Annual Progress in Child Psychiatry and Child Development 2000-2001 (Annual Progress in Child Psychiatry and Child Development)

ANNUAL PROGRESS IN CHILD PSYCHIATRY AND CHILD DEVELOPMENT 2000–2001

ANNUAL PROGRESS IN CHILD PSYCHIATRY AND CHILD DEVELOPMENT 2000– 2001 Edited by

MARGARET E.HERTZIG, M.D. Professor of Psychiatry Cornell University Medical College and ELLEN A.FARBER, Ph.D. Clinical Assistant Professor of Psychology Cornell University Medical College

Brunner-Routledge New York and Hove

Published in 2003 by Brunner-Routledge 29 West 35th Street New York, NY 10001 www.brunner-routledge.com Published in Great Britain by Brunner-Routledge 27 Church Road Hove, East Sussex BN3 2FA www.brunner-routledge.co.uk Copyright © 2003 by Taylor & Francis Books, Inc. Brunner-Routledge is an imprint of the Taylor & Francis Group. This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk”. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. 10 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data is available from the publisher. ISBN 0-203-44952-5 Master e-book ISBN

ISBN 0-203-45789-7 (Adobe e-Reader Format) ISBN 0-415-93548-2 (Print Edition)

CONTENTS Introduction I. DEVELOPMENTAL ISSUES 1. Child Development and the PITS: Simple Questions, Complex Answers, and Developmental Theory Frances Degen Horowitz 2. Developing Mechanisms of Self-Regulation Michael I.Posner and Mary K.Rothbart 3. Implications of Attachment Theory for Developmental Psychopathology L.Alan Sroufe, Elizabeth A.Carlson, Alissa K.Levy, and Byron Egeland 4. Attachment Security in Infancy and Early Adulthood: A Twenty-Year Longitudinal Study Everett Waters, Susan Merrick, Dominique Treboux, Judith Crowell, and Leah Albersheim 5. Behavioral and Physiological Responsivity, Sleep, and Patterns of Daily Cortisol Production in Infants with and without Colic Barbara Prudhomme White, Megan R.Gunnar, Mary C.Larson, Bonny Donzella, and Ronald G.Barr 6. Imaginary Companions of Preschool Children Tracy R.Gleason, Anne M.Sebanc, and Willard W.Hartup II. PARENTING 7. Contemporary Research on Parenting: The Case for Nature and Nurture W.Andrew Collins, Eleanor E.Maccoby, Laurence Steinberg, E.Mavis Hetherington, and Marc H.Bornstein 8. Social versus Biological Parenting: Family Functioning and the Socioemotional Development of Children Conceived by Egg or Sperm Donation Susan Golombok, Clare Murray, Peter Brinsden, and Hossam Abdalla 9. Parenting among Mothers with a Serious Mental Illness Daphna Oyserman, Carol T.Mowbray, Paula Allen Meares, and Kirsten B.Firminger III. ATTENTION DEFICIT-HYPERACTIVITY DISORDERS 10. Diagnostic Efficiency of Neuropsychological Test Scores for Discriminating Boys with and without Attention Deficit-Hyperactivity Disorder

viii

3 19 39

57

66 91

113

141

160

11.

12.

13.

Alysa E.Doyle, Joseph Biederman, Larry J.Seidman, Wendy Weber, and Stephen V.Faraone Efficacy of Methylphenidate among Preschool Children with Developmental Disabilities and ADHD Benjamin L.Handen, Heidi M.Feldman, Andrea Lurier, and Patty Jo Huszar Murray ADHD in Girls: Clinical Comparability of a Research Sample Wendy S.Sharp, James M.Walter, Wendy L.Marsh, Gail F.Ritchie, Susan D.Hamburger, and F.Xavier Castellanos Stimulant Treatment for Children: A Community Perspective Adrian Angold, Alaattin Erkanli, Helen L.Egger, and E.Jane Costello

IV. OTHER CLINICAL ISSUES 14. The Altering of Reported Experiences Daniel Offer, Marjorie Kaiz, Kenneth I.Howard, and Emily S.Bennett 15. Developmental Coordination Disorder in Swedish 7-year-old Children Björn Kadesjö and Christopher Gillberg 16. Thirty-Three Cases of Body Dysmorphic Disorder in Children and Adolescents Ralph S.Albertini and Katharine A.Phillips 17. Case Series: Catatonic Syndrome in Young People David Cohen, Martine Flament, Pierre-Francois Dubos, and Michel Basquin 18. Toward a Developmental Operational Definition of Autism Jane E.Gillham, Alice S.Carter, Fred R.Volkmar, and Sara S.Sparrow 19. Adolescent Onset of the Gender Difference in Lifetime Rates of Major Depression: A Theoretical Model Jill M.Cyranowski, Ellen Frank, Elizabeth Young, and M.Katherine Shear 20. Social/Emotional Intelligence and Midlife Resilience in Schoolboys with Low Tested Intelligence George E.Vaillant and J.Timothy Davis V. TREATMENT ISSUES 21. Effectiveness of Nonresidential Specialty Mental Health Services for Children and Adolescents in the “Real World” Adrian Angold, E.Jane Costello, Barbara J.Burns, Alaattin Erkanli, and Elizabeth M.Z.Farmer 22. Early Intervention Programs for Children with Autism: Conceptual Frameworks for Implementation Heather Whiteford Erba 23. Treatment for Sexually Abused Children and Adolescents Karen J.Saywitz, Anthony P.Mannarino, Lucy Berliner, and Judith

197

222

236 251

272 288

305

318 331

349

364

382

395

24.

25.

A.Cohen Neuroleptic Malignant Syndrome in Children and Adolescents Raul R.Silva, Dinohra M.Munoz, Murray Alpert, Ilisse R.Perlmutter, and Jose Diaz AHA Scientific Statement: Cardiovascular Monitoring of Children and Adolescents Receiving Psychotropic Drugs Howard Gutgesell, Dianne Atkins, Robyn Barst, Marcia Buck, Wayne Franklin, Richard Humes, Richard Ringel, Robert Shaddy, and Kathryn A.Taubert

VI. SOCIETAL ISSUES: VIOLENCE AND VICTIMIZATION 26. Twenty Years’ Research on Peer Victimization and Psychosocial Maladjustment: A Meta-Analytic Review of Cross-Sectional Studies David S.J.Hawker and Michael J.Boulton 27. Charting the Relationship Trajectories of Aggressive, Withdrawn, and Aggressive/Withdrawn Children During Early Grade School Gary W.Ladd and Kim B.Burgess 28. Violent Behavior in Children and Youth: Preventive Intervention from a Psychiatric Perspective Group for the Advancement of Psychiatry, Committee on Preventive Psychiatry 29. Agents of Change: Pathways through which Mentoring Relationships Influence Adolescents’ Academic Adjustment Jean E.Rhodes, Jean B.Grossman, and Nancy L.Resch 30. Initial Impact of the Fast Track Prevention Trail for Conduct Problems: II. Classroom Effects Conduct Problems Prevention Research Group Permissions

415

435

450

461

488

521

534

553 574

INTRODUCTION This millennial edition of the Annual Progress in Child Psychiatry and Child Development includes papers published in 1999 and 2000. The collection provides an overview of the wide-ranging interests of both researchers and clinicians at the turn of the twentieth century. Thirty papers, organized into six sections: Developmental Issues; Parenting; Attention Deficit Hyperactivity Disorder; Other Clinical Issues; Treatment Issues; and Violence and Victimization include both research reports and reviews of the literature.

DEVELOPMENTAL ISSUES The six papers in this section cover a wide range of topics. The paper by Frances D.Horowitz, written as the presidential address to the Society for Research in Child Development, was a warning to researchers about how to present child development knowledge to the public. She used the acronym “PITS” (person in the street) to refer to the public. Horowitz was concerned that developmental scientists might oversimplify child development in an attempt to respond to public interest. For example, if one were asked whether child care had a negative or positive effect on development one should not give a yes/no response. She presents a model that highlights the range of experiences (environmental and relationship factors) that interact with constitution to result in developmental outcomes. The second paper by Posner and Rothbart is an intriguing forward-looking discussion of the topic of self-regulation. The authors refer to studies of the self-regulation of attention and cognitive processes. The paper highlights recent work in neuroimaging that allows us to study brain plasticity and examine individual differences in self-regulation. The authors believe that individual differences in effortful control have implications for normal and pathological development. The next two papers are on attachment. The paper by Sroufe and colleagues reviews “implications of attachment theory for developmental psychopathology.” Attachment categories typically have been proposed to be variations on normal rather than pathological development. The authors elaborate on the transactional model for understanding the various pathways underlying pathology and the role of attachment relations within that model. Waters and his colleagues present new data on the stability of attachment classifications. They assessed 50 21-year-old individuals who had been seen in the Strange Situation when they were 12 months of age. The young adults completed the Adult Attachment Interview. There was a significant correspondence of categories between age one and age twenty-one. This is a nice, clean presentation of stability in a middle-class sample. The next paper by White and colleagues is an interesting study of an important topic,

the infant with colic. The authors used parent diaries and physiological measures. The data suggested that colic might be associated with a delay in the establishment of the circadian rhythm. Colic, although only lasting for a few months, can present significant burdens on family relationships. An understanding of the physiological basis of colic will one day lead to meaningful interventions. The last paper in this section is a small data-gathering study of an intriguing topic. Imaginary friends have long been noted in child development literature. However, there have been little data to suggest which children develop imaginary friends and whether the children who have imaginary friends have socialization difficulties. Gleason and colleagues distinguish children with invisible friends, personified objects, and with no imaginary companions.

PARENTING Part II presents three papers on parenting. The first paper, “Contemporary research on parenting: The case for nature and nurture,” is a collaborative effort by five psychologists, all well-established researchers on parenting. This is a thoughtful presentation of the different contexts for studying parental influence on child development. These include behavior genetics models that tease apart the percentage of nature and nurture on specific characteristics, gene-by-environment models, and parental influence models. They also present a discussion of environmental influences such as peers and neighborhood that affect parental influence. The second paper by Golombok and Murray and colleagues, discusses issues in parenting created by new reproductive technologies. They investigated parental and child functioning in four groups of families in which the parentchild genetic link varied. The groups included adoptive families, families created by in vitro fertilization, egg donation families, and donor sperm families. It is only since the 1980s that woman can have donor eggs implanted and conceive a child not genetically linked to them. Results are counterintuitive and worthy of continuing investigation. The paper raises interesting issues, including telling children about genetic parentage. The third paper is, “Parenting among mothers with a serious mental illness.” Improvements in medication, deinstitutionalization, and communitybased support programs have resulted in more women with serious mental illness being able to have and raise children. Oyserman and her colleagues review an important literature. They describe what is known about mothers with serious mental illness, including schizophrenia and affective disorders.

ATTENTION DEFICIT-HYPERACTIVITY DISORDER The diagnosis and treatment of attention deficit-hyperactivity disorder (ADHD) is the subject of increasing interest and concern among those devoted to enhancing the welfare of children, including parents, pediatricians, child psychiatrists and psychologists, as well as educators. Debate, often acrimonious, has tended to focus on the validity of diagnosis

and the appropriateness of various treatment options, most particularly pharmacological interventions. The four papers in this section, which provide a sampling of recent research, expand the empirical base for clinical decision making. As Doyle, Biederman, Seidman, Webber, and Faraone indicate in the first paper in this section, clinicians have long speculated that neuropsychological tests could aid in the diagnostic classification of children with ADHD. However, the results of this important study clearly demonstrate the limitations that attach to efforts to use neuropsychological test results to “validate” the diagnosis of ADHD. Careful history taking, clinical interviewing, and reports of informant observations of behavior, provide the basis for clinical diagnosis. Neuropsychological tests of attention and executive functioning under-identify children who exhibit abnormal patterns of inattention, impulsivity, and hyperactivity. Nevertheless, by clarifying patterns of strengths and weaknesses, neuropsychological testing may usefully supplement educational and treatment planning for individual children. The study reported by Handen, Feldman, Lurier, and Murray is a small N study, but nevertheless, it provides much needed information regarding the effects and side effects of methylphenidate (MPH) in preschool children with ADHD and developmental disabilities. The issue of medicating preschool children with developmental disabilities and/or mental retardation is controversial because it is often difficult to determine whether activity level and impulsive style are in excess of what would be expected for mental age. Nevertheless as the authors emphasize, the ADHD-like behaviors exhibited by at least some developmentally disordered preschoolers may result in suspension from intervention programs as well as severe family disruption. The results suggest that preschool children with developmental disabilities respond to MPH at rates similar to those of typically developing children, but might well be at greater risk of developing significant adverse side effects. The authors provide useful guidelines for noting MPH effects and side effects during standard office visits via observations of play and motherchild interactions. In the third paper in this section, Sharp, Walter, Marsh, Ritchie, Hamburger, and Castellanos describe the clinical characteristics and response to stimulant medication of girls with ADHD. As these authors point out, the investigation of ADHD in girls poses complex questions of referral bias and selection criteria, and almost all research has focused exclusively on boys. The clinical and medication response of this sample of girls proved to be strikingly similar to a previously studied research sample of boys with ADHD. The final paper in this section provides a community perspective on the use of stimulant medication for the treatment of ADHD. The study by Angold, Erkanli, Egger, and Costello examines the use of prescribed stimulants in relation to research diagnoses of ADHD in a community sample of children living in an 11-county region in the Great Smoky Mountains. Data on a representative sample of 4,500 children and adolescents aged 9, 11, and 13 years were collected in four waves between 1992 and 1996. The results of this study provide evidence for both the over- and under-treatment of symptoms of ADHD. Although the authors conclude that stimulant treatment was being used in ways substantially inconsistent with current diagnostic guidelines in this geographic area, it should be noted that the extent of inappropriate treatment is difficult to determine

because the diagnoses were based on parental report alone. Nevertheless, the results underscore how important it is for every clinician to establish clear indications for stimulant treatment on a case-by-case basis, to monitor the effectiveness of treatment in reducing target symptoms on an ongoing basis and discontinue treatment in a timely manner if clearly defined treatment goals are not met.

