior parental affective disorders and child psychopathology.

OBJECTIVE: To examine the role of major parental and child diagnostic factors in predicting episodes of serious affective disorder in adolescents in a nonreferred sample. METHOD: The sample included 139 youngsters (average age 14 years at enrollment) drawn from a health maintenance organization and evaluated at two points in time 4 years apart. Both parents and adolescents were assessed using structured diagnostic instruments scored according to criterion systems. Parent and child lifetime diagnoses identified in the first assessment were used to predict the onset of episodes of serious affective disorder in the adolescents which occurred between the first and second assessment. RESULTS: Stepwise multiple regression analyses of the significant univariate factors showed that the most powerful predictors of episodes of affective disorder were total number of diagnoses the adolescents received prior to first assessment, lifetime duration of parental major depressive disorder, and total number of lifetime nonaffective disorders of the parents. CONCLUSION: Broad risk factors from different domains best predict episodes of affective disorder in children and adolescents.

Psychological distress in mothers of preterm infants.

The purpose of this study was to identify infant and maternal characteristics that predict psychological distress among mothers of preterm infants admitted to the neonatal intensive care unit (NICU). Infant characteristics included birth weight, gestational age, and ventilatory support, and maternal characteristics included age, parity, and socioeconomic status. Mothers (n = 142) completed questionnaires including a demographic form, the Parental Stressor Scale, and the Symptom Checklist 90-R. In hierarchical regression analyses, maternal NICU-specific distress was more strongly predicted by infant characteristics [F(3,135) = 6.80, p < .05] with maternal variables covaried. Maternal general psychological distress was more strongly predicted by maternal characteristics [F(3,135) = 6.05, p < .05]) with infant variables covaried. Twenty-eight percent of mothers reported clinically significant psychological distress compared with 10% in a normative population. Psychological distress among mothers of preterm infants appears to be common and deserves clinical consideration. The use of standardized questionnaires as part of the assessment process may improve case identification and psychosocial service delivery in the NICU.

The relationship between oxygen saturation and the clinical assessment of acutely wheezing infants and children.

The objective of this study was to determine the relationship between oxygen saturation (Sao2) and traditional clinical assessment measures in infants and young children presenting as outpatients with acute wheezing. To accomplish this, Sao2 before and after medication was compared in a post hoc analysis with the clinical response to treatment (respiratory rate and a standardized index of respiratory distress) in children who participated in a randomized, placebo controlled medication trial. The study was done in a pediatric emergency department and outpatient clinic, and the participants were 74, full-term previously well infants and young children, aged 1 to 36 months (mean age 16.1 months), presenting with acute wheezing and participating in the randomized trial. The results showed that Sao2 was found to be inversely correlated with both respiratory rate (r = -0.29, P < or = 0.05) and an index of respiratory distress (r = -0.36, P < or = 0.01) prior to medication but not afterward. There was no significant difference in Sao2 when infants, who had a clinical response to treatment based on a priori criteria, were compared to nonresponders (mean difference per patient: responders = 0.86% vs nonresponders = 0.79%, P = 0.51). This was due to a large amount of individual variability in postmedication Sao2 in both groups. We conclude that, before therapy, there are only weak correlations between SaO2 and both respiratory rate and an index of respiratory distress in acutely wheezing infants and children. After therapy, young children can appear clinically improved but measured oxygen saturation may be variable and not correlated with traditional clinical assessment measures.