Journal of Pediatric Psychology Advance Access published online on October 1, 2008
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsn089
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Triple Risk: Do Difficult Temperament and Family Conflict Increase the Likelihood of Behavioral Maladjustment in Children Born Low Birth Weight and Preterm?
1Partners for Inclusive Communities, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, 2Center for Research on Teaching and Learning, University of Arkansas at Little Rock, 3Center for Applied Research and Evaluation, and 4Division of Developmental–Behavioral Pediatrics, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences
All correspondence concerning this article should be addressed to Leanne Whiteside-Mansell, Partners for Inclusive Communities, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA. E-mail: whitesidemansellleanne{at}uams.edu
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Abstract |
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Objective This study examined the impact of family conflict on internalizing and externalizing behavior at age 8 for children born low birth weight (LBW) and preterm (PT), with specific attention to the moderating role of early temperament. Methods The sample included 728 families enrolled in the longitudinal study of the Infant Health and Development Program. The study relied on maternal reports of child temperament at age 1, family conflict at age 6
years and 8 years, and child behavior at age 8 years. Results Children exposed to high levels of family conflict had more internalizing problems. Child temperament assessed in infancy moderated the impact of family conflict on externalizing but not internalizing problem behavior. Discussion LBW/PT children with a difficult temperament are more at risk for poor developmental outcomes, such as externalizing behavior problems, when exposed to family conflict than children with a less difficult temperament. Key words: behavior problems; family conflict; temperament.
School-aged children born low birth weight (LBW) and preterm (PT) carry an increased risk of behavioral maladjustment such as elevated internalizing and externalizing behavior and delinquency (Bhutta, Cleves, Casey, Cradock, & Anand, 2002
; Dahl et al., 2006; Klebanov, Brooks-Gunn, & McCormick, 1994; McCarton, 1998; Reijneveld et al., 2006; Taylor, Klein, Minich, & Hack, 2000) with some problems persisting into adulthood (Hack et al., 2004). However, not all such children have poor outcomes (Räikkönen, et al., 2008). As infants, LBW children are more likely to exhibit higher sensory thresholds, be more intense, and be less adaptable than full-term children (Hertzig & Mittleman, 1984; Weiss, St Jonn-Seed, & Wilson, 2004). While the mechanisms responsible for behavioral maladjustment may derive from problems connected with prenatal or postnatal brain development (Breslau, Chilcoat, Del Dotto, Andreski, & Brown, 1996), research indicates that environmental conditions experienced by LBW/PT children, such as family conflict, add significant risk to the development of behavior problems (Adams, Hillman, & Gaydos, 1994; Miceli et al., 2000).
Most families experience disagreements and conflict is often part of family life (Buehler & Trotter, 1990). Children from infancy onward are sensitive to these conflicts; and it has been established that family conflict has negative consequences for a wide range of child developmental outcomes, including global internalizing behavior, externalizing behavior, traumatic stress symptoms, developmental delay, low self-esteem, and poor social functioning (Kelly, 2000). The negative consequences of family conflict have also been demonstrated in LBW children (Lucia & Breslau, 2006). However, not all children who experience family conflict have behavior problems; some appear resilient (Hughes, Graham-Berman, & Gruber, 2001). This variation in response to conflict has encouraged the examination of the mechanisms by which family conflict impacts children (Davies, Harold, Goeke-Morey, & Cummings, 2002; Fincham, 1994).
Since Rutter (1979) first discussed the roles of stress response and temperament, a variety of child characteristics have been examined as potential moderators (i.e., characteristics that may increase the likelihood or protect children from poor development) of stressful life events on development. For example, high positive emotionality acted as a protective factor for elementary school children exposed to poor parenting practices. That is, in families rated as having poor parenting practices, children with high levels of emotionality were less likely to exhibit conduct problems than children who had low levels of positive emotionality (Lengua, Wolchik, Sandler, & West, 2000). In the context of family conflict, Grych and Fincham (1990) offered three potential pathways through which a difficult temperament contributes to less optimal child development for children exposed to high levels of family conflict. First, children with a difficult temperament may be more vulnerable to stressful life events such as family conflict and dysfunctional parenting (Belsky & Jaffee, 2006). Second, children who tend to respond aggressively may show even higher levels of aggression when they encounter stressful events. Third, because parent–child relationships develop as a function of reciprocal interactions between parent and child, the quality of those relationships are likely to be affected by child characteristics, such as temperament, as well as the emotional climate of the family (Rutter, 1979).
