EMOTION REGULATION IN PRESCHOOL-AGED CHILDREN WITH VERY LOW

BIRTH WEIGHT: OUTCOMES RELATIVE TO NORMAL BIRTH WEIGHT

CHILDREN AND ASSOCIATIONS OF CHILD CHARACTERISTICS AND

MATERNAL BEHAVIOR

by

LEAH J. ORCHINIK, M.A.

Dissertation submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Department of Psychological Sciences

CASE WESTERN RESERVE UNIVERSITY

January, 2015 ii

CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES

Dissertation Committee for

Leah J. Orchinik

candidate for the Doctoral degree *.

H. Gerry Taylor, Ph.D. (Chair of Committee)

Arin Connell, Ph.D.

Elizabeth Short, Ph.D.

Terry Stancin, Ph.D.

(date) September 20th, 2013

*We also certify that written approval has been obtained for any proprietary material contained therein. iii

TABLE OF CONTENTS

List of Tables...... iv

Acknowledgements...... vi

Abstract…………...... vii

Chapter 1.

INTRODUCTION…………………………………………………….…………………..9

Chapter 2.

METHOD………………………………………………………………….…………….31

Chapter 3.

RESULTS………………………………………………………………….…………….44

Chapter 4.

DISCUSSION…………………………………………………………...………...…..…48

Tables….………………...…………………………………………………………….…67

Appendix A: Child, Maternal, and Dyadic Coding Variables.……...………….………..91

References………………………………………………………………………………..93

iv

List of Tables

Table 1. Participant Characteristics……………………………………………………...67

Table 2a. Frequencies of Observed Child Variables, Child-only Condition…………….68

Table 2b. Frequencies of Observed Child Variables, Child With Mother Condition…....69

Table 2c. Frequencies of Observed Maternal Variables………………………………....70

Table 2d. Frequencies of Observed Dyadic Variables………………………...…….…...71

Table 3. Item Loadings in Principal Components Analyses for Child Variables……..…72

Table 4. Group Comparisons of Child and Maternal Characteristics………………...….73

Table 5a. Intercorrelations of Observed Child Factors…………………………………..74

Table 5b. Correlations of Observed Child Factors Across Conditions…………………..75

Table 5c. Correlations of Observed Child Factors Across Tasks………………………..76

Table 5d. Intercorrelations of Observed Maternal Variables…………………………….77

Table 5e. Correlations of Observed Maternal Variables Across Tasks………………….78

Table 6. Group Differences, Disappointing Gift Task…………………………………...79

Table 7. Group Differences, Locked Box Task………………………………………….80

Table 8. Group Differences of Maternal Variables……………………………………...81

Table 9. Group Differences of Dyadic Variables…………………………………….….82

Table 10a. Associations of Observed Maternal Variables and Observed Child Factors, Disappointing Gift Task, Linear Regressions…………………………………………....83

Table 10b. Associations of Observed Maternal Variables and Observed Child Factors, Disappointing Gift Task, Logistic Regression…………….……………….…………….84

Table 11a. Associations of Observed Maternal Variables and Observed Child Factors, Locked Box Task, Linear Regression……………………….…………………………...85

Table 11b. Associations of Observed Maternal Variables and Observed Child Factors, Locked Box Task, Logistic Regressions…………….…………….……....……………..86

v

Table 12a. Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Disappointing Gift Task, Linear Regressions……………....87

Table 12b. Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Disappointing Gift Task, Logistic Regression….……...... …88

Table 13a. Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Locked Box Task, Linear Regression…..…………………..89

Table 13b. Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Locked Box Task, Logistic Regressions………...……….…90

vi

Acknowledgements

A number of people deserve recognition for their roles in this project. I would like to thank the families who participated for their willingness and in the study. I also wish to acknowledge my dedicated undergraduate research assistants, Emily Gibbs and

Christopher McFarlane, for their help. I also appreciate the assistance of Dee Wilson-

Costello in facilitating the recruitment of families. In addition, I am grateful for the expertise and input of my committee members, Elizabeth Short, Arin Connell, and Terry

Stancin, throughout this process, and I especially appreciate the guidance and encouragement I received from my advisor, H. Gerry Taylor. I would also like to thank my research lab for all of their support. In particular, I want to acknowledge Nori Minich for her patience, willingness to help at any hour, and vast knowledge of data management and analysis. I would also like to thank my parents and sister for their many years of support. Last, but not least, thank you to my wife, Maia Noeder, who provided unconditional support in every aspect of my life throughout graduate school.

vii

Emotion Regulation in Preschool-Aged Children with Very Low Birth Weight: Outcomes

Relative to Normal Birth Weight Children and Associations of Child Characteristics and

Maternal Behavior

Abstract

By

LEAH ORCHINIK

The construct of emotion regulation is defined as the process of initiating, modulating, and sustaining emotional states and expressions and is important for successful social and emotional development. A child’s emotion regulation skills are influenced by numerous factors, including parenting characteristics such as sensitivity, intrusiveness, and responsiveness. Based on evidence of early social deficits, children with very low birth weight may be at risk for delayed or impaired social competence and emotion regulation skills, and research suggests parents of these children have more difficulty perceiving behavioral and affective cues from their children. The current study explored child emotion regulation, maternal behavior, and mother-child interactions in a sample of 3- and 4-year-old children with very low birth weight compared to a normal birth weight control group on two laboratory tasks designed to elicit child and disappointment. In addition, mothers completed questionnaires on child behavior and temperament and parent characteristics. The observational tasks were videotaped and coded using the Parent Child Interaction System. Findings revealed that for one of the tasks, children with very low birth weight were less expressive than the normal birth viii

weight controls. For one task, greater maternal sensitivity was predictive of less autonomous coping and more child negative , maternal responsiveness was associated with less autonomous behavior and greater child expressiveness, and maternal positive content was associated with less autonomous coping, though these findings did not vary by group. Results are interpreted in the context of the demands placed on the child and mother, and the need for future research is emphasized.

9

Chapter 1. INTRODUCTION

The development of emotion regulation in children has received considerable empirical attention over the last two decades (e.g., Cole, Martin, & Dennis, 2004; Gross,

2007; Thompson, Lewis, & Calkins, 2008). Nevertheless, the construct of emotion regulation is still not well defined. Several definitions of emotion regulation have been proposed, such as “internal and external processes involved in initiating, maintaining, and modulating the occurrence, intensity, and expression of ” (Morris, Silk,

Steinberg, Myers, & Robinson, 2007). However, a single definition of this process has not yet been determined, likely due to the complex nature of the construct. Evidence suggests that the successful regulation of emotions has a positive influence on numerous aspects of healthy psychological functioning and development, including cognitive, intrapersonal, and social domains (Cole et al., 2004).

Research also points to early childhood as a critical period for the development of many psychological processes, during which time caregivers exert significant influence on the quality of children’s development. Emotion regulation is no exception, as it is well documented that emotion regulation develops through interactions between caregivers and infants (Berlin & Cassidy, 2003; Braungart-Rieker, Garwood, Powers, &

Wang, 2001; Crockenberg & Leerkes, 2004; Diener, Mangelsdorg, McHale, & Frosch,

2002; Kopp, 1989; Thompson, 1991), and that infants learn to elicit reactions from caregivers through certain behaviors and expressions of emotion. This interaction is bidirectional nature, with infants eliciting responses from caregivers, and in turn affecting how the infant learns to express, modulate, and understand their own emotions

(Eisenberg, Cumberland, & Spinrad, 1998). For this reason, the study of child emotion 10

regulation involves investigation of characteristics of the child, parent, and parent-child dyad.

Similarly, while it is important to increase understanding of the development of and influences on emotion regulation in typically developing children, it is also necessary to explore how self-regulation differs in certain populations of children, especially those who may be at-risk for deficits in social and emotional competencies. One such population is children with very low birth weight (VLBW). The current study examines emotion regulation and the influence of maternal behavior and the mother-child relationship on the regulation processes in a sample of 3- and 4-year-old children with

VLBW compared to children of normal birth weight. Relevant literature on children with

VLBW and their emotion regulation skills will be discussed in detail later, following a review of emotion regulation in early childhood.

Emotion Regulation as a Construct

Most current conceptualizations of emotion consider it to be a psychological state involving communication, appraisal, and physiology (Fox & Calkins, 2003). Others have suggested that emotions are functional and are “appraisal-action readiness stances” that motivate an individual (Cole et al., 2004), or that emotions serve to impact the relationship between the self and another object (Campos, Mumme, Kermoian, &

Campos, 1994). Attachment theory also highlights the communication function of emotions in that they help caregivers understand infants’ needs.

Emotion regulation can involve unconscious, automatic processes as well as conscious, effortful ones (Cole et al., 1994; Gross, 2007; Thompson, 1994) and is influenced by both intrapersonal and interpersonal processes. While emotion regulation 11

is often conceptualized as an outcome variable, it also serves as a predictor and moderator for other factors. For example, developing the ability to manage one’s emotions is associated with greater academic productivity and achievement, even after accounting for cognitive ability (Graziano, Reavis, Keane, & Calkins, 2007). Greater emotion regulation skills are also associated with better adjustment, increased popularity at school, and greater in preschoolers (Losoya, Eisenberg, & Fabes, 1998). In older populations, successful emotion regulation has been identified as a protective factor against substance abuse (Skitch & Abela, 2008), , (Nolen-Hoeksema, Stice,

Wade, & Bohon, 2007), and aspects of physical health in adults (Denollet, Gidron,

Vrints, & Conraads, 2010).