OTHER CLINICAL ISSUES The seven papers in this section address a range of topics of interest to practicing clinicians. In the first report, Offer, Kaiz, Howard, and Bennett direct attention to how reported experiences may be altered. The authors utilized data from a longitudinal study of development from adolescence to middle adulthood of a group of essentially normal males to investigate the stability of memory concerning perceptions of events and relationships that had occurred during adolescence. The findings indicate that the degree of concordance between responses made during adolescence and adulthood was no better than would be expected by chance. Whether these findings of this study of normal mentally healthy individuals can be extended to reports of past experiences of those who are medically or psychiatrically ill remains to be determined. Nevertheless, these results direct attention to the importance of the use of collateral sources to enhance the validity of relevant historical information when assessing adults and older adolescents. That some children lack the motor skills required for everyday activities is well known, but the prevalence, comorbidity, and outcome of developmental coordination disorder (DCD) is less clear. Kadesjo and Gillberg remedy this gap in their report of a population study of Swedish 7-year-old children, who were followed up at yearly intervals for an additional three years. DCD is a common problem, frequently comorbid with ADHD. Clinicians are urged to fully assess motor clumsiness, particularly in children with ADHD, to provide a basis for the development of treatment plans to minimize the functional impact of DCD. Although body dysmorphic disorder (BDD), a preoccupation with a nonexistent or slight defect in appearance, usually begins during adolescence, the disorder has been little studied in this age group. In the third paper in this section Albertini and Phillips report on the demographic characteristics, phenomenology, associated psychopathology, and treatment history and response of 33 children and adolescents below the age of 17, meeting DSM-IV criteria for the diagnosis of BDD. The results of this carefully executed descriptive study clearly indicate that social impairment is nearly universal among children and adolescents with BDD. Although surgical, dermatological, and dental procedures appear ineffective, serotonin reuptake inhibitors (SRIs) often appear to be helpful, even if the symptoms are delusional. The wealth of clinical information in this paper will aid clinicians to recognize and more effectively treat this distressing, often secret and underrecognized, but very debilitating condition. In the next paper in this section, Cohen, Flament, Dubos, and Basquin direct attention to catatonia, an infrequent but severe condition in young people. The authors’ augment their review of all reports of catatonic adolescents found in the literature between 1977 and 1997 (boys=25, girls=22) with an additional 9 consecutive cases seen during the past

6 years. The clinical features of catatonia as well as etiologies, complications, and treatment are similar to those reported in the adult literature. However, unlike adult studies, in which catatonic women represent 75% of the cases, of the total of 51 children and adolescents summarized in this report 60% were male. Although schizophrenia appears to be the most frequent associated diagnosis in adolescents, comorbid organic conditions, mood disorders, and developmental disorders have also been described. This paper provides clinicians with crucial information necessary for the diagnosis and treatment of this rare but sometimes fatal condition as it presents in children and adolescents. In their paper, “Toward a developmental operational definition of autism,” Gillham, Carter, Volkmar, and Sparrow point out that traditional diagnostic schemes typically list symptoms, but provide little guidance on how to incorporate information about developmental level in making a diagnosis. This study explores the ability of the Vineland Adaptive Behavior Scales to identify children with autism. The findings suggest that evaluating children’s socialization in the context of their developmental level may allow for a better appreciation of the ways in which symptoms change with age, and may reduce confusion about diagnosis among clinicians and parents. Depression is the next clinical issue addressed in this section. In it Cyranowski, Frank, Young, and Shear offer a theoretical model for understand-ing the adolescent onset of the gender difference in lifetime rates of major depression. In it the authors bring a vast array of information to bear as they outline the affiliative proclivities and potential depressogenic vulnerabilities of adolescent girls. As the authors indicate, the proposed theoretical framework has considerable heuristic value because it connects multiple fields of inquiry pointing the way to further programmatic research. The final paper in this section examines social/emotional intelligence and midlife resilience in schoolboys with low tested intelligence. As Vaillant and Davis point out, the natural history of low intelligence has been largely ignored, and the findings of this study will shatter many stereotypes. When the adult adjustment of 73 inner-city boys with a mean IQ of 80, followed prospectively from age 14 to 65 were compared with a socioeconomically matched sample of 38 boys with a mean IQ of 115, half of the low-IQ subjects were found to enjoy incomes as high and had children as well-educated as did highIQ men. Moreover the resilient low-IQ men were more likely to be generative, use mature defenses, and enjoy warm object relations than the high-IQ group as a whole. The authors provide several case vignettes to illustrate the proposition that “during the school years, low tested IQ is a terrible curse, but IQ is not destiny.” Resilience with respect to low tested intelligence appears to be mediated by those social skills often termed “emotional intelligence,” which includes the ability to know and manage feelings.

TREATMENT ISSUES The five papers in this section examine the current status of a range of treatments for psychiatrically and developmentally disordered children and adolescents. In the first paper, Angold, Costello, Burns, Erkanli, and Farmer provide an epidemiological perspective on the effectiveness of psychiatric treatment in the “real world.” As these

authors note, efficacy studies usually take place in resource-rich, university-based settings and involve highly selected, often nonreferred subjects who are willing to be randomized and who have relatively homogeneous histories. Whether such treatments are effective in the real world of the mental health practitioner’s office is clearly an important question—and the results of this study provide some answers. The use of a large, longitudinal, nonexperimental, community-based study to explore treatment effects naturalistically trades experimental rigor for ecological validity. Within these constraints, however, the results do suggest that the mental health care system for children can reduce symptoms in the real world, provided that the length of treatment is of sufficient length to be efficacious. Because real improvement does not become apparent until an individual has received more than 8 sessions, it is incumbent upon both individual practitioners and service planners to be cognizant of this important finding. Although there is a growing consensus that the functional potential of children with autism can be increased following exposure to intensive early intervention programs, evidence regarding the differential effectiveness of different programmatic contents is less clear. Nevertheless, families, physicians, and other service providers require information in order to make informed decisions regarding various intervention strategies. In the second paper in this section, Erba describes four diverse early intervention programs—discrete trial training, LEAP, floor time, and TEACCH, for children with autism. The theoretical underpinnings, intervention procedures, and connections between theory and practice are illustrated and available research outcomes are discussed. The paper is a useful resource for the practitioner, providing guidance to the family of a recently diagnosed young autistic child. Saywitz, Mannarino, Berliner, and Cohen provide an encyclopedic and very thoughtful review of research demonstrating the variable effects of childhood sexual abuse, the need for intervention, and the effectiveness of available treatment models. The authors emphasize that there is no evidence of a single cohesive syndrome resulting from child sexual abuse, although more than 50% of sexually abused children meet partial or full criteria for post-traumatic stress disorder. This review explicates well-controlled outcome studies that provide empirical evidence for extending and modifying treatment models from mainstream clinical practice to sexually abused children. Sensationalistic fringe treatments that treat sexually abused children as a special class of patients are not considered. A continuum of interventions, ranging from psychoeducation and screening, to short-term, abuse-focused, cognitive-behavioral therapy with family involvement, to more comprehensive long-term plans for multiproblem cases are considered. This review provides an invaluable guide, both to those who specialize in the area of the assessment and treatment of children who have been sexually abused as well as the practitioner seeking guidance regarding a rarely encountered individual case. The final two papers in this section summarize currently available information regarding serious and potentially fatal adverse effects of psychotropic medication. Neuroleptic malignant syndrome (NMS), a cluster of symptoms including hypertonicity, autonomic instability, fever, and cognitive disturbance, occurs in 0.5% to 1.4% of all individuals exposed to neuroleptics. Silva, Munoz, Alpert, Perlmutter, and Diaz summarize what is known about this condition as it occurs in children and adolescents. Their review of 77 reported cases of NMS provides a guide to early detection and

treatment interventions that can reduce the mortality and morbidity of this serious iatrogenic condition. The official scientific statement of the American Heart Association summarizes the cardiovascular effects of commonly used psychotropic medications in children and adolescents. The review—which details drug effects on the electrocardiogram, summarizes potentially dangerous drug interactions, and provides recommendations for cardiovascular monitoring—was prompted by reports of sudden deaths in children and adolescents receiving psychotropic medication. Its several tables and clearly stated recommendations make muchneeded information readily available to the prescribing practitioner.

SOCIETAL ISSUES: VIOLENCE AND VICTIMIZATION This section contains five papers. In the past few years, there have been several highly publicized cases of school violence. These incidences of children killing other children as well as teachers were exceptionally dramatic because they occurred in “unexpected” places, such as suburban and rural schools rather than urban, inner-city schools. These incidents have led more child professionals to try to understand which children are at risk for violence and what interventions might be successful at curbing violence. The first paper in this section is a review of cross-sectional studies of peer victimization on children’s adjustment. The meta-analysis by Hawker and Boulton indicated that children who are bullied by others tend to be high on psychosocial distress, particularly depression and loneliness. The second paper presents two years of longitudinal data highlighting the early behavioral characteristics that place children at risk for maladjustment and relationship problems. Ladd and Burgess present data from the Pathways Project, a multisite study. Teacher ratings of children’s aggressive and antisocial behaviors in the fall of kindergarten were used to place children into one of four behavioral risk groups. The trajectories of these groups were studied through the second grade in the current paper. The withdrawn group in kindergarten did not have relationship difficulties in the early years. Aggressive children had relationship difficulties with peers and teachers. The aggressive/ withdrawn children had the most difficulty. They were most often friendless, victimized, and dissatisfied. This study highlights the stability of behavioral risk and maladaptive relationships in the early grade school years. The third paper is a position paper by the Group for the Advancement of Psychiatry. Based on a literature review, the committee presented rates of violence and identified biological, psychological, and sociocultural factors that increase the risk of perpetrating violence. Because attempts to treat violence on an individual basis are costly and of limited success, the group advocates a tripartite model of prevention. This includes introducing universal measures to affect populations, selective measures designed for atrisk groups, and individual measures. In sum, the authors contend that violence is not really a sudden event. Its associated psychopathology develops slowly and has numerous psychiatric markers, thus putting child mental health practitioners in a position of early identification and intervention.

Numerous interventions to reduce violence and victimization have been developed and are being tested to determine their effectiveness. These include anti-bullying and conflict resolution curricular. The last two papers describe interventions. One is an individual intervention using mentors and the other is a “universal” classroom-based intervention. Rhodes, Grossman, and Resch studied 959 youth who applied to the Big Brother programs. Previous studies have found reduced rates of juvenile delinquency and substance abuse. Approximately half of the sample was placed with mentors and the remainder was used as controls. The children completed baseline and follow-up interviews 18 months later. This study highlights that a consistent mentoring relationship can serve as a corrective emotional experience for youth who have had unsatisfying relationships with their own parents. A positive mentoring experience was associated with improved parental relationships that in turn led to improved self-worth and achievement. The last paper is an interesting example of using entire schools to introduce interventions aimed at reducing violence. The Conduct Problems Prevention Research Group funded by NIMH and others is doing multi-site longitudinal studies. Someone interested in the topic should see other papers by members of this group. This paper describes the method of combining a universal intervention, the Fast Track PATHS (Promoting Alternative Thinking Strategies) classroom curriculum with a selective intervention. The selective intervention involved identifying the 10% of children with the highest incidence of early conduct problems and offering weekly parenting support classes, small-group social skills interventions, academic tutoring, and home visits. This intensive intervention was deemed necessary to reduce risk factors and promote protective factors in children on the path for antisocial behavior. It was believed that providing services to the classrooms would allow children to generalize their newly learned skills in a supportive setting. Promoting the development of social competence in all children should improve classroom atmosphere and social relations for all. The classroom was the unit of analysis in this paper and there is an interesting discussion of teachers’ interest and ability to implement interventions. This is an early paper from an ongoing study that will be of interest to many in education and school-age intervention. In summary, the papers included in this edition of the Annual Progress in Child Development and Child Psychiatry cover a multiplicity of topics. Some serve to deepen our understanding of the diagnosis and treatment of long recognized and well-described clinical phenomena, others direct attention toward issues of broader social concern, whereas still others focus normal developmental processes from both a neural and behavioral perspective—and as such, reflect the state of research interest and clinical practice at the turn of the century.

Part I DEVELOPMENTAL ISSUES

PART I: DEVELOPMENTAL ISSUES

1 Child Development and the PITS: Simple Questions, Complex Answers, and Developmental Theory Frances Degen Horowitz

The enormous popular interest in the field of child development makes it incumbent upon developmental scientists to convey with care the complexity of development lest oversimplified popular accounts gain credibility. Recent attempted models of development do include the range of variables and complexities that need to be accommodated in accounting for development. A model is presented here that incorporates many of the elements of recent models but elaborates on the role of experience in relation to the constitutional, cultural, economic, and social factors that contribute to advantages and disadvantages in children’s development. The importance of accommodating data from prior theoretical perspectives and the importance of the contributions from neuroimaging studies are discussed as they are critical for successful theory building in the field of child development.

INTRODUCTION For those who have not yet heard or figured it out, “Child Development and the PITS” translates into Child Development and the Person in the Street—the person in the street who asks simple questions and wants simple answers, who is puzzled by complex responses, and is terribly impatient with the nuances and qualifications that characterize contemporary theories of development. Some of you might have thought PITS was a reference to William James’ “TCPITS,” the common people in the street, but I actually modeled it on the title of a 1940s book on symbolic and mathematical logic by Lillian Lieber, MITS, WITS, and Logic (Lieber, 1960). MITS is the Man-In-The-Street and WITS is the Woman-In-The-Street. That slim volume, in its several editions, was and is a clever and sometimes humorous attempt to convey the essential aspects of symbolic logic to the person in the street. 1999 Presidential address to the Society for Research in Child Development.

Annual progress in child psychiatry and child development 2000–2001

4

Now if symbolic and mathematical logic for the man and woman in the street was a novelty 50 years ago, not so for child development. From the beginning of the modern serious focus on the study of children, well before the founding of the Society for Research in Child Development in 1933, surely dating back at least to the early days of the child study movement in the 1880s, popularized information about children and their development was aimed at people in the streets—at mothers and fathers and those responsible for the health and welfare of children (Cairns, 1983; Sears, 1975; Senn, 1975). And certainly, throughout the twentieth century, there has been no dearth of welland ill-informed books advising parents on the care of infants and children; wonderful and sometimes scary admixtures of well-grounded evidence and passionate advocacy. And it continues, increasing geometrically. Hit “parenting” at Amazon.com and one can browse the 75 bestsellers under the general title of parenting and families, or the 75 bestsellers on discipline, or on emotions and feelings, or on morals and responsibility. In the 12 pages that you can print out listing the 75 bestsellers on parenting and families you will note a number of volumes written by members of our Society along with the old standards—Spock’s Baby and Child Care (Spock, 1998)—as well as recent books of advice on raising the spirited child, the strong-willed child, the emotionally intelligent child, the nonconforming child, and the happy child. For the web sophisticate there is the National Parent Information Network (www.npin.org) which lists, among other items, more than 150 national parent information organizations. All this at the immediate—and literal—fingertips. As the information base in child development and the information resources for parents increase geometrically, we have a concomitant geometric decline in the amount of time it takes to access that information, along with a geometric decline in the amount of time it takes for information to go from academic debate and the research laboratory to translation and mutation into advice books, into the Sunday supplement articles, onto the radio and television talk shows, to be formed exquisitely and unforgettably into the media sound bite. All this—child development made easy for the PITS, the person in the street—is an understandable response to expressed and unexpressed needs of parents, and caregivers, and teachers. The media are only responding to the market. And responsive they are, proffering advice made sometimes too attractive, especially if it is made up of one part fact to three or four parts exaggeration, hype, and overgeneralization. What we have is a seemingly insatiable hunger for simple answers to simple questions. How else can we explain the relatively frequent headlines that claim the single-variable responsibility for developmental outcomes: it’s all about peers (parents are irrelevant), or the genes—more specifically, a gene—for shyness, for intelligence, for personality, for grammar. “First Gene to Be Linked with High Intelligence Is Reported Found” headlined science writer Nicholas Wade’s (1998) article for The New York Times with the tantalizing inset teaser: “A new clue in the debate over what determines ability.” “Variant Gene Tied to a Love of New Thrills” was The New York Times headline for Natalie Angier’s (1996) rather informed article about the “partial genetic explanation for a personality trait called ‘novelty seeking.’” Even when the texts of such articles make reference to appropriate qualifications and