Zimet and Jacob (2001) emphasized the lack of empirical studies addressing child temperament as a potential moderator of relations between family conflict and children's adaptive behavior. Since their review, three studies have examined the moderation of temperament on child problem behavior in normal weight, full-term children. In a study of 145 preschool children, Tschann and colleagues (Tchann, Kaiser, Chesney, Alkon, & Boyce, 1996) found that children with a difficult temperament (e.g., negative mood, distractibility) in high-conflict families had higher levels of internalizing and externalizing behavior problems compared to children with less a difficult temperament or a less conflictual home. A key limitation in the Tschann et al. study was that teacher report was used to measure both temperament and child problem behavior, leaving open the possibility of reporter bias. Further, temperament and behavior were assessed concurrent with parents’ report of family conflict, leaving unclear the direction of causality. To their credit, Tschann and colleagues controlled for some important factors related to socioeconomic status (SES) and child characteristics (child's gender, hours worked weekly by mother, and two vs. single-parent households) but did not include other important indicators of SES such as parental age or education. The generalizability of their study is limited because the sample consisted of healthy children from upper income families and targeted preschool children. Their findings were largely replicated in a sample of 108 mostly White, middle-class 7- to 10-year-old-children (Ramos, Guerin, Gottfried, Bathurst, & Oliver, 2005). Although child externalizing behavior was the only area of adjustment examined, the results are consistent with the earlier study suggesting that children with a difficult temperament who lived with elevated family conflict had higher levels of externalizing behaviors than children living in homes with less conflict. These results suggest that the pattern observed for preschoolers may continue for school-age children. However, the study did not include any controls and so leaves open the possibility that family conflict cooccurred with other factors that contribute to behavior problems. Finally, in a study of 174 boys and 163 girls, parents reported on temperament and marital adjustment when children were 5-years old (Leve, Kim & Pears, 2005). The study sample was mostly White (88%) but included low- to middle-income families. Latent growth curve modeling was used to examine the link between early family life and internalizing and externalizing behavior at age 17. Family income, child gender, early maternal depression, and early harsh discipline practices were examined in the study. Results did not support the previous findings (i.e., temperament did not moderate the effect of marital discord on problem behavior). Based on these mixed results and limitations in generalizability, more studies are needed with (a) adequate controls for key socioeconomic and family composition factors known to be associated with behavior problems in children, (b) early assessment of temperament, (c) samples that include higher risk children (e.g., low-income families, children with health problems, etc.), and (d) controls for behavior problems that predate the exposure to recent family conflict. Furthermore, by controlling for the level of preschool behavior problems when examining the impact of family conflict on behavior problems of children during the early years of school, it is possible to determine how exposure to conflict during the early school years affects change in behavior problems from preschool to early school age. This analysis is conservative in that it adjusts for the link between unmeasured early family conflict experienced before or during preschool and preschool behavior problems. Including earlier levels of behavior problems as a control provides a clearer picture of how family conflict experienced during the early school years contributes to the level of behavior problems children manifest as they approach middle childhood.
The extent to which findings derived from samples of normal birth weight children apply to LBW/PT children is not clear. There is substantial evidence that many developmental outcomes, such as cognitive development and behavior problems for LBW/PT children, are influenced not only by the growth compromised in utero but also by environmental factors such as poverty (McCarton, 1998) and poor parenting (Dadds & Salmon, 2003), and also by child temperament (Hertzig & Mittleman, 1984). However, the factors that moderate development in LBW/PT infants have been shown in some cases to function differently than in normal birth status children (Gorman, Lourie, & Choudhury, 2001).