Emotion regulation is a key component of ‘’, which includes understanding of emotions (both one’s own and others), culturally and situationally appropriate displays of emotions, and the modulation and inhibition of experienced and expressed emotions (Eisenberg et al., 1998). Thus, across age groups, emotion regulation is viewed as a crucial component of social competence, and in part determines one’s ability to regulate themselves in social settings, through both the understanding and control of . The development of emotion regulation is well established as a crucial task in early childhood (Calkins et al., 1999; Eisenberg and

Fables, 1995; Rubin et al., 1995; Saarni, 1999). Adaptive emotion regulation, which includes both self-initiated behaviors as well as caregiver-assisted, extrinsic behaviors, serves to facilitate one’s ability to meet immediate and long-term goals. Thus, regulation strategies can be considered adaptive when they aid in one’s attentional control, assist in 12

goal-oriented behavior, appropriately stimulate the help of others/caregivers, and serve to reduce distress (Cole et al., 1994; Thompson, 1991).

Conversely, poor emotion regulation, meaning emotional that is disproportionate to the context, can be maladaptive and is associated with negative psychological outcomes. For example, difficulty regulating negative emotions has been linked to a greater incidence of Attention-deficit/hyperactivity disorder and Oppositional

Defiant disorder (Barkley, 1997), as well as depressive symptoms and problem behaviors

(Cicchetti, Ackerman, & Izard, 1995; Eisenberg et al., 2001; Silk, Steinberg, & Morris,

2003). Maladaptive emotion regulation in infancy has also been linked with more negative parent-child relationships during the toddler years, including avoidance and noncompliance to parental requests (Stifter, Spinrad, & Braungart-Rieker, 1999).

Early Emotion Regulation

In infancy, emotion regulation is guided primarily by the caregiver, as illustrated by an infant being physically soothed or the caregiver providing a distraction from an unpleasant stimulus. Nevertheless, infants do show basic self-initiated emotion regulation behaviors, such as gaze aversion and sucking (Buss & Goldsmith, 1998;

Rothbart, Ziaie, & O’Boyle, 1992). The level of reactivity to stimuli in their environment, which is an aspect of temperament, is also indicative of early self-control of emotions and is often a stable characteristic. In addition, Kopp (2002) asserted that a key component of early emotion regulation is the self-control of attention, a complex cognitive process that emerges during the first year. In a study of infants from 3 to 6 months of age, Rothbart (1986) found that increased positive affect and decreased distress were associated with episodes of focused attention. 13

Not surprisingly, the nature of emotional expressions as well as regulatory strategies become more sophisticated with development (e.g. Fox & Calkins, 2003).

During infancy, negative emotions are typically experienced as generalized distress and are observable through vocal and facial expressions. By one year of age, children are able to read caregivers’ emotions, and they will also actively seek assistance in regulating their emotions, such as by seeking proximity to caregivers (Calkins & Hill, 2007; Kopp,

1989). By year 2, children will demonstrate additional strategies of emotion regulation, such as distracting themselves from a forbidden object by playing with another toy

(Grolnick, Bridges, & Connell, 1996). During the preschool years children acquire greater self-regulation-both behaviorally and emotionally, learn to modulate their emotions in focused ways, and learn to create more complex and self-reflective responses to emotional stimuli (Carlson & Wang, 2007). Emotions are much more differentiated by this age, with , , and experienced and recognized as separate affect states (Calkins & Fox, 2002). At 3 years of age, children still have trouble regulating their emotions but are much more successful by age 5 (Carlson & Wang, 2007), as increased social demands require more complex strategies.

Factors Affecting Emotion Regulation

A variety of factors influence emotion regulation abilities. Twin studies have demonstrated that emotion regulation is a partly heritable characteristic (Goldsmith,

Lemery, & Essex, 2004). At the neural level, imaging studies have found associations between voluntary emotion regulation of negative emotions and greater amygdala activation (Schaefer et al., 2002; Ochsner et al., 2002). Research also suggests involvement of the prefrontal cortex in the regulation of emotions (Davidson, 2000). 14

Children’s language skills develop rapidly and become more sophisticated during the preschool period. Verbal communication, both self-talk and dialogue with others, becomes one of the major strategies for regulating emotions (Winsler, Feder, Way, &

Manfra, 2006) and children with language deficits, such as children with VLBW, are at- risk for impaired emotion regulation. Much of the early emotion regulation literature focuses on infancy through the preschool period, as it is thought that social, temperamental, and maturational influences are critical at this time. Children’s language skills may thus be a further factor affecting emotion regulation.

A child’s temperament also influences emotion regulation processes. Eisenberg and Fabes (1992) developed a tripartite model to explain the link between temperament and emotion regulation. Because under controlled children are highly reactive and demonstrate impulsivity and low emotion regulation abilities, they have heightened emotional expressions, which in turn can lead to impaired social competence and problematic peer interactions (Cassidy, 1994). Highly controlled children have regulatory capacities but do not demonstrate emotional flexibility, i.e. they have difficulty changing their emotions in response to situational demands, and as a result, may become sad, anxious, or socially withdrawn. Children with optimal regulation have self-control as well as emotional flexibility. These children are more likely to use adaptive emotion regulation strategies and are thus generally more popular and socially competent (Losoya et al., 1998). Zimmerman and Stansbury (2003) also investigated the impact of temperament and situational context on emotion regulation in 3-year-olds and found that both factors predicted the use of certain regulatory strategies. Specifically, shyer children were likely to use instrumental strategies such as withdrawing from the distressing 15

stimulus. Results also suggested that the influence of temperament may be associated with situation context in that temperamental differences are particularly evident in more distressing situations.

In addition to heritable, neural, and temperamental factors, cognitive factors can also affect emotion regulation. One set of complex cognitive processes found to relate to emotion regulation is executive functioning (e.g. Carlson & Wang, 2007). This ability, which also develops rapidly during the preschool years, consists of planned, goal-directed behavior that includes inhibitory and attentional control. Although executive functioning is conceptualized as a cognitive process, deficits in this area can include behavioral aspects, such as problems with impulsivity, poor planning skills, and difficulties in self- monitoring (Anderson & Doyle, 2004; Harvey, O’Callaghan, & Mohay, 1999). Cole and colleagues (2004) described emotion regulation processes as emotion as regulated and emotion as regulating. As suggested by some researchers (Carlson & Wang, 2007), this distinction demonstrates the bidirectional influence of emotion regulation and executive functioning in that emotions can help one organize and plan behavior, i.e. emotions as serving a regulating function, and consciously inhibit one’s behavior and , i.e. emotions as being regulated (Cole et al., 2004). The decision (although sometimes implicit) to modulate one’s emotions, such as dampening the intensity of anger, requires the formulation of potential strategies, the ability to keep such ideas in mind, and the successful implementation of the selected plan all while experiencing a strong negative emotion.

The Socialization of Emotion Regulation 16

Despite the intrapersonal characteristics that influence children’s ability to regulate their emotions, emotion regulation does not develop in and is considered an interpersonal process with social influences (Cole et al., 2004). Thus, the socialization of emotion is a major component that contributes to one’s ability to regulation emotions. Emotion socialization refers to the process by which the behavior of others helps children understand, express, and regulate their own emotions (Eisenberg,

1998). Socialization processes include parent reactions to children’s emotions, parent- guided discussions of various emotions, and parental expression of emotion. Emotion socialization begins very early in life, with parents serving as emotion “coaches” for children by helping them label emotions, providing and validation of the child’s expressed emotions, and guiding problem solving (Gottman, Katz, & Hooven, 1996).

Parenting behaviors also significantly influence the development of emotion regulation abilities, although this relationship is rather complex. Parental expression of positive emotions, emotion-related discourse, and of emotional expression are associated with increased emotion understanding and competence (Denham et al., 2003).

However, findings are less consistent regarding the impact of parents’ negative emotionality and negative responses to children’s emotional expressions. Some studies found that parents’ negative emotionality is linked to greater negative emotionality and poorer social competence in children (Eisenberg et al., 1998; Eisenberg et al. 2003). In contrast, others have found that parent negative emotionality can be beneficial. For example, Teti and Cole (1995) found that parental negative emotional expressions in response to their preschoolers’ expressions of negative emotions were associated with 17

low levels of children’s externalizing problems. This perhaps indicates the adaptive impact of parent-child emotional synchrony and parental sensitivity.