Child Development and the PITS 5 note the complexities, the headlines convey the simpler message. These simpler messages get tucked into minds and shape popularized ideas into present and future belief systems. A number of years ago it was bonding, with dire implications foretold if there was no mother-infant skin-to-skin contact in the first hours after birth. More recently, the popular media have reported new recommendations, liberally mixed with political ideology, about infant feeding on demand needing to give way to feeding on strict schedules as corrective for generations of poorly disciplined children. Tomorrow, next month, next year, it will be other variables—identified in isolation, heralded as all-important if not all-determining. And there will be no surcease in supplying the stories for the reporters and the headline writers by those who, for a variety of reasons, some sincere and informed, some ideological and self-serving, are more than willing to satisfy the craving for simple answers to simple questions. This is not to deny that the ultimate scientific ideal is nothing if not the embodiment of the search for the simplifying and unifying assumptions that will integrate disparate pieces of evidence to explain highly complex phenomena. For sure, given the current state of affairs, our developmental science has a long way to go before we might achieve such scientific elegance—if ever we will. Though one might think, looking at the expansion of our database on children and their development, that we are making significant advances toward an elegant integration of our vast database into overarching theory. Witness the growth of “manuals” and “handbooks” from one volume to two volumes to four volumes to four fatter volumes (Carmichael, 1954; Damon, 1998; Mussen, 1970, 1983), to say nothing of the growth of the program of our own biennial meeting over the years. We have, I believe, the possibility of making significant progress toward the goal of a theoretical integration of our vast and growing database, but not if we persist in some of the peculiar tendencies of our science wherein each new theoretical formulation, rather than being tested by how well it accommodates existing data, is used to delegitimize data generated in the context of a previous theoretical fixation. I say delegitimize rather than ignore in the Kuhnian (Kuhn, 1970) sense, because, unlike in other sciences, where the success of new theoretical formu-lations is judged by how much of the existing verified data can be accommodated by the new theory, in human behavioral development new theories seem to be judged as successful by the numbers of adherents who are eager to reject data and principles generated by existing or older theories. Thus American Piagetian research ignored or rejected the data and principles established in the behaviorist tradition; behaviorism dismissed Gesellian data as uninformative and excoriated Freudian derived psychodynamic data. Behaviorism’s data, demonstrating more or less efficacious strategies for learning, were dismissed as nonlearning because they appeared to not consider more generic matters of cognition. Behaviorists were severely criticized and caricatured quite dismissively because they seemingly failed to include in the learning process the role of the “active child” acting on the environment to foster his or her own development. I’ve lost count of how often stimulus-response formulations of learning were said to be completely invalid because the S-R approach viewed the child as an entirely passive receptacle. One got the impression that critics were willing to suggest that it mattered little to behaviorists whether their participants were alert or anesthetized. To turn the

Annual progress in child psychiatry and child development 2000–2001

6

tables, how often have behaviorists dismissed discussions of data that included difficultto-operationalize speculations and propositions that are, in some important ways, the stuff of the imaginative musings that give rise to scientific and theoretical advances? How often have they eschewed data analysis techniques as representing group fictions?

GROWING CONSENSUS? All said, however, I detect important progress and some growing consensus in recent years, if not yet widespread agreement in our science, that recognizes a need to embrace data from a variety of theoretical perspectives in the service of formulating more overarching developmental theories. To be sure, we may just be in an era of a new set of buzzwords and phrases—dynamic, nonlinear, systems, plasticity, life-course trajectories, bioecological, person-in-context, reciprocal influences, mediators, connectionism, and attractors. It may also be said that we seem to be in an era of enthusiasm for models. In 1983, the first volume of the Handbook of Child Psychology was entitled History, Theory, and Methods (Kessen, 1983); in 1998, the first volume of the Handbook is entitled Theoretical Models of Human Development (Lerner, 1998). The models include Overton’s Bio/Social-Cultural Action Matrix (Overton, 1998), Gottlieb’s systems view of psychobiological development (Gottlieb, Wahlsten, & Lickliter, 1992), Fischer and Bidell’s dynamic, domain-specific, skill structure developmental web model (Fischer & Bidell, 1998), and Thelen and Smith’s dynamical systems and modified epigenetic landscapes (Thelen & Smith, 1994). Encouragingly, the current academic jargon and models involve more acknowledgments of complexity than has been previously true, driven in large part by the complexity of the data, especially in relation to large cross-sectional and longitudinal data sets. Against the media popularity of single-variable stories, the science itself is moving inexorably toward greater and greater data-driven, integrative theoretical complexity. An exception to this is behavioral genetics. In contrast to the dynamic nonlinear interactive models full of reciprocity between and among levels and variables, behavioral genetics presents a relatively nondynamic linear additive model that tries to assign percentages of variance in behavior and development that can be attributed to genes. The enterprise rests on the assumption that genetic influence can be expressed as a value accounting for a portion of the variance in a nondynamic linear equation for predicting behavioral functioning, and, furthermore, that individual experiences of shared and nonshared environments can be assessed inferentially by the degree of biological relatedness of individuals without empirical observations of experience (Hoffman, 1991; Horowitz, 1993). Behavioral genetics involves a relatively simplistic approach when compared with the kinds of dynamic system theories currently being elaborated. Perhaps that is why, in the mode of wanting simple answers to simple questions, behavior genetic reports are so media-attracting. However, so as not to seem to be repeating the practice I’ve just criticized of dismissing data in the face of new theoretical formulations, it needs to be said that the data reported in behavioral genetics studies involving degrees of

Child Development and the PITS 7 relationships among twins, siblings, and biologically unrelated individuals are in themselves interesting, even if it is doubtful that these relationships tell us anything about the direct and unmediated impact of genes. In formulating the more recent complex models of development one sees increasing skepticism about what is to be learned from assigning variance percentages to genes (e.g., Elman et al., 1998; Kagan, 1998). The skepticism is informed by approaches that see genes, the central nervous system, and other biological functions and variables as contributors to reciprocal, dynamic processes which can only be fully understood in relation to sociocultural environmental contexts. It is a perspective that is influenced by the impressive recent methodological and substantive advances in the neurosciences. Data from studies that employ neuroimaging techniques are providing extremely important information about structural plasticity in neuropsychological function. Most critically, this structural and functional plasticity across developmental time is being tied directly to the amplifications and constraints of the social/cultural contexts that determine the opportunities that children and adults have to experience and learn (Elman et al., 1998; Lewontin, Rose, & Kamin, 1984; Nelson & Bloom, 1997).

TOWARD AN INTEGRATIVE THEORY Let me suggest that these advances lead us, if not anywhere near the brink of an integrative theory and the elegance to be achieved by a set of unifying and simplifying assumptions, then at least toward a better understanding of the complex and dynamic nature of the relationships that impact development and the operation of developmental processes. Permit me to enter, not a new model of development per se, but a graphic to represent the range and complexity of what we must understand to achieve a fuller description of development and developmental processes (see Figure 1.1). It represents a way of thinking that I believe will accommodate and perhaps elaborate a number of the developmental models now being described and the data they are generating. In other words, this is not a de novo entrant into the arena of models but an attempt at a synthesis that might better organize our data and how we think theoretically. You will recognize in Figure 1.1 shades of a number of models and graphics by others with respect to organism-environment reciprocity (e.g., Gottlieb, Wahlsten, & Lickliter, 1998; Wachs, 1992) and efforts to parse the environment (e.g., Bronfenbrenner, 1979; Bronfenbrenner & Ceci, 1994; Horowitz, 1987; Horowitz & Haritos, 1998). In this model, as in some of the others, the assumption is made (supported by data) that from the moment of conception development is influenced by constitutional, social, economic, and cultural factors and that these factors, furthermore, continue in linear and nonlinear relationships, to affect development across the life span, with development broadly defined to accommodate both the increase and decrease in ability and function. Throughout the model, I use the word “experience” rather than “environment” to emphasize that the operative aspect of environment is experience. What is suggested by large amounts of data across many different studies (and not surprisingly to many in this audience) is that, taken together or in various linear and nonlinear combinations and

Annual progress in child psychiatry and child development 2000–2001

8

Figure 1.1 A depiction of the constitutional, social, cultural, and economic sources of influence on development with respect to the nature of experience and in relation to the circumstances of advantage, risk, and promise. permutations, constitutional, economic, social, and cultural factors provide the set of circumstances, or context, for development. These circumstances may, in aggregate, generally provide normal advantage, poor advantage, or high advantage. Unaggregated, as will be illustrated in a bit, they can also provide advantage or disadvantage in a particular developmental domain. In this schematic, the greater the presence of poorly advantaging circumstances, the more overall development is put at risk; the greater the presence of highly advantaging circumstances, the more promise for overall development. The circumstances that condition the possibilities of risk and promise begin with conception; past the moment of conception, in addition to the normal genetic and biological processes during the prenatal period, social, economic, and cultural variables of environmental origin, mediated by maternal biology, begin to operate. They contribute to setting the base of the child’s initial constitutional circumstances at birth. The point being made here is that already in the prenatal period, as a number of investigators have

Child Development and the PITS 9 shown, we have to consider experiential aspects of environmental origin, albeit mediated through maternal biology. Past the prenatal period, it becomes important and, I believe, useful to think about how to organize our thinking and data with regard to parsing the functional dimensions of experience in terms of what is the minimal level, amount, or nature of experience necessary for the development of the universal human behavioral repertoire—experience that is highly probable for the normally developing human organism; experience insured by the extensive amount of naturally occurring redundancy. Beyond the minimal level, I believe the data suggest there is a normal, highly likely range of experience provided postnatally for most children growing up in normal and near-normal environments. These experiences serve to sculpt and elaborate the basic species-typical universal human behaviors. They begin also to shape the vast repertoire of nonuniversal behaviors important to functioning in different social, cultural, and economic societies. The conundrum for many is to explain the regularities of the postnatal emergence of the normal universal species-typical behaviors in each individual child despite the seeming variations in the gross nature of environments. The nativist answer is recourse to instincts, to predetermined, architecturally and genetically driven explanations, both for the species as a whole and for the individuals in particular (Chomsky, 1965; Pinker, 1994; Spelke, Breinlinger, Macomber, & Jacobson, 1992; Spelke & Newport, 1998). To the Person in the Street these explanations seem to provide the simple answers to simple questions though the nativist position is by no means simplistic and the position is often supported by very interesting data. The alternative view and, I believe, the more compelling view is to consider that within all the gross environmental variations there is present the essential minimal experience necessary for the acquisition—the learning—of the basic universal behaviors of our species. There is a growing agreement that universal behaviors and physical structures are not built into the organism but that humans are, at the very least, evolutionarily primed to take advantage of the transactional opportunities provided by what Brandstäder (1998) sees as the universal physical and social ecologies available to all normal human organisms—the kinds of transactional opportunities so beautifully analyzed by Thelen and her colleagues with respect to early motor development (Thelen & Ulrich, 1991). As a result of these transactional experiences, the forms and functions of the universal developmental domains are constructed, whether as described in Thelen’s dynamic systems approach to motor development (Thelen & Smith, 1994; Thelen & Ulrich, 1991), or in Katherine Nelson’s (1996) powerful analysis and synthesis of the role of language in cognitive development, or in Kurt Fischer’s notion of the “constructive web” and his attempts to document the linear and nonlinear mechanisms involved in the construction and development of the hierarchies of skills (Fischer, 1980; Fischer & Bidell, 1998). These points of view are gaining in credibility because, with the aid of neuroimaging techniques (Nelson & Bloom, 1997), we are learning how actively responsive is the developing brain to experience. In all, the evidence is accumulating that the regularities of development are constructed as a result of the transaction of the individual with the seemingly big, buzzing, confusing, noisy environmental surround—an environmental context that provides a high level of redundant experiential opportunities for these universal capacities to be sculpted and, at the same time, for the variations across

Annual progress in child psychiatry and child development 2000–2001

10

environments to begin to shape the development of the nonuniversal behaviors that define individuals in linguistic, social, cognitive, economic, and cultural contexts (Horowitz & Haritos, 1998). For example, the capacity for language is a universal species-typical behavior of all normal humans. Its initial development and expres-sion rest on the normally occurring prenatal environment and the minimal level of the postnatal essential experience of hearing language and experiencing it in a social context. The acquisition of language is then further sculpted by the normal range of experiences involving the language of the cultural surround—Mandarin Chinese for one, Hebrew for another, Portuguese for another, and so on. I use the word “sculpted” here not to refer to some passive organism on which experience is writing the script but rather to an active collaboration of organismic (read constitutional) characteristics with experiential opportunities that impact the development of nonuniversal behaviors—nonuniversal behaviors that are determined in a social, cultural, economic, and constitutional context. In the normal range of experience, the capacity for language and the acquisition of a specific language is embedded in the social contexts that influence the use of language in communication, determining how language comes to serve the behavioral repertoire of social and cultural exchange expected of individuals in that cultural and social context. In turn, these experiences affect the development of constitutional characteristics in terms of brain structure and function with the constitutional characteristics also in dynamic relationship with experience and with the social, economic, and cultural contexts in which development is occurring. Until now, our attempts to parse and categorize experience have been relatively crude, crude as in Figure 1—suggesting, without much specification, that there is a minimal level of experience necessary for the development of basic universal behaviors, that a normal range of experience further enables the development of universal behaviors as well as the initial shaping of the nonuniversal behavioral repertoires. Beyond this, environments can provide for a range of normal additional experience and, further, extraordinary additional experience (all yet to be defined in terms of components and dynamic processes) which may or may not be the same across different environments. But there is a growing body of evidence that demonstrates the powerful effect of variations in experience, assuming some minima, on language development, on cognitive development, and on intelligence. In a detailed and painstaking study of the language input experiences and of the consequent language output of very young children growing up in different socioeconomic environments, Hart and Risley (1995) have shown that although all of the children they observed learned to talk and acquired the basic grammatical structure of English, children reared by professional parents had five times more words addressed to them over the first three years of life than did children reared by parents in poverty, with the concomitant effect of an increasingly widening gap between the recorded size of the children’s vocabulary so that by 3 years of age children reared by the more language-restricted parents in poverty had a vocabulary of less than 500 words, while those reared by language-rich professional parents had a vocabulary of about 1,100 words; children reared by middleand lower-income parents had a vocabulary of about 700 words. Huttenlocher and her colleagues (Huttenlocher, Levine, & Vevea, 1998) have shown the sensitivity of cognitive growth involving language, spatial operations, and concept

Child Development and the PITS 11 development to the experience reflected in the simple measure of amount of time spent in school. Brooks-Gunn, Klebanov, and Duncan (1996) have provided impressive evidence of the powerful impact of impoverished family resources on IQ such that when they controlled for the constellation of the social, economic, and cultural dimensions of poverty, the oft-reported black-white differences in IQ all but disappeared. It is almost 30 years since Sameroff and Chandler (1975), in their seminal chapter on the “continuum of caretaking casualty,” alerted us to the effects of the advantaging and disadvantaging macrosocial characteristics of environments on the postnatal developmental journeys of high-risk infants. The accumulating data since the 1970s has permitted us to refine our understanding of the variables and dynamics that impact the developmental outcomes of those infants. The data do, I believe, also permit us to conceptualize about the circumstances— constitutional, social, cultural, and economic—that conspire, effectively, to bestow normal, low, or high degrees of advantage during development—in general or with respect to particular developmental domains. The specific studies I have cited illustrate in a most general way that poorly advantaged environments, defined as providing children with impoverished or limited or sometimes only a little experience beyond the minimum, put the fullest realization of children’s development at risk by offering few or fewer opportunities for enriching additional experience or extraordinary additional experience. Conversely, highly advantaged environments, defined as providing many more opportunities for additional and enriched experiences, hold promise for the fullest realization of children’s development. At the extremes, at the ends of the continuum of advantage, a confluence of constitutional, social, economic, and cultural circumstances for poor advantage or enriched advantage can coalesce into what I call “swamping conditions.” That is, at the extremes a dense concentration of resources made possible, for example, by high socioeconomic advantage can have the effect of swamping development in a positive manner. Conversely, a dense concentration of disadvantaged circumstances can swamp development negatively. However, the picture is likely more complex. Swamping conditions at the extremes of disadvantage or advantage may or may not affect all domains of development, and they may have their origin in particular social, economic, cultural, or constitutional circumstances. For example, cerebral palsy or Down syndrome are constitutionally swamping conditions. Cerebral palsy is a swamping condition that involves severe constitutional compromises with respect to motor development. The presence of cerebral palsy may or may not have constitutional disadvantages in other developmental domains, and the child with cerebral palsy may be born into social, economic, and cultural circumstances that hold normal, low, or high degrees of advantage. In the case of cerebral palsy, its presence can render ineffective the minimal level of experience necessary for the development of the basic species behavioral universals related to human motor development. One can speculate that someday it will be possible, as it is now possible with the inborn metabolic disorder involved in phenylketonuria, to detect and then provide a physical/ biological/socially mediated intervention either prenatally or postnatally that would nullify cerebral palsy as a swamping condition for