The current study extends previous work by examining the risk of family conflict experienced during early school years and difficult child temperament in a sample of LBW/PT children, with specific attention to the moderating role that child temperament plays in the relation between family conflict during this period and problem behavior at age 8 years. Specifically, this study targeted the influence of family conflict during the early school years on changes in behavior problems during these years by controlling for the level of behavior problems present prior to school entry. In effect, this study attempted to disentangle the impact of early family conflict on behavior problems at age 8 from the impact of family conflict experienced after school entry. This study also included an array of potential confounders as controls; specifically, maternal education, maternal age, family composition, and race (Belle, 1990). Child gender and child health status at birth were included as part of the analytic design because boys have been shown to have higher rates of aggressive behavior than girls and cultural norms are thought to influence the expectations for maturity and limits of acceptable behavior (Campbell, 2002).
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Methods |
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Sample
Participants for this study were drawn from the Infant Health and Development Program (IHDP). The sample and the design for IHDP have been described in previous publications (Casey et al., 1990
; Gross, 1990; McCarton et al., 1997). The IHDP began in 1985 and was designed as a eight-site, randomized clinical trial evaluating early childhood development, center-based education, and home-based family support services, as well as pediatric surveillance in an attempt to reduce the risk for developmental delay, behavioral issues and health problems LBW, PT (
37 weeks gestational age) infants. Two-thirds of the infants were born 2000 g; the remaining infants were between 2001 and 2500 g. Given that the purpose of the original study was to evaluate the IHDP intervention, children who had an illness or neurological deficit too severe to participate in the intervention were excluded (Gross, 1990).
The IHDP protocol called for data collection eight times in the first 3 years of life, and at 4, 5, 6, and 8 years of age. Families were randomly assigned to the intervention group (n = 377) which consisted of home visits (birth to 3 years), child development interventions services (age 1–3 years), and parent group meetings (age 1–3 years). Children were eligible to attend the child development center 5 days per week for 
6 hr per day for 2 years.
Of the 985 participants, children in situations such as foster care and extended family custody were excluded (n = 63). Of the remaining 922 families, 108 were not assessed (89% retention) when the child was 8-years old, 55 were not rated on the temperament assessment at 1 year, and 31 were missing some other analysis variable. This resulted in a final study sample of 728.
The study sample (Table I) was diverse with respect to maternal education (79.9% of mothers had a high school degree or equivalent) and marital status (48.9% married). For most families, the mother (97%) was interviewed. About half of the respondents (48.4%) reported incomes below $25,000 and 35.6% received cash public assistance (e.g., welfare benefits). In most families (57%), one or both parents was employed (56.0% respondents were working; M = 35.7 h per week, SD = 11.6 and 53.6% had employed partners). Most mothers lived with a partner (62.6%; 45.7% lived with the child's biological father). On average, mothers were 25.1 years of age (SD = 5.9 years) at the birth of the child. Half (50%) of children were male and 46.2% were first born. At the 8-year assessment, children were between 7.5 and 8.8 years (M = 8 years, SD = 1.2 months). As was defined by the IHDP protocol in which one-third of participants received treatment, 38% of this subsample was in the treatment group.
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Measures
Family Environment Scale
Family conflict was assessed twice using the Conflict subscale (9-item) from the Family Environment Scale (FES, Moos & Moos, 1976
). The subscale measures the extent to which the open expression of anger and aggression and conflictual interactions are characteristic of the family. Mothers completed the FES when children were 6.5 and 8 years of age. The items were rated on a 4-point scale, where 4 indicated high levels of agreement with statements such as, "We fight a lot," and "Family members sometimes hit each other." Internal consistency was high at both assessments (
= .76). Because our goal was to examine the impact of the child's exposure to family conflict from 6.5 to 8 years of age, an average score was computed for the two assessments with high scores indicating more conflict within the family.
Child Behavior Checklist
Problem behavior was assessed when children were 8-years old using the Achenbach's Child Behavior Checklist (CBCL/4-18, Achenbach, 1992). The CBCL was completed by the parent. The CBCL is a widely used measure of emotional and behavior problems which results in separate externalizing and internalizing behavior scores. The 118-item CBCL consists of behaviors that parent's rate using a 3-point scale (not true, somewhat or sometimes true, or very/often true) as it applies to their child within the past 2 months (e.g., "Argues a lot"). Scores (0–2) are summed and then converted to normalized T-scores based on norms for girls and boys ( = .96). T-scores 
60 are within the borderline/clinical referral range—higher scores represent more deviant behavior. However, recent examinations of the CBCL suggest that a score above 55 is problematic (Hudziak, Copeland, Stanger, & Wadsworth, 2004).