Morris and colleagues (2007) have developed a model to illustrate the influence of family factors on children’s emotion regulation. They outline three areas in which the family environment can influence the emotion regulation development. One way is through observational learning and modeling behaviors, such as , in which emotions expressed by the family help the child to “catch” and express those same emotions. Morris and colleagues have also posited that emotion-focused parenting practices affect a child’s emotion regulation. Specifically, the technique of emotion- coaching, outlined by Gottman et al. (1996), is a positive influence on the development of successful emotion regulation. Emotion coaching consists of parental awareness of a child’s emotion, parental labeling of that emotion for the child, empathy and validation, and the provision of assistance in problem-solving how the child can cope with the emotion. In essence, parents who are warm and responsive also demonstrate behaviors that are associated with good child emotion regulation (Lunkenheimer, Shields, &

Cortina, 2007; Gottman et al., 1996). Furthermore, the way that parents themselves react to emotions affects children’s emotion regulation abilities, as punishing reactions to children’s emotions are associated with an increased use of escape and -seeking behaviors and poorer social competence (Eisenberg & Fabes, 1994).

Parent mental health has a direct impact on children’s development. In particular, maternal depression negatively impacts numerous facets of child development, including children’s emotional expression and emotion regulation. Children of depressed mothers themselves demonstrate impaired emotion regulation (Radke-Yarrow, Nottelmann, 18

Belmont, & Welsh, 1993; Silket al., 2006). In addition, mothers with depression show fewer positive emotions and are generally less emotionally responsive to their children

(e.g. Field, Healy, Goldstein, & Guthertz, 1990; Hoffman, Crnic, & Baker, 2006) and demonstrate less effective emotional scaffolding, which refers to the ability to shape an experience in an emotionally positive manner for the child.

The attachment literature has also identified links between attachment styles and emotion regulation, suggesting that children with secure attachments can use that relationship to help regulate their emotions (Sroufe & Waters, 1977). Benefits of secure attachments extend into the developmental period during which children are learning to regulate themselves. For example, children who are more securely attached at 18 months of age have been found to demonstrate better emotion regulation skills at 3 years

(Gilliom, Shaw, Beck, Schonberg, & Lukon, 2002). Emotion regulation may also serve as a mediator between parent-child attachment and peer social competence (Contreras,

Kerns, Weimer, Gentzler, & Tomich, 2000).

Additionally, a number of more specific parenting behaviors have been shown to influence a child’s early self-regulation. Maternal sensitivity is one parent characteristic associated with social-emotional competence in children (e.g. Propper & Moore, 2006).

The term refers to behaviors in which mothers recognize their children’s cues and respond in appropriate, prompt and reliable ways. Maternal sensitivity to infant distress is distinct from sensitivity to an infant’s neutral and positive affective states. Specifically,

Leerkes, Blankson, and O’Brien (2008) found that maternal sensitivity to distress, but not nondistress, at 6 months of age was associated with fewer behavioral problems and greater social competence. Similarly, Grolnick and colleagues (1996) found that toddler 19

distress was negatively associated with maternal use of redirection, active engagement and reassurance, but negatively associated with maternal behaviors that were unrelated to the task. These authors also suggested that more sensitive mothers used appropriate scaffolding rather than simply taking control of the task. Because children are most likely to actively seek parental assistance during emotionally distressing events (Dieneret al., 2002), understanding the influence of maternal sensitivity on children’s emotional competence and regulation has been a topic of considerable attention in the developmental literature. The relationship is not fully understood as there are other constructs of parental behavior that can simultaneously influence child self-regulation outcomes.

Another parental behavior that affects children’s early emotion regulation skills is intrusiveness, which refers to the amount of negative and/or ill-timed physical or verbal control a parent attempts to exhibit over a child. Some researchers have found that intrusive mothers did not allow children to develop independent emotion regulation strategies (Grolnick et al., 1996), and others found that toddlers whose mothers who took control of tasks had greater distress and were more likely to act out aggressively (Calkins

& Johnson, 1998). The valence of mothers’ expressed emotions can also influence children’s regulation abilities. Calkins, Smith, Gill, and Johnson (1998) found that when mothers engaged in more negative behaviors, including scolding, negative verbal directives, and physical control towards their 2-year-old children, the children were less able to utilize adaptive emotion regulation strategies such as distraction and were more focused on the unpleasant stimulus. 20

In addition to these predictors of emotion socialization, there are several moderators of children’s emotion regulation abilities. These include the consistency of parental emotion reactions, the intensity and clarity of both the child’s and the parent’s expressed emotions, and the appropriateness of their emotional reactions (Eisenberg et al., 1998). However, there are not universally accepted definitions of the concepts of sensitivity and responsiveness, with some researchers using the terms interchangeably.

For the purposes of this study, responsiveness will refer to one’s reaction to another (e.g. a mother has any type of reaction to her child crying) and sensitivity will refer to a correct appraisal of the emotion and an appropriate response (e.g. a mother responds by verbally comforting her crying child).

Although parenting behaviors influence children’s emotional behavior, this pathway is bidirectional. That is, children’s characteristics and behaviors can also influence their parents’ behavior towards them (Eisenberg et al., 1998; Morris et al.,

2007). For example, parent socialization behaviors that lead to a child’s ability to express emotion appropriately can in turn promote more constructive parental responses, leading to increased socialization of emotions. Tronick, Cohn and Shea (1986) created the

Mutual Regulation Model to account for this process. The model posits that infants frequently seek out attention and social interaction, and when mothers respond, infants will in turn demonstrate positive affect to continue the interaction. Over time, this sequence of actions becomes reinforcing, with infants developing an “affective core” of positive emotions, and beginning to control and master their own emotional experiences.

Thus, emphasis should be placed on the interactions between mother and child and not only the mother and child behaviors as separate entities. Similarly, the transactional 21

model of development (Sameroff, 1975) posits that child behavior is a function of bidirectional interactions between parent and child, within the context of various environments. The interaction is particularly important to consider when attempting to understand the development of emotion regulation in children who may have behavioral issues, cognitive deficits, or chronic medical conditions, such as children with VLBW, which is the focus of the current study.

Very Low Birth Weight

Children with VLBW, defined as <1500g, may be at especially high risk for problems in emotion regulation. Although representing only about 2% of the total population of live births in the United States, survival rates for VLBW infants have increased considerably over the last several decades. These infants are also at high risk for numerous acute and long-term problems, including medical conditions, such as neurosensory impairments (e.g. cerebral palsy, hearing or vision impairment), mental retardation, and other health problems, such as growth impairment, pulmonary disease, asthma, and seizures. An estimated 17% of children with VLBW will suffer one or more of these sequelae (Taylor, Klein, &, Minich, & Hack, 2000; Wood et al., 2000).

In addition, this population is at risk for behavior problems, including issues with attention, socialization, and internalizing symptoms (Frost, Reinherz, Pakis-Camras,

Giaconia, & Lefkowitz, 1999; Taylor et al., 2000). Children with VLBW are 3 times more likely than their normal birth weight peers to develop attention deficit hyperactivity disorder (ADHD; Mick, Prince, Fischer, & Faraone, 2002), with the combined

(inattentive and hyperactive/impulsive) subtype of ADHD linked to greater in school-age children (Maedgen & Carlson, 2000). Furthermore, this 22

population is at risk for both global cognitive impairments as well as more specific deficits such as memory, and perceptual motor, and executive functioning (e.g. Luu et al.,

2009; Orchinik et al., 2011; Taylor, Minich, Klein, & Hack, 2004). Given the link between executive processes and self-regulation, it is not surprising that children with

VLBW have difficulty in both cognitive self-regulation (Davis & Burns, 2001; Landry et al., 2002) and emotional regulation (Clark, Woodward, Horwood, & Moor, 2008).

However, a variety of additional factors may contribute to impaired emotion regulation skills in children with VLBW.

Emotion Regulation in Children with VLBW

A difficult child temperament, defined as a negative style of responsiveness to the environment, such as or over-reactivity, is one factor that may be related to problems in emotion regulation. The relationship between temperament and the effects of birth weight and gestational age is not well understood (Lynn, Cuskelly, O’Callaghan,

& Gray, 2011) and although several studies indicate that children with low birth weight

(<2500 g) exhibit temperamental differences compared to their healthy weight peers, others have not found such effects. For example, Oberklaid, Sewell, Sanson, and Prior

(1991) found that compared to full-term children, preterm children (less than 37 weeks gestational age) do not differ in temperament during infancy or in early childhood.

However, in a more recent study using more strict birth-weight and gestational age inclusion criteria, Weiss, Jonn-Seed, and Wilson (2004) found that 80% of 152 6-month- old children with a mean birth weight of 1687g and 31 weeks gestational age were classified as having difficult temperaments. Moreover, Sajaniemi, Salokorpi, and von 23

Wendt (1998) found that 2 year-olds with a mean birth weight of 1205g demonstrated more passive behavior and were less attentive and less persistent.

Hughes, Shults, McGrath, and Medoff-Cooper (2002) found that preterm infants are less likely to demonstrate early patterns of general regulation, such as eating and sleeping. These researchers also found that preterm infants (24-32 weeks gestational age) exhibited more symptoms of withdrawal than did full-term infants. These early observable differences suggest that early regulation problems are evident from infancy in preterm children and that some temperamental differences may resolve during the first year of life, while others persist across the first year of life and beyond (Hughes et al.,

2002).