Annual progress in child psychiatry and child development 2000–2001

12

normal motor development. In the meantime, this swamping condition may be ameliorated when children with cerebral palsy are provided with extraordinary additional experience designed to moderate the effect of the condition on motor functioning. This is not the occasion to explore the combinations and permutations and the linear and nonlinear functions that need to be taken into account in a refined analysis of the constitutional, social, economic, and cultural circumstances interacting with various degrees of experience, by domain and across time. Suffice it to say it is likely that the dynamics and constituents of developmental processes are not static across time, nor are they linear. Further, a systems analysis of these variables accommodates the idea that we are dealing also with the interactive impact of individual differences as well as the power of suddenly appearing or enduring variables to change the dynamics of the system, perhaps to function as disadvantaging swamping conditions: psychological trauma, cultural upheaval, physical disability and disease, and social chaos. In the same way, conditions of economic stability and affluence, social cohesion, high-quality education, and consistent and saturating extraordinary additional experience can function as advantaging variables and, if intensive enough, as advantaging swamping circumstances. We must recognize, too, the confluence of organism and environment or of particular constitutional and/or social and cultural circumstances that make for individual resilience in the face of adversity, and individual vulnerability in the face of advantage. As has been noted, poverty in our society is clearly a disadvantaging economic variable, although under certain constitutional social, historical, and cultural contexts its disadvantaging effects may well be attenuated (Elder, 1999; Werner & Smith, 1982, 1992), especially when not compounded by the added negative factors of racism and discrimination. Affluence is an obviously advantaging condition, although under certain constitutional social, cultural, and historical circumstances its advantaging power may be diminished. In other words, the degree to which any constitutional, social, economic, and cultural circumstance is relatively advantaging or disadvantaging is highly contextualized. Further, the functional consequences of these circumstances will rest strongly on the nature and extent of focused and fortuitous environmentally organized and mediated experiences. At the extremes, in certain domains the constitutionally or economically swamping conditions may well play stronger roles than social and cultural variables in determining the degree of advantage. The presence of cerebral palsy is a disadvantaging condition for motor development, as is Down syn-drome for mental development, but not necessarily for all aspects of social development. In the case of Down syndrome, we know that providing early extraordinary additional experience attenuates some of the mental retardation (Carr, 1992). In addition, children who may be constitutionally or otherwise advantaged with respect to extraordinary giftedness and talent in athletics, in music, in art, in language, typically require extraordinary additional experiences in learning, training, and opportunity for such gifts to be fully expressed and realized (Feldman, 1986). Toward an integrative theory of human behavioral development, the challenge for the approach outlined here, or for any such attempt, is to determine how well this kind of a theoretical approach accommodates, explains, and encompasses our reliable database. I believe we may now be nearer to some partially successful efforts in this regard than we

Child Development and the PITS 13 have been in the whole history of our discipline. That is reason to step back and acknowledge that as a result of the collective of our scientific enterprise across the globe, we can say, with some satisfaction, that we are indeed making important progress.

ON SOCIAL RESPONSIBILITY Of course, for the Person in the Street, our progress may not be all that comforting because it doesn’t lend itself to providing simple answers to simple questions. Yet it is often the simple answer that is wanted, the simple variable, the blanket relief from parental responsibility, or the blanket prescription that will fix what is wrong, or, prospectively, the blanket formula that will insure the best developmental outcome. Thus the popularity of the 75 bestsellers giving advice on how to raise the spirited, the strongwilled, the emotionally intelligent, the nonconforming, the happy child, to say nothing of how to increase your child’s IQ. Thus the popular media interest in conceptualizations that say not much will make a difference, just good enough parenting is all that is wanted. It is interesting to think that while “good enough parenting” (Scarr, 1992) may have some appeal, the idea of “good enough teaching” is currently quite out of sync with our expectations of schooling and the almost epidemic fervor in this country about raising academic standards and increasing the level of school achievement. Just a little inconsistency here, especially when, increasingly, at both the micro and macro levels, we are coming to understand parenting as teaching, the kind of nondidactic teaching embedded in the subtle and notso-subtle variations in children’s parentally organized experiences, the kind of parental teaching that increasingly appears to be critical for the developing child, especially in relation to the nonuniversal behavioral repertoire. Yet consider that if you give credence to the notion of “good enough parenting” and combine that with the popularized simple answer that it is really the genotype that is the determining factor and that little the parent does will make a difference, and if you assume that what is true for parental efforts holds true for the teacher in the classroom, then you have a seemingly scientific rationale for the failure to educate, a rationale you can claim is sanctioned by scientific authority citing specific facts. But unlike Gertrude Stein’s rose, a developmental fact is only a fact in a theoretical context, a lesson we should have learned well from Piaget, an understanding generally resisted by doctrinaire behaviorists. Keeping control of facts in relation to theoretical context becomes increasingly important as knowledge grows but also as the posing of simple questions and the desire for simple answers just does not abate. The urge to simplify and especially to geneticize is a strong one. I recall a request to reprint Figure 1 used in my book on developmental theories. I had labeled one of the dimensions in the figure as organismic and the other as environmental (Horowitz, 1987), but the colleague requesting to reprint the figure in a book had crossed out the word organismic and substituted the word genetic. No, I said, the two were not equivalent and, unless the original label was to be used, my permission would not be granted. Similarly, in this discussion, “constitutional” is not equivalent to “genetic,” and purposely so. Constitutional includes the expressed functions of genes—which, in

Annual progress in child psychiatry and child development 2000–2001

14

themselves require some environmental input—but constitutional includes the operations of the central nervous system and all the biological and environmental experiences that impact organismic functioning and make constitutional variables part of the dynamic and reciprocal interactions that change across the life span as they affect the development of and the decline of behavior. In this perspective, the scientific challenges before us are severalfold. One is, as I have already indicated, to make significant progress in identifying the functional units and roles of experience. We need to learn how best to parse experience for the purpose of seeing its role within the dynamic systems responsible for development. Another challenge is to integrate more fully into our account of behavioral development the evidence emerging from the neurosciences about the effect of experience in shaping neurological function and structure. Still another is to remain vigilant in submitting any new theoretical formulation to the test of how well it accommodates the reliable database of the phenomena it purports to cover. Beyond the scientific challenge, however, is the challenge of helping the Person in the Street to learn to ask less simple questions and the challenge of communicating our knowledge and making clear the limitations of our knowledge in the most socially responsible manner possible. A fact is a fact is a fact is not analogous to Gertrude Stein’s rose. Moreover, the image of Stein’s unyielding rose does not carry with it serious social implications for the fabric of a society, even though Stein’s formulation may have had some existential import and influence on asthetic appreciation and theory. The social import of our facts and their interpretation is something we must care about. For good or for ill, our knowledge base is of enormous interest to the Person in the Street. None of us can singlehandedly deter the determined maker of the sound bite but we can make it difficult. None of us can singlehandedly cause the quest for simple answers to disappear but we can consciously attempt to suggest, in every venue, in every forum, that at the present state of our discipline most simple questions about human behavior and development require complex, often incomplete and unsatisfying answers. If we accept as a challenge the need to act with social responsibility then we must make sure that we do not use single-variable words like genes or the notion of innate in such a determinative manner as to give the impression that they constitute the simple answers to the simple questions asked by the Person in the Street lest we contribute to belief systems that will inform social policies that seek to limit experience and opportunity and, ultimately, development, especially when compounded by racism and poorly advantaged circumstances. Or, as Elman and Bates and their colleagues said in the concluding section of their book Rethinking Innateness (Elman et al., 1998), “If our careless, underspecified choice of words inadvertently does damage to future generations of children, we cannot turn with innocent outrage to the judge and say ‘But your Honor, I didn’t realize the word was loaded.’” As SRCD has so clearly acknowledged in its effort to communicate responsibly what we know for the purpose of informing enlightened social policy, we must do so only if we repeatedly remind the people in the street who ask the simple questions that development is complex, that our theories are incomplete, and that we do not fully understand all the variables and systems in control of development and developmental processes, even though, I believe, we can now say that our growing database points to the

Child Development and the PITS 15 critical role of experience interacting with the organism in affecting the realization of human potential in all domains and across the life span.

ADDRESS AND AFFILIATION Corresponding author: Frances Degen Horowitz, The Graduate School and University Center, City University of New York, 365 Fifth Avenue, New York, NY 10016–4309; email: [email protected]

REFERENCES Angier, N. (1996, January 21). Variant gene tied to love of new thrills. New York Times, p. A1. Brandtstäder, J. (1998). Action perspectives on human development. In R.M.Lerner (Ed.), W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 807–864). New York: Wiley. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Bronfenbrenner, U., & Ceci, S.J. (1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychological Review, 101, 568– 586. Brooks-Gunn, J., Klebanov, P.K., & Duncan, G. (1996). Ethnic differences in children’s intelligence test scores: Role of economic deprivation, home environment, and maternal characteristics. Child Development, 67, 396–408. Cairns, R.B. (1983). The emergence of developmental psychology. In W.Kessen (Ed.), P.H.Mussen (Series Ed.), Handbook of Child Psychology: Vol. 1. History, theory, and methods (4th ed., pp. 41–102). New York: Wiley. Carmichael, L. (Ed.). (1954). Manual of child psychology. New York: Wiley. Carr, J. (1992). Longitudinal research in Down syndrome. In N.W.Bray (Ed.), International review of mental retardation research (Vol. 18, pp. 197–223). New York: Academic Press. Chomsky, N. (1965). Aspects of a theory of syntax. Cambridge, MA: MIT Press. Damon, W. (Ed.). (1998). Handbook of child psychology (5th ed.). New York: Wiley. Elder, G.H. (1999). Children of the great depression. Boulder, CO: Westview. Elman, J.L., Bates, E.A., Johnson, M.H., Karmiloff-Smith, A., Parisi, D., & Plunkett, K. (1998). Rethinking innateness. Cambridge, MA: MIT Press. Feldman, D. (1986). Nature’s gambit. New York: Basic Books. Fischer, K.W. (1980). A theory of cognitive development: The control and construction of hierarchies of skills. Psychological Review, 87, 477–531. Fischer, K.W., and Bidell, T.R. (1998). Dynamic development of psychological structures in action and thought. In R.M.Lerner (Ed.), W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 467–561). New York: Wiley.

Annual progress in child psychiatry and child development 2000–2001

16

Gottlieb, G., Wahlsten, D., & Lickliter, R. (1998). The significance of biology for human development: A developmental psychobiological systems view. In R.M. Lerner (Ed.), W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 233–274). New York: Wiley. Hart, B., & Risley, T.R. (1995). Meaningful differences. Baltimore: Paul H.Brookes. Hoffman, L.W. (1991). The influence of the family environment on personality: Accounting for sibling differences. Psychological Bulletin, 110, 187–203. Horowitz, F.D. (1987). Exploring developmental theories: Toward a structural/behavioral model of development. Hillsdale, NJ: Erlbaum. Horowitz, F.D. (1993). Bridging the gap between nature and nurture. A conceptually flawed issue and the need for a comprehensive new environmentalism. In R. Plomin & G.E.McClearn (Eds.), Nature, nurture & psychology (pp. 341–354). Washington, DC: APA Books. Horowitz, F.D., & Haritos, C. (1998). The organism and the environment: Implications for understanding mental retardation. In J.A.Burack, R.M.Hodapp, & E. Zigler (Eds.), Handbook of mental retardation and development (pp. 20–40). New York: Cambridge University Press. Huttenlocher, J., Levine, S., & Vevea, J. (1998). Environmental input and cognitive growth: A study using time-period comparisons. Child Development, 69, 1012–1029. Kagan, J. (1998). Three seductive ideas. Cambridge, MA: Harvard University Press. Kessen, W. (Ed.). (1983). In P.H.Mussen (Series Ed.), Handbook of child psychology: Vol. 1. History, theory and methods (4th ed.). New York: Wiley. Kuhn, T. (1970). The structure of scientific revolutions. Chicago: Chicago University Press. Kuo, Z.-Y. (1967). The dynamics of behavior development. New York: Random House. Lerner, R.M. (Ed.). (1998). In W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed.). New York: Wiley. Lewontin, R.C., Rose, S., & Kamin, L.J. (1984). Not in our genes. New York: Random House, Pantheon Books. Lieber, L.R. (1960). Mits, wits, and logic (3rd ed.). New York: Norton. Mussen, P.H. (Ed.). (1970). Carmichael’s manual of child psychology. New York: Wiley. Mussen, P.H. (Ed.). (1983). Handbook of child psychology (4th ed.). New York: Wiley. Nelson, C.A., & Bloom, F.E. (1997). Child development and neuroscience. Child Development, 68, 970–987. Nelson, K. (1996). Language in cognitive development: The emergence of the mediated mind. New York: Cambridge University Press. Overton, W.F. (1998). Developmental psychology: Philosophy, concepts and methodology. In R.M.Lerner (Ed.), W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 107–188). New York: Wiley. Phelps, J.A., Davis, J.O., & Schwartz, K.M. (1997). Nature, nurture, & twin research strategies. Current Directions in Psychological Science, 6, 117–121. Pinker, S. (1994). The language instinct: How the mind creates language. New York: William Morrow. Sameroff, A.J., & Chandler, M.J. (1975). Reproductive risk and the continuum of

Child Development and the PITS 17 caretaking casualty. In F.D.Horowitz (Ed.), Review of child development research (Vol. 4, pp. 187–244). Chicago: University of Chicago Press. Scarr, S. (1992). Developmental theories for the 1990s: Development and individual differences. Child Development, 63, 1–19. Sears, R.R. (1975). Your ancients revisited: A history of child development. In E.M. Hetherington (Ed.), Review of child development research (Vol. 5). Chicago: University of Chicago Press. Senn, M.J.E. (1975). Insights on the child development movement in the United States. Monographs of the Society for Research in Child Development, 40(3–4), Serial No. 161. Spelke, E.S., Breinlinger, K., Macomber, J., & Jacobson, K. (1992). Origins of knowledge. Psychological Review, 99, 605–632. Spelke, E.S., & Newport, E.L. (1998). Nativism, empiricism, and the development of knowledge. In R.M.Lerner (Ed.), W.Damon (Series Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 275–340). Spock, B. (1998). Dr. Spock’s baby and child care. New York: Pocket Books. Thelen, E., & Smith, L.B. (1994). A dynamic systems approach to the development of cognition and action. Cambridge, MA: MIT Press/Bradford Books. Thelen, E., & Ulrich, B.D. (1991). Hidden skills: A dynamical systems analysis of treadmill stepping during the first year. Monographs of the Society for Research in Child Development, 56(1), Serial No. 223. Wachs, T.D. (1992). The nature of nurture. Newbury Park, CA: Sage. Wade, N. (1998, May 14). First gene to be linked with high intelligence is reported found. The New York Times, p. A16. Werner, E., & Smith, R. (1982). Vulnerable but invincible: A study of resilient children. New York: McGraw-Hill. Werner, E.E., & Smith, R.S. (1992). Overcoming the odds. Ithaca, NY: Cornell University Press.