Infant Characteristics Questionnaire
Infant temperament was assessed from parental report on the condensed (22 item) version of the Infant Characteristics Questionnaire (ICQ, Bates, 1983) when children were 12-months old. Questions addressed areas such as child's fussiness, sleeping routine, mood, and adaptation to new experiences. The scale consists of nine items, each rated on a 7-point scale. For each item, a rating of 1 represents an optimal temperament and rating of 7 represents a difficult temperament ( = .69). For example, parents responded from never to "more than 14 times per day" to the item "How many times per day, on average, does BABY get fussy and irritable—for either short or long periods of time?"
Control Variables
Constructs assessed at the birth of the child included treatment status (1 = treatment, 0 = follow-up), race/ethnicity: Black (1 = Black, 0 = other), race/ethnicity: Hispanic (1 = Hispanic, 0 = other), child gender (1 = male, 0 = female), birth weight, neonatal health status, and maternal age. The neonatal health status (NHI) was calculated on the basis of length of stay in the newborn nursery, adjusted for birth weight. The NHI was standardized to a mean of 100, with higher scores indicating better health. The NHI was found to be strongly related to neonatal complications and to health outcomes at 12 months corrected age (Scott, Bauer, Kraemer, & Tyson, 1989). Maternal report on the CBCL/2-3 (Achenbach, 1992) when children were 36-months old was used to control for early behavior problems (i.e., Internalizing and Externalizing). Control variables from the 8-year assessment included number of children in the home, number of adults in the home, and highest year of education for mothers.
Statistical Analysis
Preliminary bivariate analyses were conducted between each predictor variable and child problem behaviors. Cases missing data (n = 194, 21%) were compared to cases with complete data on an array of demographic characteristics; no differences in child (e.g., treatment status, gender, birth weight, birth health status, early indicators of behavior), family (e.g., composition, conflict), or parent characteristics (e.g., race/ethnicity, education level, age) were found.
In the second phase of analysis, we regressed 8-year externalizing and internalizing behavior on 12-month temperament, current family conflict, and their interaction, while controlling for the factors marked as control variables in Table I using ordinary least square (OLS) multiple regression. Variables were entered into the regression model hierarchically as shown in Table II with control variables entered first, 12-month temperament, 36-month externalizing or internalizing behavior, current family conflict, and finally, the interaction of conflict and temperament. To minimize problems with multicollinearity and to facilitate interpretation of results, temperament and conflict variables were centered in all analyses (Aiken & West, 1991). Collinearity statistics were examined in each analysis and were below acceptable levels. Analyses using OLSs are reported; however because of the extent of missing data all analyses were confirmed using multigroup full information maximum likelihood estimation (FIML, Allison, 2002; Ender, 2001a, 2001b). FIML uses all the cases and is an acceptable option to address missing data (Widaman, 2006).
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Using recommendations from Aiken and West (1991
), the multiple regression interaction terms for externalizing were probed in post hoc analyses to facilitate interpretation of the findings. In these post hoc analyses, regression equations were generated for children one SD above and for children one SD below the centered value of difficult temperament, as shown in Fig. 2. This also allowed the test of regression slopes to determine if each was significantly different from zero. Significant interaction terms indicate that the slopes of the two lines are different from each other; however, it is possible that one of the regression slopes could be not statistically different from zero.