In addition to these risk factors for impaired emotion regulation skills, children with VLBW or preterm birth are more likely to have brain abnormalities that may affect emotion regulation. For example, their brain volumes are typically smaller in some regions, such as the basal ganglia, corpus callosum, and hippocampus, compared with normal birth weight children (Peterson et al., 2000). Disruption of the circuits connecting the frontal, striatal, and thalamic areas may affect cognitive skills related to emotion regulation such as attention, arousal, and higher-level cognition (Isaacs et al., 2000).

Other physiological data may also help to explain impaired emotion regulation in children with VLBW. For example, respiratory sinus arrhythmia, a marker of vagal tone flexibility, is an early childhood predictor of emotional health (e.g. El-Sheikh & Erath,

2011), and Doussard-Roosevelt, Porges, Scanlon, Behjat, and Scanlon (1997) found that higher respiratory sinus arrhythmia was associated with better overall social functioning in children with VLBW/preterm birth. 24

Because there is a shift from parent driven regulation to self-regulation during the toddler years, it is important that children develop the necessary social skills to communicate their needs as they learn to regulate themselves. Similarly, children who lack the social competence to aid in this transition will likely demonstrate impaired self- regulation and will have difficulty modulating emotions on their own. As preterm children have less social competence than their full-term peers (Landry, Chapieski,

Richardson, Palmer, & Hall, 1990), socialization difficulties may be an additional factor contributing to poor emotion regulation in this population. Specifically, children with

VLBW demonstrate difficulty initiating social interactions (Landry, Chapieski,

Richardson, Palmer, & Hall, 1990; Landry, Smith, Miller-Loncar, & Swank, 1997), which can make it difficult for children to request emotional support and assistance from caregivers.

In addition to deficits in social competence, from an early age children with

VLBW demonstrate language and communication impairments and are at a greater risk for language delay and language disorder (Foster-Cohen, Edgin, Champion, &

Woodward, 2007). This lack of developmentally appropriate communication can also hinder children’s ability to verbalize their emotions and their needs, especially in view of findings indicating that children with specific language impairments demonstrate impaired emotion regulation (Fujiki, Brinton, & Clarke, 2002).

As in the development of normal birth weight/full-term children, parenting and maternal-child interactions are other important influences in the development of emotion regulation abilities in VLBW children. The quality of the mother-child relationship can worsen or improve the outcomes of low birth weight/preterm birth as well as affect 25

parents’ emotions and attitudes regarding their children’s needs (Beckwith & Rodning,

1996). Children with VLBW demonstrate increased social competence, including emotion regulation, from maternal behavior that is sensitive (Landry, Garner, Swank, &

Baldwin, 1996). One study conducted with preterm infants at 6 months of age and identified a “ cooperative pattern” of behavior, in which mothers were sensitive and the infant was responsive and cooperative, and a “controlling pattern”, in which mothers were controlling and infants demonstrated more compulsive but compliant behaviors

(Forcada-Guex, Pierrehumbert, Borghini, Moessinger, & Muller-Nix, 2006). At an 18- month follow up, it was found that infants in the controlling dyads demonstrated a variety of negative outcomes such as increased behavioral concerns, sleeping problems, and worse social-personal development, highlighting the importance of the quality of the maternal-child relationship.

Parents of children with VLBW may experience additional challenges given the greater risk for temperamental and communication concerns. As a result, research suggests that mothers may have more difficulty picking up in their children’s cues and may thus have trouble behaving in an effectively sensitive and synchronized manner. For example, mothers of preterm infants have been found to be less sensitive and more controlling than mothers of term-born children (Muller-Nix et al., 2004). Mothers of children with VLBW are also more likely to experience distress during their child’s first month of life, and those with children at higher medical risk may experience parental through the third year (Singer et al., 1999).

A variety of evidence to indicates that in both normal birth weight/full-term infants and VLBW/pre-term infants, maternal behaviors and the mother-child interaction 26

influences the development of children’s emotion regulation skills, with more positive, sensitive, responsive parenting leading to children’s greater emotional control and use of adaptive regulatory strategies. Research additionally suggests that infants and children with VLBW have more difficult developing appropriate emotion regulation skills, possibly due to a variety of factors including greater medical complications, language and communication impairments, and temperamental differences. It is also thought that as a result of these child characteristics, the mother-child interaction patterns may differ for children with VLBW compared to the patterns more typically observed for normal birth weight children. Although there has been an increase in empirical interest in this area in the last several years, most research on children at high risk for developmental disorders has focused on infancy through the first year of life (Clark et al., 2008).

Less is known about maternal-child interactions in the following years, despite the fact that toddlerhood and the early preschool period mark a crucial developmental period and a time during which mothers continue to provide emotional support as children learn to draw increasingly more on their own emotion regulation skills. While there have been studies of maternal behaviors with children with VLBW as it relates to broader constructs such as social competence (Landry et al., 1996), limited research has focused on the degree of emotion regulatory deficits in these children and their associations with maternal characteristics. To our knowledge, only one study has been conducted on preschool-aged children with VLBW that specifically examines emotion regulation and parenting characteristics. Clark and colleagues (2008) investigated both emotional and behavioral self-regulation in a longitudinal study of preterm children at ages 2 and 4.

Findings indicated that the most significant predictors of children’s regulatory 27

capabilities were white matter abnormalities and an insensitive parenting style when the children were 2 years. These results highlight both the biological risk factors that are often present in preterm children and the importance of the quality of the parent-child relationship, which, unlike neonatal complications, can be altered to improve emotion regulation.

The Current Study

The current study sought to address several gaps in the literature. First, it addressed children’s regulation of the emotions of frustration and disappointment, the latter being an emotion that, to our knowledge, has not been explored in VLBW children.

While sadness, frustration, anger, and fear are negative emotions, they can elicit very different reactions from both parents and children (Cole et al., 2004). Furthermore, although such emotions are readily distinguishable in older children and adults, infants are less able to discern separate emotions and experience a more generalized distress to unpleasant affect states (Calkins & Hill, 1998). Thus, as suggested by Cole and colleagues (2004), it is important to assess regulatory strategies in contrasting conditions or situational contexts. This study aimed to use separate tasks to elicit both anger and disappointment to examine behavior across conditions, and it also explored the nature of potentially distinctive reactions of 3- and 4-year-olds to different aversive emotional stimuli. However, despite the benefits and widespread use of observational measures, there are some limitations to using them exclusively, as children behave differently in a novel environment than they might in more familiar settings, such as at home. Therefore, the current study also obtained data on participants’ temperament and behavior using parent questionnaires as well as direct observation. 28

In addition, this study provides a value-added contribution to the literature that can inform clinical interventions. Given the numerous factors affecting emotion regulation that are largely unchangeable, such as the degree of biological risk and heritable traits, studying the dynamics of mother-child interactions that are associated with emotion regulation is likely to yield information useful in guiding potential parenting and/or child interventions to improve competence in this area. These interventions could, in turn, facilitate numerous areas of development and reduce the risk of later psychopathology, as good emotion regulation skills have been found to correlate with fewer internalizing problems (Shaw, Keenan, Vondra, Delliquardi, & Giovannelli,

1997). In addition, there is promising evidence for the efficacy of parenting interventions designed to improve parenting behaviors (Landry, Smith, Swank, & Guttentag, 2008). A better understanding of the particular behaviors of children, mothers, and their interactions, particularly in a higher-risk population such as children with VLBW, could help enhance these interventions.

Three- and 4-year-olds were chosen for the current study because at that age, children have begun to demonstrate a variety of independent emotion regulation skills but continue to rely heavily on their caregivers for emotional support (Cole et al., 2008). In addition, expressive language is significantly more developed than at previous ages, allowing for an exploration of the impact of children’s verbal skills on their emotion regulation abilities as well as the use of parent-child communication to facilitate emotion regulation strategies. A final basis for the selection of that age group was evidence that sensitive maternal behavior has a significant long-term impact on certain skills, such as executive functioning, at age 3 but that it may not at age 4 (Landry & Crockenberg, 29

2002). Thus, including a range of preschool ages allows for the examination of the impact of age on emotion regulation.

The specific aims of this study were to assess the emotion regulation skills of 3- and 4-year-old children with VLBW compared to 3- and 4-year-old children of normal birth weight, using both standardized measures as well as in a laboratory observational setting, during two structured tasks designed to elicit anger/frustration and disappointment. The study also examined such regulatory capacities in these children in the context of maternal behaviors, as well as the nature of mother-child interaction patterns as they may relate to the child’s emotion regulation.

Hypotheses

The current study was designed to explore the hypothesis that emotion regulation, as assessed by children’s ability to regulate their own emotions in a laboratory setting, is adversely affected by very low birth weight (VLBW). A secondary aim was to investigate associations of emotion regulation with behavioral and temperamental factors, maternal behaviors, and language skills. Based on the literature reviewed above (e.g., Landry et al., 1990; Muller-Nix et al., 2004), the following hypotheses were tested:

1. VLBW children will display fewer adaptive self-initiated emotion regulation

strategies and behaviors and more maladaptive emotion regulation strategies,

including less use of self-distractions and greater levels of acting out/disruptive

behavior, than normal birth weight (NBW) children. These group differences will

be observed when the child responds to the task without the mother present

(child-only condition) as well as when the mother then joins the child (child-with-

mother condition). 30

2. Maternal intrusiveness will be greater in mothers of VLBW children than in mothers of NBW controls, while maternal sensitivity and responsiveness will be lower in the VLBW group.