PART I: DEVELOPMENTAL ISSUES

2 Developing Mechanisms of Self-Regulation Michael I.Posner and Mary K.Rothbart

Child development involves both reactive and self-regulatory mechanisms that children develop in conjunction with social norms. A half-century of research has uncovered aspects of the physical basis of attentional networks that produce regulation, and has given us some knowledge of how the social environment may alter them. In this paper, we discuss six forms of developmental plasticity related to aspects of attention. We then focus on effortful or executive aspects of attention, reviewing research on temperamental individual differences and important pathways to normal and pathological development. Pathologies of development may arise when regulatory and reactive systems fail to reach the balance that allows for both self-expression and socially acceptable behavior. It remains a challenge for our society during the next millennium to obtain the information necessary to design systems that allow a successful balance to be realized by the largest possible number of children.

INTRODUCTION We believe that understanding self-regulation is the single most crucial goal for advancing an understanding of development and psychopathology. Early in this century, Freud (1920) argued that the ego and superego developed to regulate largely unconscious motivational systems. In the latter part of this century mechanisms of self-regulation have begun to be uncovered through the study of attention and effortful control. There is also substantial reason to believe that understanding mechanisms of self-regulation in normal individuals will lead to advances in diagnosis, prevention, and possibly treatment of developmental problems like attention deficit disorder and learning disabilities. In turn, studies of these mechanisms in the developmental disorders will enhance our understanding of normal functioning. Self-regulation involves complex questions about the nature of volition and its relation to our genetic endowment and social experience. Much of the work on self-regulation has been purely behavioral. This is true in both attention studies carried out within cognitive psychology and studies of effortful control as a temperamental dimension. The lack of appropriate methods to study the physiology of the human brain has previously led to an

Annual progress in child psychiatry and child development 2000–2001

20

understandable hesitation in thinking about these processes at the neurosystems level. Kandel (1998, 1999), however, has argued persuasively that new concepts in neuroscience now make it possible to attempt to relate higher level cognitive concepts to underlying brain systems. His goal is to use modern neuroscience to reinvigorate the psychoanalytic approach to the mind, and he stresses the role of unconscious early experience in shaping the brain systems that control adult behavior. Even if such connections prove to be as yet premature, there is little question that they will be major topics in the coming years. A major goal of our chapter is to help the reader understand how new developments related to neural plasticity and neuroimaging have transformed the potential for understanding mechanisms that provide voluntary control of brain systems. Although Kandel (1998, 1999) has emphasized the relation of genetic and cellular processes to psychoanalytic concepts and therapy, our chapter concentrates mainly at the neurosystems level and deals with the mechanisms that produce voluntary control of our thoughts and actions. Discoveries within neuroscience have moved the field toward viewing the brain as plastic and open to influence by experience (Garraghty, Churchill, & Banks, 1998; Merzenich & Jenkins, 1995). The advent of neuroimaging has provided new tools for testing hypotheses about how the brain changes with experience and for exploring the behavioral mechanisms of self-regulation (Posner & Raichle, 1994). In this chapter we first examine some of the historical background for considering attention networks as mechanisms of self-regulation in the human brain. Next, we take advantage of imaging methods to examine how the brain might be altered by experience on a time scale from milliseconds to years. We then examine the role of high-level attentional networks as a vehicle for self-regulation and consider evidence that similar brain areas control regulation of emotion and cognition. We consider how individuals differ in effortful control and what some of the consequences of those differences might be for normal and pathological development. In our final section, we speculate on future developments in this field.

HISTORY Within cognitive psychology, the mechanisms thought to be involved in self-control are collectively called attention. In 1958, Donald Broadbent summarized British work in the field of attention in his volume Perception and Communication. He proposed a filter that held back messages from an unattended channel to keep them from interfering with selected input. Broadbent’s beautiful studies, summarized in nearly every textbook in psychology, provided a basis for studying how we make a selection of relevant information from the masses of potential input. The studies reviewed in his book viewed attention as a high-level skill that allowed some experts to perform selective feats such as simultaneous translation and even novices to have a role in selecting their environment. There were challengers to Broadbent’s ideas, but it is remarkable, in view of the four decades that have passed since 1958, how even his strongest critics have followed his general ideas. For example, Anne Treisman (1969) showed that the filter could better be

Developing mechanisms of self-regulation 21 described as an attenuator, with much less interference when input was to separate modalities (eye and ear), rather than to one. Norman (1969) argued it would be better to see the filter as operating later in the system, after input had already activated material stored in long-term memory. Indeed, experiments rather quickly established that familiar words could look up their meanings even prior to being perceived (Posner, 1978). Allport (1980) challenged whether limited capacity was related to attention, and argued that interference instead resulted from contradicting behavioral task demands. However, all of the ideas about attention that dominated cognitive journals for the last half century were clearly derivatives of the basic question Broadbent (1958) had posed about selective listening: How was it that some aspects of the input were perceived and others not? The connection between selective processes in perception and more general issues of selfregulation had to await a link between cognitive and the neurophysiological level of analysis. An important early link between studies of attention within human cognition and those using the methods of neurophysiology was provided by Sokolov (1963) in his treatment of the orienting reflex. The orienting reflex provided a physical basis for filtering input and presaged the intense interest within neurophysiology in how attention might modulate activity within sensory specific areas (Hillyard & Lourdes, 1998). The concept of the orienting reflex was readily adapted to the study of preverbal infants who could not be instructed as to where to attend by experimenters (see review by Ruff & Rothbart, 1996). Ruff and Rothbart (1996) identify landmark periods in the first year of life with regard to orienting to objects and control of distress and in the second year and beyond in children’s ability to plan and regulate cognitive skills. It was a relatively easy step to identify these changes in the ability of the child to regulate behavior with the development of brain areas that carried out attentional selection in adults. This step, however, has a powerful consequence. It allows us to transfer knowledge on the anatomy and circuitry of attentional networks (Posner & Raichle, 1994) to the development of orienting and regulation in infants and adults (Posner & Rothbart, 1998), providing mechanisms for understanding self-regulation and its development. In the following, we consider changes in the human brain that might reflect both the rapid switch of content that occurs when adult subjects shift the focus of their attention and the much slower accumulation of the ability to control attention that occurs over the early years of development.

PLASTICITY In neuroscience, the issue of plasticity in brain activity has been discussed mainly at the synaptic level. For example, correlated neural firing among neurons in contact with each other leads to a change in the probability of one neuron being able to induce firing in the other. This principle of learning, first discussed by Hebb (1949), has been shown to be a basic principle for synaptic plasticity. The use of neuroimaging methods, however, has provided an altogether different level of analysis of plasticity. Instead of individual synapses, the focus is on the question of how experience influences the set of neural areas active within a task and their time

Annual progress in child psychiatry and child development 2000–2001

22

course of activation. This work has begun to allow us to consider possible neural mechanisms for many of the kinds of changes involved in children’s learning and education. Table 2.1 indicates some of the ways in which the person’s own activity or learning from external-based events might work to change brain circuitry on a temporary or more permanent basis.

TABLE 2.1 Mechanisms of Plasticity

Time 1. Milliseconds 2. Seconds to minutes 3. Minutes to days 4. Weeks 5. Weeks 6. Years

Phenomenon Shifts in attention Priming

Mechanism Amplification

Reference Corbetta et al. (1990)

Tuning

Jiang et al. (2000)

Practice New associations Rule learning Development

Pathway Connections

Raichle et al. (1994) McCandliss et al. (1997)

Structures Attention networks

McCandliss et al. (1997) Posner & Rothbart (1998)

The top row of Table 2.1 refers to the finding that attention allows rapid changes in neural activity in local brain areas. Neuroimaging methods are sensitive to changes in blood flow that accompany neural activity. When a brain area is being used to perform computations in high-level skills, it will increase in activity (Corbetta, Miezin, Dobmeyer, Shulman, & Petersen, 1990). As children learn a new skill, they may show a high level of variability as they try different strategies (Siegler, 1997). Each of these strategies is represented by a connected set of neural areas that carry out particular computations in some order. In adult studies, it is possible to demonstrate how a particular strategy may assume momentary dominance. Attention can provide priority to some computations, reprogramming the organization of the circuits by which tasks are executed. Priority is produced by amplifying the amount of neural activity within the area performing the computation. Often this is done voluntarily, as one tries to select a set of operations that seem most appropriate to a given task. This is what we call effortful control by attention. However, strategies may also arise from the physical situation. In the presence of a calculator, the person may enter numbers and press the appropriate key. If the calculator is absent, the numbers may be written down and the operations perform mentally. In this way, the environment primes one network of areas rather than another. Priming (row 2 of Table 2.1) is produced by the presentation of a sensory event (e.g., the calculator mentioned in the preceding), or by thought (e.g., the activation of a visual or auditory word), which changes the processing pathway so that stimuli sharing some or the entire pathway will be processed more efficiently. Priming can produce reduced reaction time for responding to a related target that follows the prime. Neuroimaging and cellular studies suggest that the number of neurons activated by a primed target is reduced over

Developing mechanisms of self-regulation 23 those activated in nonprimed target processing. The prime apparently tunes the neurons involved in the target event so that only those most appropriate to processing the subsequent target are activated (Ungerleider, Courtney, & Haxby, 1998). The mechanisms of rows 1 (attention shifts) and 2 (priming) of Table 2.1 provide two means to improve the processing of a target. The first method requires the person to attend to the computation. The involvement of attention sets up a network for processing the stimulus, but at the cost of making attention less available for handling other events. Priming, however, may occur when attention is now no longer involved in the process, leaving it free to deal with other items. Nevertheless, the network remains active for a period to make the processing of previously attended computations available. Priming may also occur without attention as the result of a sensory process. A pathway that has been tuned by a priming event does not require current attention and thus does not produce interference with ongoing activity (Posner, 1978). Effortful control through attention and automatic pathway activation apparently achieve the same behavioral results by quite different underlying mechanisms. Practice on a set of already learned but not recently rehearsed associations (row 3 of Table 2.1) shows that automaticity can completely change the pathway used to accomplish the task. In one study using PET (Raichle et al., 1994), people were required to generate a use for a read or heard noun (e.g., pound as a use for a hammer). When a new list of words was presented there was activity in the left frontal and posterior cortex, anterior cingulate, and right cerebellum. Activity in the anterior insula was reduced over what was found in simply reading the words aloud. A few minutes of practice at generating an associated use shifted activation so that the left frontal and posterior areas important in generating a new use dropped away and the anterior insula, strongly activated during reading aloud, increased. When generating a given word became automated with practice, the same circuit was used as when skilled readers read words aloud. There appeared to be one circuit associated with the thought needed to generate a familiar but unpracticed use, and another when the task was automated, as in reading aloud or generating again a just practiced association. The circuit used for thought includes attentional mechanisms involving effortful control, whereas an automated circuit does not involve attention. In the study cited in the preceding, people are dealing with already wellknown associations; for example, the association between hammer and pound. Even when they have not practiced them recently, connections between hammer and pound are available. However, it is often necessary to acquire entirely new associations, as in learning the words of a foreign language. This involves establishing new connections in the brain (row 4 of Table 2.1) and may require many weeks of practice. In one study of learning 40 lexical items in a new artificial language, it took 20 to 50 hours of practice before the words showed the same superiority in reaction time usually found for reading the native language (McCandliss, Posner, & Givon, 1997). Even more complex than learning a few new associations is developing a whole system to carry out an important linguistic function (row 5 of Table 2.1). Studies using PET with literate adults have shown that areas of the visual system of the brain become active when strings of letters are possible words in English, whether they have meaning or not (Petersen, Fox, Snyder, & Raichle, 1990). This area of the brain is not active for nonsense

Annual progress in child psychiatry and child development 2000–2001

24

strings like a series of consonants. It seems to represent English orthography and has been called the visual word form system (Petersen et al., 1990). This system appears to be a left posterior function that serves to group letters of a word automatically into a single chunk. No such unified chunk occurs for a string of consonants. This system appears to require some years to develop. Evidence suggests it is not present in 7-year-olds, even in those who know how to read, and can be found in 10-year-olds to a limited degree. Moreover, once this system is developed, it appears to be strongly resistant to change (Posner & McCandliss, in press). The final row of Table 2.1 refers to changes in brain structures that develop over the early life span of the person. We have in mind the several years apparently required to develop attentional networks. One form of attentional control deals with the selection of information by orienting to a sensory modality or location (e.g., eye movements or shifts of visual attention in vision). Orienting shows marked development in the first year of life (Ruff & Rothbart, 1996). In the visual system, early development includes improvements in acuity, control of fixation, ability to disengage, preference for novel objects and locations, and the control of emotional distress (Ruff & Rothbart, 1996). A second form of attention shows strong development in the second year of life and after (Posner & Rothbart, 1998). It provides the child with the necessary independence from his or her sensory world to develop an agenda of his or her own. The development of this system and its significance for the child are described further in the following.