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Results |
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Table I provides descriptive statistics for variables included in the multiple regression model. The CBCL scores are about one-third of a SD above the T-score mean of 50 established for the norm group; but below the T-score of 60 most often used to identify clinically relevant cases or the more liberal cut off of 55 suggested by Hudziak and colleagues (2004
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Significant correlations were observed between family conflict and child 8-year externalizing behavior [r (728) = .40, p <.01] and internalizing behavior [r (728) = .26, p <.01]. Statistically significant (but small) correlations were observed between temperament and 8-year externalizing behavior (.17, p <.01) and internalizing behavior (.15, p <.01). Finally, significant correlations were observed between 12-month temperament and 36-month externalizing behavior (.29, p <.01) and internalizing behavior (.26, p <.01). When clinical cutoff scores for externalizing problems and internalizing problems were examined, a pattern suggestive of independent, but additive, links was observed. For this comparison, we defined high conflict and difficult temperament groups as scores above the mean of each measure. As seen in Fig. 1, only 9.6% of children without a difficult temperament who lived in low conflict families had clinically significant levels of externalizing problems (12.8% of such children had Internalizing problems). In contrast, almost four times the rate of children with a difficult temperament and living in a high conflict home manifested internalizing problems [(42.9%, 
2(3, n = 728) = 77.71, p <.01)]. The corresponding figure for externalizing problems was 37.4% [2(3, n = 728) = 37.48, p <.01)].
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Results from the multiple regression analyses are displayed in Table II. The R2 change for each step was significant, indicating that family conflict, temperament, and the interaction between family conflict and temperament contribute independently to the prediction of child behavior problems. The significant interaction indicates that the negative effect of family conflict was moderated by the temperament of the child. The overall F was significant and the full model resulted in an adjusted R2 of .29. The additional variance explained by the interaction term was small (.01) but in the range typically found in the literature for interaction terms (Frazier, Tix, & Barron, 2004
). Simple slope analyses as suggested by Aiken and West (1991) revealed that higher levels of temperament exacerbated the relationship between family conflict and child externalizing behavior. From the simple slope analyses, findings are illustrated in Fig. 2 by investigating the relationship 1 SD above and below the mean for conflict and temperament (see www.jeremydawson.co.uk for example). Point estimates illustrate values of externalizing behavior evaluated at 1 SD above and below the mean for conflict based on regression equations estimated for values of temperament 1 SD above and below the mean. The standardized slope for children with a difficult temperament (1 SD above the mean) was .35 (p <.01) and .23 (p <.01) for children with a less difficult temperament (1 SD below the mean). Nearly identical slopes were estimated with multigroup FIML analyses indicating that missing data did not impact the findings. Unlike the simple slope analyses, in FIML analyses, the data were split into two groups with one group consisting of children with temperament scores below the mean and the second group consisting of children above and equal to the mean. Overall, these findings indicated that the association between conflict and externalizing behavior was increased as child temperament became more difficult. For internalizing behavior, an identical analysis was conducted as seen in Table II. The results indicated that child temperament did not moderate the impact of family conflict on internalizing behavior. That is, the interaction of conflict and temperament was not a statistically significant predictor of 8-year internalizing behavior. Nearly identical estimates were obtained with multigroup FIML analyses indicating that missing data did not impact the findings.
In both analyses, the increase in R2 at each step indicated that the addition of temperament, preschool behavior problems, and conflict added statistically significant information useful in predicting the behavior problem. In the final model (with all factors included), temperament is not a significant factor.
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Discussion |
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LBW children are at increased risk for internalizing (Reijneveld et al., 2006
) and externalizing (Taylor et al., 2000) behavior problems. For example, Gray and colleagues (Gray, Indurkhya, & McCormick, 2004) found LBW/PT children in the IHDP study to have twice the prevalence of behavior problems expected in the general child population. Combining Gray and colleague's finding with results reported here, a group of children at triple risk for externalizing behavioral problems during the early school years can be identified. This high risk group is at increased risk for externalizing behavior problems during early school years based on their (a) LBW/PT status, (b) exposure to family conflict, and (c) temperament. That is, in addition to their LBW/PT status, children with a difficult temperament who experience family conflict during early elementary school years have poorer adaptive functioning than LBW/PT children without these additional risks. Consistent with findings from studies that have examined normal weight full-term children, our study suggest a pervasive negative consequence of family conflict on children (Kelly, 2000). At least for LBW/PT children, having a difficult temperament exacerbates the effect of family conflict during early school years on externalizing problems. That is, while both family conflict and difficult temperament increase externalizing behavior, they act together in a synergistic way.