3. Because of the anticipated delays in emotional competence in VLBW children and the greater psychological distress and intrusiveness in their mothers, mother- child dyads in the VLBW group will demonstrate fewer adaptive interactions, including cooperation and reciprocal behavior, and more conflict.

4. VLBW children will have higher parent ratings of behavior problems, higher parent ratings of more difficult temperament, lower scores on a test of child language development, and higher parent self-ratings of psychological distress.

5. Regardless of group, maternal sensitivity and responsiveness will be associated with more adaptive emotion regulation strategies and less acting out/disruptive behavior.

6. Regardless of group, poorer emotion regulation skills will be associated with higher parent ratings of behavior problems, higher parent ratings of more difficult temperament, lower scores on a test of child language development, and higher parent self-ratings of psychological distress.

31

Chapter 2. METHOD

Participants

Participants in the current study included 21 children who were born VLBW (<1500 g) and treated in the Neonatal Intensive Care Unit at Rainbow Babies and Children’s

Hospital. Children were recruited from those who were followed in the Neonatal

Network Follow-Up Program. A group of 21 age-matched NBW children were recruited from several local preschools. Initially, recruitment also included seeking NBW participants from several local pediatricians’ offices in order to obtain a sample of children with backgrounds similar to those in the VLBW group. However, recruitment from pediatrician’s offices did not yield any participants and an alternative strategy implemented in which families were introduced to the study by preschool administrators.

After hearing about the study from preschool staff members, parents provided contact information if they were interested in participating. The study investigator then conducted a brief telephone screening to determine each interested family’s appropriateness for participation in the study. The protocol was approved by the

University Hospitals Case Medical Center IRB and consent was obtained from parents prior to participation.

At the time of their participation, children were required to have been within 36 to 60 months of age. Exclusion criteria for both groups included children with severe neurosensory impairments, cognitive deficits, or pervasive developmental disorders, or families in which the mother was not available to participate in the study. Exclusion criteria for in the control group also included a birth weight under 2500g or a gestational age of less than 36 weeks. Information regarding level of maternal education was 32

collected as a measure of socioeconomic status. Sample demographic characteristics for each group are presented in Table 1. There were no group differences in demographic variables or in rates of preschool attendance.

Overview of Laboratory Observation and Testing Procedures

Participant assessments were completed in a single session lasting approximately

1.5 hours. Mothers accompanied their children to the research laboratory on the campus of Case Western Reserve University. During the visit, mothers and children participated in tasks designed to elicit negative emotions from the children (i.e. anger and disappointment). A graduate student and an undergraduate research assistant conducted the visits. Families entered the study room, and children were given several minutes to adapt to the environment and play while the mother remained in the room. During this time, the mother participated in the informed consent process. After this initial

(approximately 5-10 minute) free play/warm-up period with the child, mother, and experimenter, mothers completed several questionnaires in a separate room while children played for an additional period of time if needed to acclimate to being separation from his/her mother. Some children required several additional minutes of free play before comfortable to separate from their mothers, and experimenters tried to ensure that children were minimally distressed about this separation. Then children were assessed on a measure of language development. Following the language assessment, the videotaped observation of the structured tasks began. The order of administration of these two tasks was counterbalanced across participants in both groups. Only one child, who was in the VLBW group, was unwilling to separate from his mother at any time during the visit. Because his mother was present during the child-only condition, this 33

invalidated the task and this participant was removed from analyses. All other children were able to warm up adequately to the testing environment and were able to separate from their mothers without distress. When mothers were not present in the room, they were able to watch the tasks being administered through a computer monitor in another room. Each family received a $20 Target gift card as compensation for their time. In addition, following the visit, families received a brief report on their child’s general receptive language skills that were assessed at the visit.

Primary Observational Measures

Disappointing Gift task. The Disappointing Gift task is a laboratory paradigm that assesses children’s ability to regulate their emotions, particularly disappointment, and allows for observation of both social, i.e. interactive with their mothers, and nonsocial displays of emotion and associated regulatory strategies. The format of the task used in the current study was based on from procedures adapted from Saarni’s

(1984) Disappointment Task paradigm, and was it was also used in other early studies of children’s emotions (e.g. Cole, 1986). In addition, this task is a commonly used procedure in more current emotion regulation research and has been used in numerous studies with preschool-aged children (e.g. Johnson, Walden, Conture, & Karrass, 2010;

Orta, Corapci, Yagmurlu, & Aksan, 2013). In this task, an experimenter asks the child to rank-order a series of five toys, which include a range of both desirable and undesirable items. The experimenter writes down the child’s ordered preferences, tells the child that he/she will receive the favorite toy, and leaves the room. Then, a second examiner enters and provides the child with their least favorite toy, without indicating that anything is wrong, and then exists the room, leaving the child alone. In the standard Disappointing 34

Gift paradigm, the experimenter returns after several minutes. However, this paradigm was adapted from the original format. In the adaptation used in the current study, the child’s mother was not present in the room when the disappointing toy is given, but she has been told that the purpose of the task is to observe how her child handles disappointing situations. She was also instructed interact with her child as she typically would in this type of emotional situation. The mother entered after waiting 1 minute and was present for the remaining 1 minute of the task. This allowed for assessment of the child’s independent emotion regulation abilities as well as a comparison regarding how the interaction with mother impacts the child’s emotion regulation.

The task was videotaped, and coding began when the experimenter leaves the room. Coding was conducted in conjunction with 2 segments: 1. the first minute after the child is given the least favorite toy; and 2. the second minute during which the mother joins the child. The child’s behavior was coded separately for the time alone and during the dyadic conditions. The mother’s behavior and mother-child interactions were coded during the dyadic condition. Global assessments of several variables (discussed below) will be calculated for each segment. Videos were coded by a trained undergraduate research assistant (see Coding of Observational Tasks for description).

Locked Box task. The Locked Box task is a paradigm that was initially developed in the Laboratory Temperament Assessment Battery (Goldsmith, Reilly, Lemery,

Longley, & Prescott, 1995) and is also a commonly used task in studies of young children’s emotion regulation (e.g. Cole, Dennis, Smith-Simon, & Cohen, 2008;

Blankson, O’Brien, Leerkes, Marcovitch, Calkins, & Weaver, 2013). Similarly to the

Disappointing Gift task, in the Locked Box task the experimenter is initially present in 35

the room. The experimenter gives the child a clear, locked plastic box with a visible toy inside. The experimenter demonstrates how the padlock can be unlocked with keys and the box can be opened. The child is given a different set of keys that does not contain the correct key. This is designed to elicit frustration. Like the Disappointing Gift task, this task was also adapted to allow for assessment of individual child emotion regulation as well as when the children are with their mothers. In standard administrations of this task, mothers are either not present in the room or are busy filling out paperwork and are instructed to ignore children’s requests for help. In the current paradigm, after the child spent 1 minute alone in the room, the child’s mother was told to enter the room and that she is able to help the child as she normally would at home during a time of frustration.

She was also informed that there is a possibility that the child may have the wrong key, which would make it an impossible task to unlock the box. However, she did not have the correct key either. After the mother and the child have spent one minute in the room together, the experimenter re-enters, and informs the child that the wrong set of keys was given. The correct key was then given, and the child and mother worked together to open the box so the child can obtain the toy. This task involved the same 2-part coding process used for the Disappointment Gift task.

Coding of Observational Tasks

The coding system used for both of these tasks is a version of the Parent Child

Interaction System (PARCHISY; Deater-Deckard, Pylas, Petrill, 1997) that was adapted with permission from the authors. PARCHISY is a system designed to assess both children’s and parents’ individual emotions and behavior as well as the nature of the dyadic relationship. Thus, the system is grouped by variables that focus on child 36

behavior and emotion regulation, i.e. child codes. variables that specifically measure mother behaviors and affect, i.e. mother codes, and several variables that assess the interaction between mother and child, i.e. dyadic codes. The coding system adapted for use in the current study also incorporated aspects of toddler’s emotion regulation strategies as described by Grolnick and colleagues (1996), such as self-soothing behaviors and use of distractions. The coding system will be used for both laboratory observation tasks and uses a Likert scale ranging from 0-3. Several of the child codes that refer to the child’s behavior independent of his/her mother’s presence were assessed twice: during the child-only condition and while the mother is present. The remaining child codes that measure the child’s behavior in relation to the mother, as well as the mother and dyadic variables, were calculated only in the child-with-mother condition.

