Early risk factors associated with behavioral dysregulation trajectories


Risk detection practices and targeted interventions promoting adaptive developmental trajectories for at-risk children can be successful by identifying the earliest antecedents of persisting emotional and behavioral dysregulation.

Early risk factors associated with behavioral dysregulation trajectories  | Image Credit: © Gary - © Gary - stock.adobe.com.

Early risk factors associated with behavioral dysregulation trajectories
| Image Credit: © Gary - © Gary - stock.adobe.com.

Preterm birth, prenatal substance exposures, and psychosocial adversities were associated with persisting high and borderline Child Behavior Checklist-Dysregulation trajectories in children aged 18 to 72 months, according to a study in Jama Network Open.

Emotional and behavioral dysregulation during early childhood stages have been associated with severe psychiatric, behavioral, and cognitive disorders throughout adulthood, according to study authors. Risk detection practices and targeted interventions promoting adaptive developmental trajectories among at-risk children can be informed by identifying the earliest antecedents of persisting emotional and behavioral dysregulation.

The goals of this cohort study were to characterize Child Behavior Checklist Dysregulation Profile (CBCL-DP) trajectories and identify early psychosocial and neonatal characteristics associated with resilience compared with persisting dysregulation. The CBCL-DP is a “well-validated measure,” yielding subscores for anxiety and depression, attention, and aggression, according to authors.

Participants included 3934 children aged 18 to 72 months born in 1990 to 2019 that were enrolled in 20 the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) programcohorts. Singleton births, data on prenatal exposure to alcohol, nicotine, marijuana, opioids, illicit substances, and the Child Behavior Checklist (CBCL/1.5-5) data at age 18 to 72 months were inclusion criteria.

Self-report, medical record abstraction, and/or biological assays were used for prenatal substance use data. Each category (nicotine, alcohol, marijuana, opioids, and illicit substances) was assigned a value of 1 and the sum of each substance category was calculated (range: 0-5) to quantify cumulative prenatal exposures. For socioenvironmental characteristics, maternal education was characterized as, “(1) less than high school degree, (2) high school graduate or GED, (3) some college, and (4) bachelor’s degree and above,” authors wrote. Partner status was characterized as married or living with a partner, or not married nor partnered. None and publicly subsidized, or private and employer-provided were insurance designations.

Psychiatric diagnoses and depressive symptom scores from self-reported questionnaires or medical records were used to operationalize maternal psychological history. Maternal psychiatric diagnoses included major depression, dysthymia, phobias, along with bipolar, anxiety, panic, obsessive-compulsive, posttraumatic stress, and attention-deficit disorders. Maternal psychological history was defined as “yes” if there was a prior psychiatric diagnosis, or Patient-Reported Outcomes Measurement Information System v1.0 (PROMIS) depressive symptom T-score greater than or equal to 55, prior to the first CBCL assessment.

A Psychosocial Adversity Index (PAI) was created to quantify cumulative burden of adverse conditions in which children were developing. Based on previously validated methods, the following criteria were assigned a value of 1; Maternal age at delivery less than 21 years, maternal education less than some college, publicly subsidized or no health insurance, single-parent household, and prior maternal psychiatric diagnosis or positive depressive symptom screen. PAI (range: 0-5) was modeled as a continuous variable.

Gestational age (GA) included term (37 weeks or more), preterm (less than 37 weeks), moderate or late preterm (62 to 36 weeks), and very preterm (less than 32 weeks). Postnatal length of hospital stay (LOS) was calculated from dates of birth and neonatal discharge. When continuous LOS was available, GA-specific median LOS was determined. Children were categorized as less than vs greater than or equal to the media GA-specific LOS as a proxy for illness severity at birth.

For cohort-specific 18- to 72-month assessment protocols, caregivers completed CBCLs. Items were rated as 0 (not true as far as you know), 1 (somewhat or sometimes true), and 2 (very or often true). Subscores from emotional reactivity, sleep and somatic problems, withdrawn, anxiety or depression, attention, and aggression were calculated and transformed into standardized T-scores (mean [SD]: 50 [10]). The CBCL-DP is the sum of subscores for 8 items related to “Anxious/Depressed,” 5 items for “Attention Problems”, and 19 items for “Aggressive Behavior Problems.” Scores greater than 180 defined clinically validated dysregulation using categories validated in preschool samples.

Of the 3934 mother-child pairs studied at 18 to 72 months, 718 mothers were Hispanic (18.7%), 275 (7.2%) were non-Hispanic Asian, 1220 (31.8%) were non-Hispanic Black, 1412 (36.9%) were non-Hispanic White; additionally, 3501 (89.7%) were at least 21 years of age at time of delivery. Among children (2093 [53.2%] male), 1178 of 2143 with PAI data (55%) experienced multiple psychosocial adversities, 1148 (29.2%) were prenatally exposed to at least 1 psychoactive substance, and 3066 (80.2%) were term-born.

Growth mixture modeling (GMM) used a 3-class CBCL-DP trajectory model that included high and increasing (2.3% [n = 89]), borderline and stable (12.3% [n = 479]), and low and decreasing (85.6% [n = 3366]). Children in high and borderline dysregulation trajectories had more prevalent maternal psychological challenges (29.4% to 50.0%). Children born preterm were more likely to be in the high dysregulation trajectory (adjusted odds ratio [aOR], 2.76; 95% CI, 2.08-3.65; P < .001) or borderline dysregulation trajectory (aOR, 1.36; 95% CI, 1.06-1.76; P = .02) vs low dysregulation trajectory, indicated by multinomial logistic regression analyses. Compared to boys (aOR, 0.60; 95% CI, 0.36-1.01; P = .05), and children with lower PAI (aOR, 1.94; 95% CI, 1.51-2.49; P < .001) high vs low dysregulation trajectories were less prevalent for girls. “Combined increases in PAI and prenatal substance exposures were associated with increased odds of high vs borderline dysregulation (aOR, 1.28; 95% CI, 1.08-1.53; P = .006) and decreased odds of low vs high dysregulation (aOR, 0.77; 95% CI, 0.64-0.92; P = .005),” authors found.

The cohort study demonstrated associations between behavioral dysregulation trajectories and early risk factors. Identifying these antecedents associated with resilience and risk in dysregulation pathways across the first 6 years of life warrants “support for children with early indicated needs for monitoring and targeted interventions to address risk for persisting dysregulation,” authors concluded.


Hofheimer JA, McGrath M, Musci R, et al. Assessment of psychosocial and neonatal risk factors for trajectories of behavioral dysregulation among young children from 18 to 72 months of age. JAMA Netw Open. 2023;6(4):e2310059. doi:10.1001/jamanetworkopen.2023.10059

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