EXECUTIVE CONTROL The central issue of this section is to describe an approach for examining executive function as a developmental process in early childhood. The goal is to provide an experimental means to link individual differences in self-regulatory behaviors developing in early childhood to the maturation of underlying neural systems. Norman and Shallice (1986) developed a model of adult attention very much in the spirit of the Broadbent approach. They argued that a supervisory attention system comes into play in adults in resolving conflict, correcting errors, and planning new actions. There now appears to be excellent data that the ability to resolve conflict undergoes development in early childhood. Adult studies using positron emission tomography (PET) have been consistent in showing activity in midline frontal areas during tasks that might be thought to involve executive attention (Bush et al., 1998; Posner & DiGirolamo, 1998). One such task we have already discussed is generating the use of a word. When blood flow due to reading words aloud is subtracted from blood flow in generating a use, there is a strong activation in the frontal midline along with language related areas of the left hemisphere and in connected areas in the cerebellum. Subsequent studies using high-density electrical recording have shown that midfrontal activity is detected very early, about 150 ms after input. This suggests that the first activity involves marshaling the cognitive effort needed to generate a use beyond that needed in the relatively effortless task of reading aloud. This view also agrees with PET studies showing that midfrontal activity may occur even before the task starts, when subjects know that a difficult task will occur (Murtha,

Developing mechanisms of self-regulation 25 Chertkow, Beauregard, Dixon, & Evans, 1996). The most frequently studied task found to activate the frontal midline has been the Stroop effect. In this task, subjects must respond to one dimension of a stimulus (usually the ink color), while ignoring another prepotent dimension (usually the color word name). A summary of the many results on Stroop effect conflict shows a remarkable convergence on areas of the frontal midline in the anterior cingulate gyrus (Bush et al., 1998). Because the anterior cingulate is the major outflow of the limbic system, however, it seems reasonable that its main function would be related to emotion, not cognition, and there is clear evidence that anterior cingulate activity is a part of the brain’s system for evaluating pain (Rainville, Duncan, Price, Carrier, & Bushness, 1997) and for distress vocalization (Devinsky, Morrell, & Vogt, 1995). The pain studies have shown cingulate activity when heat stimuli were judged as painful in comparison to merely warm. Moreover, the cingulate activity appears to be more related to the amount of subjective distress caused by the pain than to the intensity of the sensory stimuli involved (Rainville et al., 1997). When an effort was made to control the distress produced by a given stimulus using hypnotic suggestion, the amount of anterior cingulate activation reflected felt distress, whereas the somatosensory cortex reflected stimulus intensity. Recent studies of negative emotion in adults have suggested that distress is also related to activity in the amygdala (Davidson & Sutton, 1995). When pictures depicting frightening or horrible scenes are shown to subjects, there is strong activation of the amygdala, and evidence now exists that activation of the amygdala can be modulated by frontal activity (Davidson & Sutton, 1995). There is some evidence that cingulate activity is related to our awareness of emotion rather than to the emotion itself. To measure emotional awareness, people are asked to describe how they feel about situations. Their written responses are coded for use of emotional terms and descriptors (Lane & Schwartz, 1992) and the resultant score is taken as a measure of their emotional awareness. In a recent study, twelve subjects were shown each of three highly emotional movies and three neutral movies during a PET scan (Lane et al., 1996). Differences in anterior cingulate blood flow between the emotional and neutral movies were positively related to the person’s level of emotional awareness. These data suggest that something about awareness of emotions during sad or happy events is related to changes in the anterior cingulate. This result is similar to the finding discussed in the preceding indicating that cingulate activity is more related to the painful feelings than to the intensity of the stimulus inducing the pain (Rainville et al., 1997). Control of distress is a major task for the infant and caregiver in the early months of life, and attention plays an important role in this regulation (Harman, Rothbart & Posner, 1997). In the first few months, caregivers help control distress mainly by holding and rocking. Increasingly, in the early months, visual orienting is also used. Caregivers then attempt to involve the child in activities that will occupy their attention and reduce their distress. These interactions between infant and caregiver may train the infant in control of distress and lead to the development of the midfrontal area as a control system for negative emotion. Later, when similar cognitive challenges arise, a system for regulating remote brain areas may be already prepared. Many psychologists agree with Denckla (1996) that “the difference between the child

Annual progress in child psychiatry and child development 2000–2001

26

and adult resides in the unfolding of executive functions” (p. 264). Luria (1973) also referred to the development of a higher level voluntary social attention system. More voluntary attentional mechanisms and individual dif-ferences in executive attention have important implications for the early development of behavioral and emotional control (Rothbart & Bates, 1998). In an early example of cognitive control in a limited domain, Diamond (1991) showed the stages from 9 to 12 months in the child’s resolving conflict between reaching along the line of sight in order to retrieve an object in a box. At 9 months, the line of sight dominates completely. Even if the infant’s hand touches the toy through the open side of the box, if its movement is not in line with the side the child is looking at, the infant will withdraw the hand and reach along the line of sight, striking the closed side. Three months later, infants are able to look at a closed side but reach through the open end to retrieve the toy. However, being able to reach for a target away from the line of sight is only a very limited from of conflict resolution. Gerstadt, Hong, and Diamond (1994) studied verbal conflict modeled on the Stroop paradigm in children as young as 3.5 years. Two cards were prepared to suggest day and night to the children: one depicted a line drawing of the sun, the other a picture of the moon surrounded by stars. Children in the conflict condition were instructed to say day to the moon card and night to the sun card. Children in the control condition were divided into two groups and instructed to say day or night to either a checkerboard or ribbon card. At every age, accuracy scores were significantly lower for conflict relative to control trials. Other efforts have been made with Stroop-like tasks (Jerger, Martin, & Piozzolo, 1988) and with the Wisconsin card sort task (Zelazo, Reznick, & Pinon, 1995) to study children as young as 31 months; little evidence of successful inhibitory control below 3 years has been found. We believe that children as young as 18 months might be undergoing development in frontal midline areas that would allow the limited conflict resolution related to eye position to become more general. We had found that children at 18 months could show context-sensitive learning of sequences (Clohessy, Posner, & Rothbart, in press). This is a form of learning that, in adults, appears to require access to the kind of higher level attention needed to resolve conflict. Adults can learn sequences of spatial locations implicitly when each location is invariably associated with another location (e.g., locations 13241324). This occurs even when the adult is distracted with a secondary task known to occupy focal attention (Curran & Keele, 1993). The implicit form of skill learning seems to rely mainly upon subcortical structures. However, when distraction is present, adults are not able to learn context-sensitive sequences (e.g., locations 123213) in which each association is ambiguous. We found that infants as young as 4 months could learn the unambiguous associations, but not until 18 months did they begin to show the ability to learn ambiguous or context-sensitive associations (e.g., locations 1213). Individual children showed wide differences in their learning abilities, and we found that the ability to learn context-sensitive cues was positively related to the caregiver’s report of the child’s vocabulary development. According to the analysis of the last section, a more direct measure of the development of executive attention might be reflected in the ability to resolve conflict between simultaneous stimulus events as in the Stroop effect. Because children of this age do not

Developing mechanisms of self-regulation 27 read, we reasoned that the use of basic visual dimensions of location and identity might be the most appropriate way to study the early resolution of conflict. The variant of the Stroop effect we designed to be appropriate for ages as young as 2 to 3 years involved presenting a picture depicting a simple object on one side of a screen directly in front of the child and requiring the child to respond with a key that matched the stimulus they were shown (Gerardi-Caulton, in press). The appropriate key could be either on the side of the stimulus (compatible trial) or on the side opposite the stimulus (incompatible trial). The child’s prepotent response was to press the key on the side of the target irrespective of its identity; however, the task required the child to inhibit the prepotent response and to respond instead based on identity. The ability to resolve this conflict is measured by the accuracy and speed of their key-press responses. Results of the study strongly suggested that executive attention undergoes dramatic change during the third year of life. Performance by toddlers at the very beginning of this period was dominated by a tendency to repeat the previous response. Perseveration is associated with frontal dysfunction, and this finding is consistent with the idea that executive attention is still very immature at 24 months. Even at this young age, however, toddlers were already showing a significant accuracy difference favoring compatible over incompatible trials. By the second half of the third and beginning of the fourth year, children showed a strikingly different pattern of responses. Children now performed with high accuracy for both compatible and incompatible conditions, showing the expected slowing for incompatible relative to compatible trials. The developmental transition appeared to occur at about 30 months. It was also possible to examine the relationship of our laboratory measures of conflict resolution to children’s performance on a battery of tasks requiring the child to exercise inhibitory control over their behavior. We found substantial correlations between these two measures. Even more impressive, elements of the laboratory task were significantly related to aspects of temperamental effortful control and negative affect. Children who were less slowed by conflict were described as showing lower negative affect. As we have seen, cingulate activity would be expected to relate well at this age to control of distress. It appears that the cognitive measure of conflict resolution has a substantial relation to the aspects of the child’s self-control that parents can report.

INDIVIDUALITY Temperament refers to individual differences in motor and emotional reactivity and selfregulation (Rothbart & Bates, 1998). The temperamental vari-able related to the development of executive attention is called effortful control, representing the ability to inhibit a dominant response in order to perform a subdominant response. The construct of effortful control is extremely important in understanding the influence of temperament on behavior. Until recently, almost all of the major theories of temperament have focused on temperament’s more reactive aspects related to positive and negative affect, reward, punishment, and arousal to stimulation. Individuals were seen to be at the mercy of their dispositions to approach or avoid a situation or stimulus, given reward or punishment cues. More extraverted individuals were expected to be sensitive to reward and show

Annual progress in child psychiatry and child development 2000–2001

28

tendencies to rapid approach; more fearful or introverted individuals, sensitive to punishment, were expected to show inhibition or withdrawal from excitement (Gray, 1987). Systems of effortful control, however, allow the approach of situations in the face of immediate cues for punishment, and avoidance of situations in the face of immediate cues for reward. The programming of this effortful control is critical to socialization. The work of Kochanska (1995) indicates that the development of conscience is related to temperamental individual differences in effortful control. Kochanska and colleagues found significant prediction from infants’ 9-month sustained attention to their contemporaneous restraint in touching a prohibited toy and to a multitask behavioral battery assessing effortful control at 22 months (Kochanska, Murray, & Harlan, 1999; Kochanska, Tjebkes, & Forman, 1998). In two large longitudinal studies (32 to 66 months and 9 to 45 months), Kochanska and her colleagues assessed children’s effortful control in a laboratory test battery (Kochanska, Murray, & Coy, 1997; Kochanska, Murray, Jacques, Koening, & Vandegeest, 1996, 1999). Although the number and difficulty of tasks was varied to assure developmental appropriateness, beginning at age 30 months, children’s performance was highly consistent across tasks, suggesting that they all measured a common process that developed over time. Children were also remarkably stable in their performance across time, with the stability of a composite measure of effortful control approaching that of some of the most enduring of traits such as intelligence or aggression. In addition, children’s performance and their parents’ reports about their temperamental effortful control capacities in their daily lives also converged significantly. Other research suggests longer-term stability of executive attention during childhood. In Mischel’s work, for example, the number of seconds delayed by preschool children while waiting for physically present rewards predicted their parent-reported attentiveness, ability to concentrate, and control over negative affect when the children were adolescents (Mischel, 1983; Shoda, Mischel, & Peake, 1990). Although temperament researchers had originally believed that temperament systems would be in place very early in development and change little over time (e.g., Buss & Plomin, 1975), we have since learned that temperament systems follow a developmental course (Rothbart, 1989; Rothbart & Bates, 1998). Children’s reactive tendencies to experience and express negative and positive emotions and their responsivity to events in the environment can be observed very early in life, but children’s self-regulatory executive attention develops relatively late and continues to develop throughout the early school years. Because executive attention is involved in the regulation of emotions, some children will be lacking in controls of emotion and action that other children can demonstrate with ease. Questionnaire studies of 6- to 7-year-olds have found a broad effortful control factor to be defined in terms of scales measuring attentional focusing, inhibitory control, low intensity pleasure, and perceptual sensitivity (Rothbart, Ahadi, Hershey, & Fisher, 1997). Effortful control scores are negatively related to children’s scores on a negative affectivity factor. This negative relation is in keeping with the notion that attentional skill may help attenuate negative affect. An interesting example involves the negative relation between effortful control and aggression. Aggression relates negatively to effortful control and positively to surgency and negative affectivity, especially anger (Rothbart,

Developing mechanisms of self-regulation 29 Ahadi, & Hershey, 1994). Because effortful control makes no unique contribution to aggression, it may regulate aggression indirectly by controlling reactive tendencies underlying surgency and negative affectivity. For example, children high in effortful control may be able to direct attention away from the rewarding aspects of aggression, or to decrease the influence of negative affectivity by shifting attention away from the negative cues related to anger. Eisenberg and her colleagues, for example, found that 4to 6-year-old boys with good attentional control tend to deal with anger by using nonhostile verbal methods rather than overt aggressive methods (Eisenberg, Fabes, Nyman, Bernzweig, & Pinulas, 1994). Empathy is also strongly related to effortful control, with children high in effortful control showing greater empathy (Rothbart et al., 1994). In a study of elderly hospital volunteers, Eisenberg and Okun (1996) found attentional control to be positively related to sympathy and perspective taking, and negatively related to personal distress. In contrast, negative emotional intensity was positively related to sympathy and personal distress. Effortful control may support empathy by allowing the individual to attend to the thoughts and feelings of another without becoming overwhelmed by their own distress. Similarly, guilt or shame in 6- to 7-year-olds is positively related to effortful control and negative affectivity (Rothbart et al., 1994). Negative affectivity may contribute to guilt by providing the individual with strong internal cues of discomfort, thereby increasing the probability that the cause of these feelings is attributed to an internal rather than external cause (Dienstbier, 1984). Effortful control may contribute further by allowing the flexibility needed to relate these negative feelings of responsibility to one’s own specific actions and to negative consequences for another person (Derryberry & Reed, 1994, 1996). Consistent with these influences on empathy and guilt, effortful control also appears to play a role in the development of conscience. The internalization of moral principles appears to be facilitated in fearful preschool-aged children, especially when their mothers use gentle discipline (Kochanska, 1991, 1995). In addition, internalized control is facilitated in children high in effortful control (Kochanska et al., 1996). Here, we see the influence of two separable control systems, one reactive (fear) and one self-regulative (effortful control), regulating the development of conscience. Although fear may provide reactive inhibition and strong negative affect for association with moral principles, effortful control provides the attentional flexibility needed to link negative affect, action outcomes, and moral principles. These findings illustrate the importance of temperament in general and effortful control in particular to the child’s emotional, cognitive, and social development. These underlying temperament systems may also serve a central role in the self-organization of personality (Rothbart, Ahadi, & Evans, 2000). This is particularly evident in the functions of attention, which select and coordinate the most important information and contribute to the storage of this information in memory. Although much theorizing emphasizes children’s behavior and influences of the immediate environment, children think about their experiences and can use attention to “replay” their positive and negative experiences. We now revisit Table 1 in its relation to temperament and effortful control. Voluntary attention shifting may moderate the experience of negative affect (row 1), whereas

Annual progress in child psychiatry and child development 2000–2001

30

involuntary orientation to negative affect may limit attentional capacity. Further, automatic emotional priming (row 2) may influence the meaning of events to the child. Emotional reactivity will also be influential in developing a system of learning that allows us to interact well with others (row 4) and to learn more arbitrary rules connected with conscience (row 5). Finally, development of the attentional systems themselves will provide the capacities underlying the development of self-regulation (row 6). Across development, one would expect emotional and attentional processes to function together to progressively stabilize particular kinds of information, shaping the child’s representation of the self and world (Derryberry & Reed, 1994, 1996; Rothbart et al., 1994). The study of temperamental individual differences thus links effortful control mechanisms to issues of empathy, aggression, and conscience that represent central issues of child socialization, and leads us now to a discussion of development and psychopathology.