For internalizing behavior, the impact of family conflict during early school years was uniformly negative regardless of child temperament after accounting for early internalizing behavior. That is, temperament did not moderate the impact of family conflict experienced by school-aged children on their change in internalizing behavior from preschool. A methodological caution should be made regarding the lack of interaction finding. Several factors influence the power to detect interactions in regression analyses including, reliability of measures, the size of the effect and the sample size (Frazier et al., 2004). However, the factor that may be most important in this situation is the reliability of the assessment of internalizing behavior Parents do not always recognize signs of depression in young children; thus, reports of internalizing problems tend to be less consistent across informants (Reynold, Anderson, & Baratell, 1985).
Children with a difficult temperament are more likely than children with an easy temperament to show behavioral maladjustment as a consequence of struggling to cope with adverse experiences (Rothbart, Ahadi, & Hershey, 1994). However, temperament has several dimensions, each of which may be implicated in different ways in long-term adaptive functioning, depending on the quality of children's experiences throughout childhood (Rothbart, Ahadi, Hershey, & Fisher, 2001). For example, young children who show shyness or avoidant behavior to novelty display anxiety symptoms in adolescence. In contrast, impulsive children exhibit more externalizing problems as adolescents (Schwartz, Snidman, & Kagan, 1999). Many dimensions of difficult temperament (e.g., negative mood, high intensity, and high activity) have been related to preschool age behavior problems (Campbell, Shaw, & Gilliom, 2000).
Examining these processes during early school years is important for a number of reasons. First, the transition into school may generate an array of new stresses for parents and children. For young children, exposure to environmental stressors may result in a variety of behavior problems. For families it may result in increases in the level of family conflict. Whether exposure to family conflict during these transitional years carries longer term impacts is important to determine. Second, although children's capacities for self-regulation continue to develop, during middle childhood they still have limited capacity to cope with the emotional insecurity engendered by exposure to family conflict and to refrain from modeling the negative behaviors they observe in adult household members. Thus, if family conflict persists, it is likely that the maladaptive behavior will persist and perhaps take on new forms (e.g., delinquency, drug use, and teenage pregnancy). However, there is a chance that problems could abate given that self-regulatory capacities generally do get stronger during middle childhood and given that children spend increasingly more time outside the home in school, with peers, and connect to other social institutions.
This study has several strengths, including its prospective design, its inclusion of over 700 children from eight different data collection sites, and the use of recognized, reliable, standardized measures of key study constructs. We also controlled for an extensive array of background variables thought to be related to the development of behavior problems. In particular, the ability to control for earlier behavior problems, allowed a clearer understanding of the impact of conflict experienced during early school years but may provide a conservative estimate. For example, conflict before age 6 may have lead to early behavior problems. Further, the early impact of temperament on child behavior is removed from the analyses by the inclusion of early behavior problems as a control. This is illustrated by the results that show that temperament is a significant predictor of 8-year behavior problems before 36-month behavior is added to the model but not after.
That said, the study is limited in that mothers were the key informants for all constructs. Unfortunately, the data do not allow an examination of the extent to which this introduces bias into the findings. Further, the sample is somewhat more impoverished than a nationally representative sample would be and should be generalized with this limitation in mind. The study also did not control for maternal psychopathology (e.g., depression), which is associated with family conflict and the development of child behavior problems. Nonetheless, the prospective nature of the study allowed for clear assessment of infant temperament and early behavior.
This study helps further delineate the processes by which LBW/PT children may develop behavior problems. It provides information that may help in the identification of children most at risk for behavior problems during their early school years. From a clinical perspective, it is important to note that LBW/PT children experiencing minor family conflict showed little indication of elevated risk for behavior problems. Absent exposure to the kinds of adversities that substantially increase emotional insecurity, most LBW/PT children seem unlikely to manifest significant behavioral maladjustment. On the other hand, LBW/PT children who are exposed to such adversity and who also have a difficult temperament showed levels of maladjustment similar to the levels reported by children in state custody, for example in foster care or group residential facilities (Heflinger, Simpkins, & Combs-Orme, 2000). Children with these three risk characteristics merit close clinical monitoring.
Conflicts of interest: None declared.
Received November 15, 2007; revision received July 13, 2008; accepted July 19, 2008
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