Drawing on relevant literature, the current study operationalized the construct of emotion regulation through several variables. These strategies included the use of children’s behaviors designed to distract themselves from the current aversive situation, comfort-seeking behaviors, e.g. calling out for their mothers, children’s disruptive or externalizing behaviors (e.g. acting out/venting and noncompliance), self-comforting or soothing (i.e. self-soothing). Of these variables, acting out/venting and noncompliance were the only strategies considered to be maladaptive, as the other strategies consist of age-appropriate behaviors. In addition to emotion regulation strategies, affect valence and level of child verbalizations were assessed as factors closely associated with regulatory strategies. See Appendix A for a complete list and description of child, mother, and dyadic variables. 37

The primary coder was a trained undergraduate student who was blind to the participant groups. This rater was trained by the principal investigator, and a minimum of 80% inter-rater reliability was established based on comparisons of tapes that had also been scored by the principal investigator. The average kappa across variables was k=.90

(range .87-.93) for child variables, k=.93 (range.91-.96) for mother variables, and k=.92

(.90-.95) for dyadic variables. The coding of parent and child variables was conducted separately, as tapes were watched at least twice: once to code the child variables and once to code the mother variables.

Measures of Child Behavior and Development

Peabody Picture Vocabulary Test (PPVT-4). This is a measure of the child’s receptive vocabulary abilities and was administered prior to the laboratory observation tasks. The PPVT-4 assesses children and adults from 2 years, 6 months to over 90 years of age. Administration time is 10-15 minutes. The PPVT-4 is widely used and was selected because it places fewer cognitive and attentional demands on children in comparison to other language measures designed for use with this age group. This test has demonstrated good internal consistency, .94 and .95 for each of the 2 test forms.

Child Behavior Questionnaire- Very Short Form. The Child Behavior

Questionnaire Very Short Form (CBQ; Putnam and Rothbart, 2006) was administered to parents as a measure of child temperament. It is a 36-item questionnaire that assesses 3 broad temperament categories: 1. surgency extraversion, which measures intensity of , activity level, and impulsivity; 2. , which assesses levels of negative emotions, e.g. anger, sadness, and an inability to be soothed; and 3. effortful control, which assesses constructs such as inhibitory and attentional control. Effortful 38

control has also been described as a child’s capacity to suppress a dominant response in order to show a subdominant response. Internal consistency was .75, .72, and .74 for these scales, respectively.

Behavior Assessment System for Children, Second Edition, Parent Rating Scales.

Mothers completed the preschool version of Behavior Assessment System for Children,

Second Edition (BASC-2; Reynolds & Kamphaus, 1992). The BASC-2 is a valid and reliable measure of emotional concerns, challenging behaviors and adaptability of children ages 3 through 5. Of the clinical, adaptive, and composite scales on the BASC-

2, the current study used the following scales: Adaptive Skills, Internalizing,

Externalizing, and Behavioral Symptom Index. Internal consistency was .87, .83, .91, and .86, respectively.

Measures of Parent Distress and Family Background

Brief Symptom Inventory (BSI). Mothers completed the BSI (Derogatis, 1993) as a measure of their own symptoms of psychological distress. The BSI is a 53-item questionnaire that produces 9 symptom dimensions, e.g. depression and obsessive-compulsive, as well as a global measure, i.e. the general severity index. Cronbach’s alpha for global and individual scales range from .71-.83, and test-retest reliabilities from .69-.91.The General Severity

Index, an overall measure of distress, will be used in analyses.

Child and Family Background Information. Parents were also administered a questionnaire consisting of background information regarding demographics, including children’s educational history, such as whether they are currently in preschool or if they had previously received any type of special services (e.g. occupational therapy, speech therapy), as well as level of maternal education. 39

Data Analysis

Two tailed, independent sample t-tests were conducted to determine group differences on demographic and background variables. A frequency analysis of the variables coded from videos of the child alone and child-with-mother conditions for the two tasks was conducted. Codes with frequencies of less than 10% in the total sample were eliminated from consideration. Remaining codes for the Disappointing Gift task included the child variables positive affect, negative affect, self-initiated distractions, comfort seeking, self-soothing, and verbalizations; and the maternal variables positive content, positive affect, responsiveness, sensitivity, and verbalizations. Remaining codes for the Locked Box task included the child variables positive affect, negative affect, self- initiated distractions, comfort seeking, and verbalizations; and the maternal codes positive content, negative content, positive affect, responsiveness, sensitivity, and verbalizations. See Table 2 for frequencies of these variables. Child-mother dyadic codes for each task included reciprocity and cooperation. Variables eliminated due to low occurrence rates were child aggression, child noncompliance, maternal negative affect, and dyadic conflict for both tasks; self-soothing for the Locked Box task; and maternal negative content for the Disappointing Gift task. Data analyses of the remaining codes were carried out in several phases.

Preliminary correlational analyses of associations between the observed child variables and background factors including age, sex, race, and maternal education, as well as the child’s receptive language test score, failed to reveal any associations.

However, based on broad literature documenting the impact of socioeconomic variables on child development and previous studies demonstrating varying emotion regulation 40

behaviors at different preschool ages (Carlson & Wang, 2007), child age (corrected for prematurity for the VLBW group) and maternal education were included as covariates.

As in the current study, other studies that examined emotion regulation in young children

(e.g. Carlson and Wang, 2007) did not find associations with sex and outcome variables, thus analyses did not control for this factor.

The first phase of analysis aimed at reducing the child variables into several emotion regulation strategies. Current studies on emotion regulation in children often examine regulatory behaviors through the use of a few strategies or combined variables that group together. For example, in an emotion regulation study of preschoolers and the effect of maternal behavior, Feng and colleagues (2008) conducted a Principal

Components Analysis and derived 2 emotion regulation factors from six observed codes.

A similar procedure was conducted in the current study; a factor analysis of the child behavior ratings for the child-only condition of each task was conducted to reduce these codes to a smaller set of conceptually meaningful summary scores (see Table 3).

Specifically, a Principal Components Analysis was conducted with oblimin rotation and

Kaiser normalization. A 3-factor structure emerged for each task, using the Kaiser

Guttman rule of including factors with eigen values greater than 1. Only items with loadings >.50 were retained. For the Disappointing Gift task, self-initiating distractions and lack of comfort seeking loaded on factor 1. This factor, referred to as autonomous coping, reflects the use of internal strategies of self-distraction occurring in the absence of efforts to seek out external support. Positive affect, self-soothing, and verbalizations loaded onto a second factor, referred to as expressiveness. Negative affect loaded 41

separately from the first two factors and thus was examined separately from the first two factors.

A similar Principal Components Analysis of child behavior variables was conducted for the child-only condition of the Locked Box task. This analysis also yielded autonomous coping and expressiveness factors, with negative affect again loading separately from these factors. The only difference in the factor structure for the

Locked Box, relative to that for the Disappointing Gift task, was that self-soothing was excluded from analyses due to its low frequency of occurrence. The expressiveness factor for this task thus included only positive affect and verbalizations. The factor scores used in analyses were created by taking the sum of scores for the individual variables that loaded onto each factor. Factor scores for the child-with-mother condition of each task were computed in the same manner. Examination of the association between these summed scores and the SPSS-generated factor scores revealed correlations of >.95 for all factors.

The maternal variables were also entered into a Principal Components Analysis, however because no consistent factor structure was produced, individual maternal variables were used in analyses. Of the resulting child, maternal, and dyadic variables, autonomous coping was normally distributed for both tasks, as was a log transformation of expressiveness for the Disappointing Gift task. Child negative affect was not normally distributed for either task. Transformations of negative affect scores for both tasks and expressiveness for the Locked Box task were unsuccessful in creating more normal distributions, thus scores for these child codes were converted to low vs. high binary variables based on median splits and analyzed using non-parametric tests. Of the dyadic 42

variables, reciprocity for the Disappointing Gift task, and cooperation and reciprocity for the Locked task were normally distributed. Cooperation for the Disappointing Gift was not normally distributed and could not be adequately transformed. This variable was thus dichotomized based on a median split and analyzed using non-parametric tests.

Correlations between the child codes, maternal codes, and dyad codes were also examined.

The second phase of analysis focused on group comparisons (VLBW vs. NBW) of the child, maternal, and dyadic codes, as well as the measures of child and mother characteristics (i.e., PPVT-4, CBQ, BASC-2, BSI). Mixed design ANOVAs, also known as split plot ANOVAs, were conducted to examine group differences on the child emotion regulation strategies. Each mixed design ANOVA included group (VLBW vs.

NBW) and condition (child alone vs. child-with-mother) as the primary factors of interest, with age and maternal education included as covariates. Because of the non- normal distribution of negative affect on both tasks and the multiple conditions being analyzed, Generalized Estimating Equations (GEE) were used to examine group differences across the child-only and child-with-mother conditions in low vs. high ratings. Covariates in these analyses were the same as those in the mixed design

ANOVAs. Regressions were conducted to examine group differences on maternal and dyadic variables.

For exploratory purposes, a series of follow-up analyses were conducted to examine potential group differences on individual variables in the child-only and child- with-mother conditions separately that may have been obscured by forming factor composites. Several individual variables were not normally distributed. A median split 43

was used to dichotomize these variables and group differences were examined using logistic regressions. As self-initiated distractions on the Disappointing Gift task were normally distributed, an ANCOVA was conducted to examine group differences on this variable. Age and maternal education were again included as covariates in these analyses.