DEVELOPMENT AND PSYCHOPATHOLOGY The early part of this century saw the development of psychoanalysis (Freud, 1920). Beginning with the neurology known in his time, Freud uncovered unconscious mechanisms that code our implicit experience and proposed methods to prevent them from controlling the behavior of patients suffering from various forms of pathology. Since that time, advances in neuroscience have changed our ability to link specific brain mechanisms to behavior (Kandel, 1998, 1999). At the same time, progress in psychology has begun to specify the mechanisms whereby individuals regulate their feelings and thoughts. We now recognize that both automatic or unconscious impulses and conscious strategies work to control behavior. Future efforts should help us forge an understanding of these concepts at cellular and genetic levels (Albright, Jessell, Kandel, & Posner, 2000). The area of development and psychopathology examines the interplay between conscious and unconscious mechanisms in both normal and atypical persons (Cicchetti & Cohen, 1995). This approach to development stresses the diverse pathways by which early temperament is refined through experience (Cicchetti & Tucker, 1994). For example, children high in fear and low in selfevaluation may come to avoid achievement situations resulting in possible feelings of inadequacy, leading to even stronger fear or anxiety and avoidance in response to novel or challenging situations. This developmental progression, however, is not without recourse. Changes in the external or internal environment may lead to improvements in an individual’s ability to master developmental changes and thus to redirect a developmental trajectory. Neuroimaging should allow us an increasing ability to examine control mechanisms of the brain and to understand how their malfunction may form the basis for pathologies. For example, to display empathy to others requires that we interpret their signals of distress or pleasure. Imaging work in normal adults shows that sad faces activate the amygdala. As sadness increases, this activation is accompanied by activity in the anterior cingulate as part of the attention network (Blair, Morris, Frith, Perrett, & Dolan, 1999). It seems likely that the cingulate activity represents the basis for our attention to the distress

Developing mechanisms of self-regulation 31 of others. Psychopaths, for example, fail to show behavioral responses to sad faces and lack empathy to the distress of others. It seems likely that they would show either reduced activity in the amygdala or a loss of cingulate activation or both. If in one person the amygdala shows a strong response to the sadness of others, empathy would emerge quite naturally, but if little or no signal occurs, effortful control as influenced by socialization might still allow successful use of whatever signal was present. This is an example of how we might understand at a biological level the various pathways by which development produces either successful socialization or antisocial pathology. With the introduction of neuroimaging studies, it became possible to discover which brain areas became active during cognitive tasks. As discussed, many conflict tasks like the Stroop effect produced activation of the anterior cingulate (Bush et al., 1998). Washburn (1998) showed rhesus monkeys could be trained to perform a version of the Stroop effect known in humans to activate the cingulate. The monkeys showed many more errors on incompatible trials than do humans, however, despite many hundreds of trials at the task. It is as though the monkeys have somewhat less capacity for avoiding interference, despite very extensive training. A recent study was conducted with adults who suffer from attention deficit disorder. They performed conflict trials only slightly less efficiently than normals, but unlike normal controls they showed no evidence of anterior cingulate activation and instead showed greater activity on incompatible trials in the anterior insula (Bush et al., 1999). It is possible that the insula represents a more primitive pathway to output, one allowing for less effortful control (Raichle et al., 1994). Genetic studies of ADHD families have shown that they possess a mutation that affects the dopamine 4 receptor (LaHoste et al., 1996; Smalley et al., 1998). The dopamine 4 receptor is expressed in layer V of the cingulate. Although the anterior cingulate is an ancient structure, there is evidence that it has evolved significantly in primates. Humans and great apes appear to have a cell type found mainly in layer V of the anterior cingulate and the insula, which is not present in other primates (Nimchinsky et al., 1999). It is not known what the function of this cell is, but it appears to be a form of projection cell. There is evidence of development in the connectivity of this cell in childhood (Conel, 1959) and it is known that layer V of the cingulate expresses several dopamine receptors (Lidow, Wang, Cao, & Goldman-Rakic, 1998). Although there is as yet no direct evidence of the cellular basis of the cingulate activity found in neuroimaging studies, the importance of this area for emotional and cognitive tasks invites further exploration of linkage between the cellular architecture of this area and its function in self-regulation. Another disorder that produces a disruption of attentional control, as well as other emotional and cognitive problems, is schizophrenia. Benes (1999) has reported subtle abnormalities of the anterior cingulate in postmortem analyses of schizophrenic brains. She argues that the problem in schizophrenic brains may be a shift in dopamine regulation from pyramidal to nonpyramidal cells. She has also argued that these changes in the cingulate are related to circuitry involving the amygdala and hippocampus. These effects involve the D2 receptor and are strongest within layer II of the anterior cingulate. However, there are strong connections between layers II and V. The schizophrenia studies thus provide an entry to possible dysregulation of the anterior cingulate at a cellular level in a second abnormality noted for its attentional deficits.

Annual progress in child psychiatry and child development 2000–2001

32

FUTURE DIRECTIONS This paper has touched upon a number of areas in which we expect significant progress in the future. These include studies at the genetic, cellular, and synaptic levels, as well as at the neurosystems levels. In our understanding of temperamental individual differences, we also see a number of important di-rections for the next century. Findings suggest developmentally changing pathways through which early temperament, in conjunction with processes of socialization, can influence the development of social-cognitive processes. Tracing such developmental pathways to adaptive outcomes and the development of behavior problems and psychopathology will be among several promising directions for future work. Needed in the future is a more thorough understanding of the processes of temperament and how they develop, including surgency and extraversion, fear, and frustration, as well as attention. Many of these advances will come from affective and cognitive neuroscience, where to date much progress has been made in understanding the emotions (Davis, 1992; LeDoux, 1996; Panksepp, 1998) and attention (Posner & Raichle, 1994), as we have discussed in this paper. We expect progress in the study of brain structure and its underlying molecular genetics to be of great future importance. In addition, we will be looking toward improved temperament assessment methods that target multiple levels: behavior in laboratory paradigms, including marker tasks for the development of brain structures; behavior in naturalistic daily contexts; physiological measures; informant reports; and self-reports, including information about felt experience. Advances in assessment and empirical understanding will further allow us to link the past and future in the study of development. We envision moving toward bridging research on temperament in childhood with that on personality in adulthood (Caspi, 1998) within a coherent framework on individual differences that temperament can provide. The pathways between early temperament and future personality outcomes will, of necessity, be intricate, because child individuality unfolds in the context of social relationships, and continuity and change cannot be understood without considering the developmentally changing impact of social experience. To understand developmental pathways, we will need to disentangle complex interaction effects among early temperament predispositions, socialization processes, relationships, and culture. Recent research has begun to provide compelling support for such interactions (Bates, Pettit, Dodge, & Ridge, 1998; Belsky, 1997a, 1997b; Belsky, Hsieh, & Cranic, 1998; Kochanska, 1991, 1995, 1997; Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996; Wachs & Gandour, 1983). Because of those complexities, we are likely to find examples of both equifinality and multifinality in development (Cicchetti, 1993). Temperamentally different children may arrive at similar or equivalent outcomes via different pathways. For example, in Kochanska’s (1995) studies, fearful toddlers whose parents used gentle discipline and fearless toddlers whose parents capitalized on positive motivation in a close relationship attained comparable levels of conscience. Temperamentally similar children’s

Developing mechanisms of self-regulation 33 developmental pathways may also diverge as a result of different effective experiences in relationships or varying cultural pressures (Rothbart, Ahadi, & Evans, 2000). Finally, in considering issues of developmental pathways, it remains the challenge of this new century, as it has for all previous periods of human history, to seek to balance the needs of the developing child in expressing his or her individuality with the needs of the society to regulate such expression. Whether by drugs, training, or social engineering, we can be sure that the struggle to control impulses will continue both within and among individuals. The case of attention deficit disorder is one interesting example. Empirical evidence favors the efficacy of drugs, which, like Ritalin, will provide many children with the help they need to attend to their school lessons (Swanson et al., 1998). However, it may also be possible that training of high-level attention during the periods when it is undergoing development would prevent the expression of the disorder, at least in some children. The use of drugs and training also does not rule out the idea that the social environment may itself be a serious cause of some pathology. Panksepp (1998), for example, suggests the importance of engineering the social environment of schools to provide access to play with peers that he feels is lacking in the current scene. His suggestion need not conflict with drug treatment and training, and, indeed, multiple avenues for change may be needed to provide the kind of human beings best able to thrive in the society we will have in the future. As students of normal and pathological development, we must continue attempts to understand the mechanisms involved in self-regulation so that we will have methods to help adapt our children to a changing environment. As members of society, we must try to use our knowledge in a way that enhances the number of children for whom a successful balance between self-expression and the demands of society can be found.

ACKNOWLEDGMENTS This work was supported by grants from the James S.McDonnell Foundation and Pew Memorial Trusts and by NIMH Grant 43361 to the University of Oregon and gratefully benefited from contributions by Grazyna Kochanska and Douglas Derryberry.

REFERENCES Allbright, T., Jessell, T., Kandel, E., & Posner, M.I. (2000). Neuronal communication: A problem for the 21st Century. Cell, 100, 51–55. Allport, D.A. (1980). Attention and performance. In G.Claxton (Ed.). Cognitive psychology: New directions (pp. 17–42). London: Routledge & Kegan Paul. Bates, J.E., Pettit, G.S., Dodge, K.A., & Ridge, B. (1998). Interaction of temperamental resistance to control and restrictive parenting in the development of externalizing behavior. Developmental Psychology, 34, 982–995. Belsky, J. (1997a). Theory testing, effect-size evaluation, and differential susceptibility to rearing influence: The case of mothering and attachment. Child Development, 68, 598–

Annual progress in child psychiatry and child development 2000–2001

34

600. Belsky, J. (1997b). Variation in susceptibility to environmental influence: An evolutionary argument. Psychological Inquiry, 8, 182–186. Belsky, J., Hsieh, K.-H., & Crnic, K. (1998). Mothering, fathering, and infant negativity as antecedents of boys’ externalizing problems and inhibition at age 3 years: Differential susceptibility to rearing experience? Development and Psychopathology, 10, 301–319. Benes, F. (1999). Model generation and testing to probe neural circuitry in the cingulate cortex of postmortem schizophrenic brains. Schizophrenia Bulletin, 24, 219–229. Broadbent, D.E. (1958). Perception and communication. London: Pergamon. Blair, R.J.R., Morris, J.S., Frith, C.D., Perrett, D.I., & Dolan, R.J. (1999). Dissociable neural responses to facial expression of sadness and anger. Brain, 1222, 883–893. Bush, G., Frazier, J.A., Rauch, S.L., Seidman, L.J., Whalen, P.J., Rosen, B.R., & Biederman, J. (1999). Anterior cingulate cortex dysfunction in attention-deficit/ hyperactivity disorder revealed by fMRI and the counting Stroop. Biological Psychiatry, 45, 1542–1552. Bush, G., Whalen, P.J., Rose, B.R., Jenike, M.A., McInerney, S.C., & Rauch, S.L. (1998). The counting Stroop: An interference task specialized for functional neuroimaging—validation study with functional MRI. Human Brain Mapping, 6, 270– 280. Buss, A.H., & Plomin, R. (1975). A temperament theory of personality development. New York: Wiley. Caspi, A. (1998). Personality development across the life course. In W.Damon & N. Eisenberg (Eds.), Handbook of child psychology: Vol. 3. Social, emotional and personality development (5th ed., pp. 311–388). New York: Wiley. Cicchetti, D. (1993). Developmental psychopathology: Reactions, reflections, projections. Developmental Review, 13, 471–502. Cicchetti, D., & Cohen D. (1995). Developmental psychopathology. New York: Wiley. Cicchetti, D., & Tucker, D.M. (1994). Development and self-regulatory structures of the mind. Development and Psychopathology, 6, 533–549. Clohessy, A.B., Posner, M.I., & Rothbart, M.K. (in press). Development of the functional visual field. Acta Psychologica. Conel, J.L. (1959). The cortex of the twenty-four month old infant (Vol. 6). Cambridge, MA: Harvard University Press. Corbetta, M., Miezin, F.M., Dobmeyer, S., Shulman, G.S., & Petersen, S.E. (1990). Attentional modulation of neural processing of shape, color, and velocity in humans. Science, 248, 1556–1559. Curran, T., & Keele, S.W. (1993). Attentional and nonattentional forms of sequence learning. Journal of Experimental Psychology: Learning, Memory, & Cognition, 19, 189–202. Davidson, R.J., & Sutton, S.K. (1995). Affective neuroscience: The emergence of a discipline. Current Opinion in Neurobiology, 5, 217–222. Davis, M. (1992). The role of the amygdala in fear and anxiety. Annual Review of Neuroscience, 15, 353–375. Denckla, M.B. (1996). A theory and model of executive function: A neuropsychological

Developing mechanisms of self-regulation 35 perspective. In G.R.Lyon & N.A.Krasnegor (Eds.), Attention, memory and executive function (pp. 263–278). Baltimore: Paul H.Brookes. Derryberry, D., & Reed, M.A. (1994). Temperament and the self-organization of personality. Development and Psychopathology, 6, 653–676. Derryberry, D., & Reed, M.A. (1996). Regulatory processes and the development of cognitive representations. Development and Psychopathology, 8, 215–234. Devinsky, O., Morrell, M.J., & Vogt, B.A. (1995). Contributions of anterior cingulate to behavior. Brain, 118, 279–306. Diamond, A. (1991). Neuropsychological insights into the meaning of object concept development. In S.Carey & R.Gelman (Eds.), The epigenesis of mind: Essays on biology and cognition (pp. 67–110). Hillsdale, NJ: Erlbaum. Dienstbier, R.A. (1984). The role of emotion in moral socialization. In C.E.Izard, J. Kagan, & R.B.Zajonc (Eds.), Emotions, cognition, and behavior (pp. 484–514). Cambridge: Cambridge University Press. Eisenberg, N., Fabes, R.A., Nyman, M., Bernzweig, J., & Pinulas, A. (1994). The relations of emotionality and regulation to children’s anger-related reactions. Child Development, 65, 109–128. Eisenberg, N., & Okun, M.A. (1996). The relations of dispositional regulation and emotionality to elders’ empathy-related responding and affect while volunteering. Journal of Personality, 64, 157–183. Freud, S. (1920). A general introduction to psychoanalysis. New York: Basic. Garraghty, P.E., Churchill, J.D., & Banks, M.K. (1998). Adult neural plasticity: Similarities between two paradigms. Current Directions in Psychological Science, 7 (3), 87–91. Gerardi-Caulton, G. (in press). Sensitivity to spatial conflict and the development of self regulation in children 24–36 months of age. Developmental Science. Gerstadt, C.L., Hong, Y.J., & Diamond, A. (1994). The relationship between cognition and action: Performance of children 3½–7 years old on a Stroop-like daynight test. Cognition, 53, 129–153. Gray, J.A. (1987). Perspectives on anxiety and impulsivity: A commentary. Journal of Research in Personality, 21, 493–509. Harman, C., Rothbart, M.K., & Posner, M.I. (1997). Distress and attention interactions in early infancy. Motivation and Emotion, 21, 27–43. Hebb, D.O. (1949). Organization of behavior. New York: Wiley. Hillyard, S.A., & Lourdes, A.V. (1998). Event-related potentials in the study of visual selection attention. Proceedings of the National Academy of Science USA, 9, 781–787. Jerger, S., Martin, R.C., & Pirozzolo, F.J. (1988). A developmental study of the auditory Stroop effect. Brain and Language, 35, 86–104. Jiang, Y., Haxby, J.V., Martin, A., Ungerleider, L.G., & Parasuraman, R. (2000). Complementary neural mechanisms for tracking items in human working memory. Science, 287, 643–646. Kandel, E.R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry, 155, 457–469. Kandel, E.R. (1999). Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited. American Journal of Psychiatry, 156, 504–524.

Annual progress in child psychiatry and child development 2000–2001

36

Kochanska, G. (1991). Socialization and temperament in the development of guilt and conscience. Child Development, 62, 1379–1392. Kochanska, G. (1995). Children’s temperament, mothers’ discipline, and security of attachment: Multiple pathways to emerging internalization. Child Development, 66, 597–615. Kochanska, G. (1997). Multiple pathways to conscience for children with different temperaments: From toddlerhood to age five. Developmental Psychology, 33, 228–240. Kochanska, G., Murray, K., & Coy, K.C. (1997). Inhibitory control as a contributor to conscience in childhood: From toddler to early school age. Child Development, 68, 263–277. Kochanska, G., Murray, K., & Harlan, E. (2000). Effortful control in early childhood: Continuity and change, antecedents, and implications for social development. Developmental Psychology, 36, 220–232. Kochanska, G., Murray, K., Jacques, T.Y., Koenig, A.L., & Vandegeest, K.A. (1996). Inhibitory control in young children and its role in emerging internalization. Child Development, 67, 490–507. Kochanska, G., Tjebkes, T.L., & Forman, D.R. (1998). Children’s emerging regulation of conduct: Restraint, compliance and internalization from infancy to the second year. Child Development, 69, 1378–1389. LaHoste, G.J., Swanson, J.M., Wigal, S.B., Glabe, C., Wigal, T., King, N., & Kennedy, J.L. (1996). Dopamine D4 receptor gene polymorphism is associated with attention deficit hyperactivity disorder. Molecular Psychiatry, 1, 121–124. Lane, R.D., Reiman, E., Ahern, G., Schartz, G., Davidson, R., Axelrod, B., & Yun, L. (1996). Anterior cingulate participates in the conscious experience of emotion. Psychosomatic Medicine, 58, 73. Lane, R.D., & Schwartz, G.E. (1992). Levels of emotional awareness: Implications for psychotherapeutic integration. Journal of Psychotherapy Integration, 2, 1–18. LeDoux, J.E. (1987). Emotion. In F.Plum (Ed.), Handbook of physiology: Vol. 5. Higher functions of the brain, Part 1 (pp. 419–460). Bethesda, MD: American Psychological Society. Lidow M.S., Wang, F., Cao, Y., & Goldman-Rakic, P.S. (1998). Layer V neurons bear the majority of mRNSs encoding the five distinct dopamine receptor subtypes in primary prefrontal cortex. Synapse, 28, 10–20. Luria, A.R. (1973). The working brain. New York: Basic Books. McCandliss, B.D., Posner, M.I., & Givon, T. (1997). Brain plasticity in learning visual words. Cognitive Psychology, 33, 88–110. Merzenich, M.M., & Jenkins, W.M. (1995). Cortical representation of learned behaviors. In P.Anderson, Ohvalby, O.Paulsen, & B.Hokfelt (Eds.), Memory concept (pp. 437– 451). Amsterdam: Elsevier. Mischel, W. (1983). Delay of gratification as process and as person variable in development. In D.Magnusson & V.P.Allen (Eds.), Human development: An interactional perspective (pp. 149–165). New York: Academic Press. Murtha, S., Chertkow, H., Beauregard, M., Dixon, R., & Evans, A. (1996). Anticipation causes increased blood flow to the anterior cingulate cortex. Human Brain Mapping, 4, 103–112.

Developing mechanisms of self-regulation 37 Nachmias, M., Gunnar, M., Mangelsdorf, S., Parritz, R.H., & Buss, K. (1996). Behavioral inhibition and stress reactivity: The moderating role of attachment security. Child Development, 67, 508–522. Nimchinsky, E.A., Gilissen, E., Allman, J.M., Perl, D.P., Erwin, J.M., & Hof, P.R. (1999). A neuronal morphologic type unique to humans and great apes. Proceedings of the National Academy of Science USA, 96, 5268–5273. Norman, D.A. (1969). Memory and attention. New York: Wiley. Norman, D.A., & Shallice, T. (1986). Attention to action: Willed and automatic control of behavior. In R.J.Davidson, G.E.Schwartz, & D.Shapiro (Eds.), Consciousness and self-regulation (pp. 1–18). New York: Plenum Press. Panksepp, J. (1998). Attention deficit hyperactivity disorders, psychostimulants, and intolerance of childhood playfulness: A tragedy in the making? Current Directions in Psychological Science, 1, 91–98. Petersen, S.E., Fox, P.T., Snyder, A.Z., & Raichle, M.E. (1990). Activation of extrastriate and frontal cortical areas by visual words and word-like stimuli. Science, 249, 1041– 1044. Posner, M.I. (1978). Chronometric explorations of mind. Hillsdale, NJ: Erlbaum. Posner, M.I., & DiGirolamo, G.J. (1998). Conflict, target detection and cognitive control. In R.Parasuraman (Ed.), The attentive brain (pp. 401–423). Cambridge, MA: MIT Press. Posner, M.I., & McCandliss, B.D. (1999). Brain circuits during reading. In R.Klein & P.McMullen (Eds.), Converging methods for understanding reading and dyslexia (pp. 305–337). Cambridge, MA: MIT Press. Posner, M.I., & Raichle, M.E. (1994). Images of mind. New York: Scientific American Library. Posner, M.I., & Rothbart, M.K. (1998). Attention, self-regulation and consciousness. Philosophical Transactions of the Royal Society of London B, 353, 1915–1927. Raichle, M.E., Fiez, J.A., Videen, T.O., MacLeod, A.M.K., Pardo, J.V., Fox, P.T., & Petersen, S.E. (1994). Practice-related changes in human brain functional anatomy during nonmotor learning. Cerebral Cortex, 4, 8–26. Rainville, P., Duncan, G.H., Price, D.D., Carrier, B., & Bushness, M.C. (1997). Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science, 277, 968–970. Rothbart, M.K. (1989). Temperament and development. In G.A.Kohnstamm, J.E. Bates, & M.K.Rothbart (Eds.), Temperament in childhood (pp. 187–247). New York: Wiley. Rothbart, M.K., Ahadi, S.A., & Evans, D.E. (2000). Temperament and personality: Origins and outcomes, Journal of Personality and Social Psychology, 78, 122–135. Rothbart, M.K., Ahadi, S.A., & Hershey, K.L. (1994). Temperament and social behavior in childhood. Merril—Palmer Quarterly, 40, 21–39. Rothbart, M.K., Ahadi, S.A., Hershey, K.L., & Fisher, P. (2000). Investigations of temperament at 3–7 years: The Children’s Behavior Questionnaire. Manuscript submitted for publication. Rothbart, M.K., & Bates, J.E. (1998). Temperament. In W.Damon & N.Eisenberg (Eds.), Handbook of child psychology: Vol. 3. Social, emotional and personality development (5th ed., pp. 105–176). New York: Wiley.

Annual progress in child psychiatry and child development 2000–2001

38

Ruff, H.A., & Rothbart, M.K. (1996). Attention in early development: Themes and variations. New York: Oxford University Press. Shoda, Y., Mischel, W., & Peake, P.K. (1990). Predicting adolescent cognitive and selfregulatory competencies from preschool delay of gratification: Identifying diagnostic conditions. Developmental Psychology, 26, 978–986. Siegler, R.S. (1997). Emerging minds: The process of change in children’s thinking. New York: Oxford University Press. Smalley, S.L., Bailey, J.N., Palmer, C.G., Cantwell, D.P., McGough, J.J., Del’Homme, M.A., Asarnow, J.R., Woodward, J.A., Ramsey, C., & Nelson, S.F. (1998). Evidence that the D4 receptor is a susceptibility gene in attention deficit hyperactivity disorder. Molecular Psychiatry, 3, 427–30. Sokolov, Y.N. (1963). Perception and the conditioned reflex. New York: Macmillan. Swanson, J.M., Sergeant, J.A., Taylor, E., Sonuga-Barke, E., Jensen, P.S., & Cantwell, D.P. (1998). Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet, 35, 429–433. Treisman, A. (1969). Strategies and models of selective attention. Psychological Review, 76, 282–299. Ungerleider, L.G., Courtney, S.M., & Haxby, J.V. (1998). A neural system for visual working memory. Proceedings of the National Academy of Sciences USA, 95, 883– 890. Wachs, T.D., & Gandour, M. (1983). Temperament, environment, and six-months cognitive-intellectual development: A test of the organismic specificity hypothesis. International Journal of Behavioral Development, 6, 135–152. Washburn, D.A. (1994). Stroop-like effects for monkeys and humans: Processing speed or strength of association? Psychological Science, 5, 375–379. Zelazo, P.D., Resnick, J.S., & Pinon, D.E. (1995). Response control and the execution of verbal rules. Developmental Psychology, 31, 508–517.

PART I: DEVELOPMENTAL ISSUES

3 Implications of Attachment Theory for Developmental Psychopathogy L.Alan Sroufe, Elizabeth A.Carlson, Alissa K.Levy, and Byron Egeland

Bowlby’s attachment theory is a theory of psychopathology as well as a theory of normal development. It contains clear and specific propositions regarding the role of early experience in developmental psychopathology, the importance of ongoing context, and the nature of the developmental process underlying pathology. In particular, Bowlby argued that adaptation is always the joint product of developmental history and current circumstances (never either alone). Early experience does not cause later pathology in a linear way; yet, it has special significance due to the complex, systemic, transactional nature of development. Prior history is part of current context, playing a role in selection, engagement, and interpretation of subsequent experience and in the use of available environmental supports. Finally, except in very extreme cases, early anxious attachment is not viewed as psychopathology itself or as a direct cause of psychopathology but as an initiator of pathways probabilistically associated with later pathology.

INTRODUCTION From its inception, attachment theory was a theory of psychopathology as well as normal development. It was concerned both with the formation and normal course of attachment relationships and the implications of atypical patterns of attachment. Bowlby’s (1944) early consideration of 44 thieves revealed a consistent background of early parental privation in the lives of these young men. He reasoned that this was no mere coincidental association but, rather, had causal implications. Still, he doubted from the start that the connection was simple, direct, and linear—an environmental malignancy with an inevitable outcome. What, then, was the nature of this link? Attachment theory evolved in large part to answer this question. What Bowlby proposed was not just a theory of outcome, but a theory of process. In the attachment trilogy and other writings he presented a very specific set of propositions regarding the way in which early experience contributed to psychological health or pathology. He began in the first volume of the trilogy (1969) by clearly dissociating his

Annual progress in child psychiatry and child development 2000–2001

40

individual differences construct from causal trait constructs. Attachment referred to a pattern of organized behavior within a relationship, not a trait infants had in varying quantity (Sroufe & Fleeson, 1986; Sroufe & Waters, 1977). Attachment patterns were not immutable and not independent of subsequent experience. In Volume 2 (1973) he wrote that the development of the individual “turns at each and every stage of the journey on an interaction between the organism as it has developed up to that moment and the environment in which it then finds itself” (p. 364, italics added). Early experience frames, but also is transformed by, later experience. In brief, he proposed what would now be called a dynamic systems theory of psychopathology, based on a complex interaction of constituents over the course of development (e.g., Sameroff, 1989). Still, within this theory a special role for early experience in the initiation of important processes was specified. Thus, attachment theory provides a third alternative to the shadow box debate about whether early experience causes later outcomes in the manner of an immutable trait or bears only a coincidental association to outcome due to its link to later experience or third factors such as SES (Fox, 1997; Lamb, 1984; Lewis, 1997). The answer is, neither. Early experience often plays a critical role in the developmental dynamic that yields pathology, but this role is dependent on a surrounding context of sustaining environmental supports. At the same time, processes engendered in the context of early experience may influence the nature of later experience and the surrounding context itself. In this paper, core propositions from attachment theory regarding the complex relation between early experience and psychopathology will be elaborated. These include formulations concerning causation (and the interplay between the individual and context), the role of early experience, and the nature of early disturbance. This will be primarily a conceptual chapter, tracing the theoretical implications of the Bowlby/Ainsworth attachment theory for developmental psychopathology. Data presented will be for the purpose of illustrating these theoretical ideas, and will be drawn primarily from the Minnesota longitudinal parentchild study. Previously published data will not be presented in detail but will be accompanied by relevant citations. Many of these data and those of other researchers have been reviewed elsewhere (e.g., Weinfield, Sroufe, Egeland, & Carlson, in press). Data that have not been published before will be presented more completely, along with relevant statistical information. Likewise, we will be unable to review extensively topics such as representation and experiencedependent brain development, which are related to the issues pursued but are not central in this discussion. Such topics will be brought in where pertinent, and citations of recent comprehensive reviews will be provided.

CAUSE IN ATTACHMENT THEORY: ORGANIZATIONAL CONSTRUCT VERSUS TRAIT Cause is complex within attachment theory. In accord with ecological views such as those of Belsky (e.g., Belsky & Isabella, 1988) and Bronfenbrenner (1986), the child is seen as nested within a network of influences operating on many levels. Some contextual influences impact directly on the child, some indirectly through their impact on parenting.

Implications of attachment theory for developmental psychopathogy 41 Developmental context is emphasized, because “changes in circumstances can lead to changes in interaction and therefore to changes in relationships” (Vaughn, Waters, Egeland, & Sroufe, 1979, p. 974). At the same time, the child’s history of experience is a critical part of the developmental context. There is an ongoing transaction between the developing child and changing circumstances (cf. Sameroff & Chandler, 1975). The impact of current circumstances depends on the pattern of behavioral and emotional organization the child brings forward to that phase of development. Child and context are mutually transforming. Although we argue in the following that early experience has special significance, still it “…cannot be more important than later experience, and life in a changing environment should alter the quality of a child’s adaptation” (Sroufe, 1978, p. 56). The individual is the product of all of his or her experiences, not early experiences alone. Many of Bowlby’s ideas regarding the roles of prior experience and current circumstances in adaptation and in psychopathology are summarized within his concept of developmental pathways (Bowlby, 1969, 1973). Metaphorically captured by the dispersion and interconnection of tracks in a railway yard or branchings on a tree, this model embodies several key ideas (Sroufe, 1997). First, there are more lines or branches in the broad center of the larger array (there is great diversity in normality). Second, beginning on any major trunk allows a large number of possible outcomes due to subsequent branchings (multifinality). Thus, ongoing circumstances may support pursuance of potentially deviating developmental pathways or deflect the individual back toward more normal adaptation. Enjoining a pathway even early on does not determine final outcome but only initiates a set of possibilities. Cause is probabilistic, not deterministic. Third, the longer an outlying pathways is followed, the more unlikely becomes a return to centrality. In this theory psychopathology results from a successive series of adaptations. A pattern of anxious attachment in infancy may initiate such a process, but only if subsequent adaptations continue to represent deviation from positive functioning does psychopathology become likely. Change remains possible but, Bowlby (1973) argues, becomes quite difficult by adolescence if development has continued to go awry. Several specific, testable hypotheses may be derived from these initial formulations: (a) At any age, current quality of care will add to early attachment history in predicting pathology, given that adaptation is always the joint product of current circumstances and early history, (b) Likewise, broader aspects of current contexts, including relationships outside of the family and stresses and challenges of the period, also will increase prediction beyond early attachment; (c) a cumulative history of maladaptation will be more pathogenic than a single early period of poor functioning, with pathology ever more likely the longer a maladaptive pathway has been followed, and (d) change itself will be predictable in light of changes in stress and/or support. We and our colleagues have examined these hypotheses by carrying out a broad-based prospective, longitudinal study of 180 children, assessing quality of care in infancy, early childhood, and adolescence, along with assessments of relationships with peers and teachers, life adversities, and social support. Based on parent, self, and teacher behavior problem checklists at age sixteen (Achenbach & Edelbrock, 1986) and a clinical interview at age 17.5 years (the child form of the Schedule for Affective Disorders and

Annual progress in child psychiatry and child development 2000–2001

42

Schizophrenia; K-SADS) as the sources for psychopathology outcome, regression analyses were utilized to evaluate various combinations of variables. For example, to test the hypothesis regarding the significance of cumulative adaptational history, we compared the predictive power of infant attachment alone with the predictive power of attachment plus cumulative assessments of quality of care in the preschool years. Although anxious attachment in infancy by itself predicted a K-SADS psychopathology index (number and severity if past and present diagnoses; see Sroufe, 1997), those with a history of cumulative unsupportive care showed significantly more problems (13% vs. 15% of variance accounted for). In addition, we found that assessments of parent-child relationship problems at age 13 years (especially boundary dissolution and lack of emotional support or support for autonomy) and anxious attachment in infancy were more powerful than either alone, although each was significant separately (see Table 3.1). Likewise, ongoing assessments of peer relationship problems added to predictions of psychopathology based on attachment alone, R2 change (2,66)=.04, p