The third phase of analysis consisted of regressions examining associations of specific maternal behaviors with child emotion regulation in the child-with-mother condition of each of the two tasks. Primary factors in these analyses were group and the group x maternal behavior interaction. The covariates of age and maternal education were entered in a single step, with the dependent variable entered in a second step. Linear regressions were conducted in analysis of autonomous coping and expressiveness, and binary logistic regressions in examining the binary negative affect variables for both tasks and expressiveness for the Locked Box task.

In the final phase of analysis, regressions were conducted to examine associations of child and maternal characteristics as assessed on the child and parent questionnaires

(i.e. the CBQ, BASC-2, and the BSI) and the child language test with the child emotion regulation in the child-only condition of each task. Analysis included each of these child and maternal characteristics considered separately, group, and the group x child/maternal characteristic interaction term as predictors of child emotion regulation. Age and maternal education were also included as covariates in these analyses.

44

Chapter 3. RESULTS

Descriptive Data

Table 4 presents results from comparisons of child and maternal characteristics.

Consistent with the literature on outcomes of VLBW, VLBW children had significantly lower scores on the PPVT-4 and each of the BASC-2 scales that were assessed (Adaptive

Skills, Internalizing, Externalizing, and the Behavioral Symptom Index). In addition, mothers of VLBW children had high scores on the Global Severity Index of the BSI.

There were no group differences on surgency, negative affect, and effortful control, as reported on the CBQ.

Table 5 presents Pearson correlations for associations between the child, maternal, and dyadic codes for each condition of each task. Survey of the correlations revealed several significant associations. There were no significant correlations between the child scores for the child-only conditions of either task. For the child-with-mother condition of the Disappointing Gift task, child autonomous coping was negatively correlated with negative affect. Across conditions of the Disappointing Gift task, negative affect for the child-only condition was negatively correlated with autonomous coping but positively correlated with negative affect for the child-with-mother condition. Across the child-only conditions of the two tasks, expressiveness for the Disappointing Gift task was positively correlated with expressiveness and negative affect on the Locked Box task. Several of the maternal variables for the two tasks were also positively correlated (see Table 4d). For the dyadic variables, correlations between reciprocity and cooperation were r=.-.16, p=.31, for the Disappointing Gift task and r=.29, p=.06, for the Locked Box. Reciprocity 45

was significantly correlated across tasks, r=.41, p=.009, while cooperation was not, r=.18, p=.27.

Group Differences

Group differences on the child, maternal, and dyadic measures are presented in

Tables 6-9, for the Disappointing Gift and Locked Box tasks. Means are listed for variables that were normally distributed and rates of high scores on binary measures are listed for variables that were not normally distributed. Findings from mixed design

ANOVAs conducted on variables for the Disappointing Gift task did not reveal any group differences. There was an effect of condition (i.e. child-only vs. child-with- mother) on expressiveness, F (1,37) = 41.85, p<.001, indicating that children were more expressive in the child-with-mother condition than in the child-only condition. However, there was no significant interaction between birth weight group and condition. Analysis also failed to reveal any other group differences or group x condition interaction effects for the Disappointing Gift task. No group differences were found for maternal or dyadic variables on this task.

For the Locked Box task, there was a significant effect for group on expressiveness, F (1,37) = 4.44, p=.04, indicating that VLBW children demonstrated less expressiveness on this task than did NBW controls. In addition, there was a significant condition effect on expressiveness, F (1,39) = 108.66, p<.001, indicating that children demonstrated more expressiveness in the child-with-mother condition than in the child- only condition. There was also a significant condition effect on autonomous coping, F

(1,39) = 20.19, p<.001, such that children demonstrated more autonomous coping 46

behavior in the child-only condition. There was also a trend toward a significant group x condition interaction for expressiveness, F (1,39) = 4.07, p=.051, suggesting that VLBW children may exhibit slightly less expressiveness than NBW children when their mothers are present. Of the maternal variables, maternal sensitivity significantly differed by group, with mothers of VLBW children demonstrating greater sensitivity, beta [standard error (SE)]= -.45 (.21), p=.04. The groups did not differ significantly on either of the dyadic variables on this task.

Despite the lack of significant group differences on dyadic variables, there was a trend for an association of group with cooperation on the Locked Box task, beta (SE) =

.50 (.25), p=.051, with greater cooperation evident for the NBW group than for the

VLBW group. Older age was also significantly associated with less cooperation for the

Locked Box task, and higher maternal education with more reciprocity for both tasks.

Results from exploratory follow-up analyses of individual child variables in the child-only and child-with-mother conditions separately revealed one significant group difference. For the Disappointing Gift task, there was a significant group difference in self-initiated distractions, with VLBW children demonstrating fewer self-initiated distracting behaviors than NBW children, F (1,37) = 4.37, p=.04. For the child-with- mother condition of the Locked Box task, there was also a trend for VLBW children to make fewer verbalizations than the NBW group, F (1,37) = 3.52, p=.068.

Associations of Maternal and Dyadic Behaviors with Child Emotion Regulation in the Child-with-Mother Condition

Tables 10 and 11 summarize the maternal behaviors as they relate to child emotion regulation. For the Disappointing Gift task, linear and logistic regression 47

analyses revealed that several maternal behaviors were associated with autonomous coping. Less autonomous coping was associated with greater maternal positive content, beta (SE) = -.52 (.25), p=.04, more responsiveness, beta (SE) = -1.17 (.31), p=.001, and greater sensitivity, beta (SE) = -.95 (.20), p<.001. More expressiveness was also associated with greater maternal responsiveness, beta (SE) = .12 (.06), p=.046, and less child negative affect with greater maternal sensitivity, beta (SE) = 1.08 (.50), p=.03.

Associations of Extra-task Measures of Child and Maternal Characteristics with

Observed Child Behaviors

Tables 12 and 13 summarize results of linear and logistic regressions relating child emotion regulation for the each of the two tasks to child characteristics as assessed by the BASC-2, CBQ, and PPVT-4, and to maternal distress as assessed by the BSI

Global Distress Index on the BSI. Results revealed that more internalizing problems on the BASC-2 predicted less autonomous coping on the Disappointing Gift task, beta (SE)

= -.06 (.03), p=.04, and more externalizing problems predicted less negative affect on the

Locked Box task, beta (SE) = -.24(.11), p=.03. Higher scores on the CBQ negative affect scale were significantly associated with greater observed negative affect for the

Disappointing Gift task, beta (SE) = .40 (.16), p=.01, and higher scores of the CBQ effortful control scale predicted more autonomous coping for this same task, beta (SE) = -

.14 (.07), p=.04. On the Locked Box, more externalizing problems on the BASC-2 was associated with less negative affect beta (SE)= -.24 (.11), p=.03.

48

Chapter 4. DISCUSSION

To the author’s knowledge, the present study was the first investigation of emotion regulation in young children with VLBW that compared behaviors in child-alone vs. child-with-mother conditions during negative-affect provoking tasks. By eliciting mild disappointment and frustration, the Disappointing Gift and Locked Box tasks permitted examination of emotion regulation in different contextual settings. In addition to exploring the effect of the mother’s presence on child emotion self regulation, the child-with-mother condition allowed for the investigation of observed maternal behaviors and their association with children’s emotional reactions to the tasks. The findings with regard to each of the study hypotheses are discussed below. Although the experimental tasks were based on previous paradigms, they were novel and thus have not been administered previously to either younger children or to children with VLBW. For these reasons, methodological issues related to these tasks are also considered. Study limitations, potential future directions, and implications are summarized in the final portion of the discussion.

Group Differences in Emotion Regulation

In support of hypothesis 1, VLBW children exhibited less expressiveness than

NBW children during the Locked Box task. Because a component of the expressiveness factor measures the level of the child’s verbal output, this result is consistent with previous literature documenting poorer language and communication skills in VLBW children (Foster-Cohen, Edgin, Champion, & Woodward, 2007). The finding that the

NBW group had higher scores on a receptive vocabulary test than the VLBW group is likewise consistent with group differences in expressivity. Self-talk was observed in both 49

the child-only and child-with-mother conditions and is considered one of the primary adaptive strategies that develops during the preschool years (Winsler, Feder, Way,

&Manfra, 2006). Consistent with expectations, results from exploratory follow-up analyses that isolated verbalizations from the composite expressivity factor score indicated a trend for more verbalizations in the NBW group in the child-with-mother condition. Although this result must be interpreted with caution, it higlights the need to examine verbalizations in future studies of emotion self-regulation in young VLBW children.

Another possible explanation for the group differences in expressiveness on the

Locked Box task is that the VLBW children were less able than NBW children to appraise this problem-solving challenge in a positive manner. Considering the fact that positive affect as well as verbalizations contributed to expressivity, the NBW children may have been more able to tolerate the frustration of the task and to display the emotional flexibility to find positive aspects about the task, thus shifting their affective state. This strategy of interpreting a situation in such a way that it alters one’s emotional response to it is known as cognitive reappraisal. In adults, it is considered a primary, adaptive emotion regulation strategy and is associated with greater positive affect and fewer depressive symptoms (Gross & John, 2003). In children, cognitive reappraisals are thought to emerge during the preschool years, and the use of this strategy has been documented in 3- and 4-year-olds in a study of emotion regulation using frustrating tasks

(Stansbury & Sigman, 2000). A weakness in cognitive reappraisal in the VLBW group would be consistent with deficits in executive functioning that have been observed in other studies of VLBW preschoolers (e.g. Clark et al., 2008; Orchinik et al., 2011). In 50

addition, previous research revealed that the neural areas involved in executive functions are also activated during cognitive reappraisal (Ochsner, Bunge, Gross, & Gabrielli,

2002). However, the present study did not include measures of executive function and it was therefore not possible to determine if these deficits contributed to the group differences in expressiveness.

Contrary to expectations, the results did not reveal weaknesses in the VLBW group in self-initiated regulation strategies as measured by the autonomous coping factor.

Nevertheless, partial support for this expectation was provided by secondary, exploratory analyses that examined individual child codes. Specifically, although group differences were not found in comfort-seeking behaviors, VLBW children were less likely to engage in self-initiated distractions than NBW children on the Disappointing Gift task. One possible reason for the lack of group differences on the composite autonomous coping factor may relate to the infrequent use of comfort-seeking in 3- and 4-year-olds.

Although Stansbury and Sigman (2000) found that 84% of 3-year-old children employed self-distracting behaviors, self-comforting behaviors were rarely used. In the current study, inclusion of comfort-seeking in the autonomous coping factor—especially because this behavior was inconsistently present--may have obscured group differences on self- initiated behaviors.

The finding of fewer self-initiated distractions in the VLBW group is consistent with other literature documenting delays in the behavior and social competence of

VLBW children compared to their same aged peers (e.g. Landry et al., 1997). Empirical studies have shown that by 3 years of age, typically developing children are able to employ deliberate strategies, including distraction (Cole et al., 2011) and by 4 years of 51

age, children can deliberately use this strategy to successfully delay feeling anger in an emotionally provocative situation. In addition, there is evidence that VLBW children are impaired and/or delayed in a number of cognitive and neurodevelopmental domains that may contribute to emotion regulation, such as executive functions and that these differences are evident even at age 4 (Woodward et al., 2009).

Negative affect, although not a specific regulatory behavior, was also of interest in this study, as previous work has found that greater negative emotionality is associated with less social-emotional competence (Eisenberg & Fabes, 1995). In addition, emotional expression is considered one component of emotion regulation (Grolnick et al.,

1996). Results revealed that there were no group differences related to the display of negative affect. Some studies on emotional reactivity in preschool-aged VLBW/preterm children suggest a tendency toward emotional overreactivity (Potijk, de Winter, Bos,

Kerstjens, & Reijneveid, 2012) and increased negative affect (Erickson, Duvall, Fuller,

Schrader, MacLean, & Lowe, 2013), but others do not find these differences (Blair,

2002). The lack of differences in this study is thus consistent with some previous findings, and the results add to the existing work on child temperament and emotionality, suggesting that VLBW/preterm children may not exhibit strong negative emotionality at this age, at least in mildly distressing situations. The fact that group differences in negative affect were not found despite differences in expressiveness, which included positive affect, is also not unexpected. Exhibiting positive emotions may be an adaptive form of coping with a stressor, whereas negative affect would be expected from most children in response to the two experimental tasks. The results of the current study suggest that the tasks elicited similar negative affect from the two groups but that the 52

VLBW children were less able to utilize more adaptive coping strategies (e.g. self- distractions) to regulate these emotions.

An additional expectation was that VLBW children would exhibit more acting out behavior, disruptive behavior, and aggression. However, both group exhibited negligible aggressive or noncompliance responses to either task, making group comparisons moot.

The lack of behavioral noncompliance may have been related to the nature of the tasks.

Because mothers were not given any particular commands or instructions to convey to their children, there were few opportunities for noncompliant behaviors. Commonly used observational tasks, such as clean-up procedures, that are designed to assess compliance typically require mothers to directly instruct their children, while these tasks did not.

Another potential reason for the lack of aggression and noncompliance is that the tasks may not have been sufficiently provocative to elicit aggression from the child. Similarly, although negative affect was evident, the majority of children in both groups failed to demonstrate negative affect on the tasks.

The lack of group differences in negative intrusive behaviors by mothers was also contrary to expectations, as was the finding that mothers of VLBW children were significantly more sensitive on the Locked Box task than mother of NBW controls. The latter finding suggests that mothers of VLBW children may have been anticipating and thus compensating more for their children’s distress than mothers of NBW children.

Compensatory maternal behaviors in the VLBW group may also have contributed to the lack of other anticipated group differences in the current study, particularly in the child- with-mother condition. Despite more recent literature documenting decreased sensitivity in mothers of VLBW children, some older studies have provided evidence that mothers 53

perceive VLBW children as vulnerable, a possibility that would be consistent with the stressful birth events experienced by these families and the often chronic health problems that continue after preterm birth (Miles & Holdistch-Davis, 1997; Singer et al., 1999).

The current study did not assess mothers’ perceptions of children as vulnerable or at high health-risk, but perhaps this may have contributed to the increased maternal sensitivity in the VLBW group.

In support of hypothesis 4, VLBW children had significantly higher scores than the NBW controls on all BASC-2 scales examined (Adaptive Skills, Internalizing,

Externalizing, and Behavioral Symptom Index). VLBW children also had significantly lower scores on the PPVT-4, and mothers of VLBW children reported more self-distress than mothers of NBW children. These findings are consistent with literature documenting both more behavior problems and language delays and higher levels of maternal distress in VLBW children compared to NBW controls (Foster-Cohen et al.,

2007; Scott et al., 2012; Singer et al., 1999). These group differences indicate that the

VLBW children had outcomes similar to those found in other studies and build in the current sample as one that was reasonably representative of the larger

VLBW population.

The Effects of Maternal Presence on Child Emotion Regulation

One of the novel features of this study is the observation of the child’s emotion regulation both alone and in the presence of the mother, allowing direct evaluation of the impact of maternal presence on children’s ability to cope with distressing tasks. Results indicated that on the Locked Box task, there was an effect of condition on both expressiveness and autonomous coping, with children demonstrating greater 54

expressiveness and less autonomous coping in the presence of their mothers than when they are alone. The significant result for expressiveness would be anticipated based on the increased opportunities for verbalizations when children are with their mothers. The finding that children exhibited less autonomous coping during the Locked Box task in the presence of their mothers would also be anticipated given that children were less likely to initiate their own regulatory strategies (specifically self-distraction) when their mothers were present to help them with the task. One would likewise expect that the children would be more likely to seek comfort from another person when there is someone present. Given the lack of previous data on the effect of maternal presence in relation to the child alone behavior in distressing experimental tasks, these findings add to the more general literature on the effect of context, specifically parental presence, on children’s response to stress, such as during painful medical procedures (Piira, Sugiura, Champion,

Donnelly, & Cole, 2005). .

Although not a significant finding, the trend toward a group x condition interaction for the Locked Box task raises the possibility that NBW children may become more expressive in the presence of their mothers than VLBW children. The trend is consistent with literature indicating that VLBW children at risk for social communication delays, impairments in social competence, and difficulty initiating social interactions

(Foster-Cohen, Edgin, Champion, & Woodward, 2007; Landry et al., 1990; Landry,

Smith, Miller-Loncar, & Swank, 1997), possibly making it more challenging for them to express themselves to their mothers during distressing tasks.

Maternal Behavior and its Relation to Child Emotion Regulation 55

An additional hypothesis was that the VLBW and NBW groups would differ in maternal parenting styles and in the effects of maternal behavior on children’s emotion regulation. Based on previous literature, mothers of VLBW children were expected to show less responsive and sensitive behavior than mothers of NBW controls (Muller-Nix et al., 2004; Singer et al., 1999). The lack of significant findings in this domain may be related to the lack of negative emotions elicited by the two tasks from either children or their mothers. If the tasks were not experienced by the children as especially upsetting, there would have been less of a need for parental support and encouragement. One significant finding for the Disappointing Gift task was that maternal sensitivity was associated with greater child negative affect. This finding can also be explained by postulating that children who are not expressing negative emotions may make few demands on their mothers to be sensitive or to show support and encouragement. On the same task, more maternal responsiveness, but not greater maternal sensitivity, was associated with greater child expressiveness, suggesting that these two dimensions of maternal behavior were related to different types of child behavior. These findings are consistent with previous work that has shown parental sensitivity is associated with greater child social competence in the context of child distress, but not nondistress

(Leerkes, Blankson, & O’Brien, 2009). Thus, it may be that while sensitive parenting was associated with greater negative affect, it may have been that sensitive parenting was needed only because the children were experiencing distress, i.e. negative affect. Thus, although the current tasks differed from those used in previous studies of social- emotional competence in young VLBW children, the findings add to those of past research showing associations of parenting characteristics with social competence and 56

emotion regulation in low birth weight/preterm children (Clark et al., 2008; Landry,

Garner, Swank, & Baldwin, 1996).

The finding for the Disappointing Gift task of associations of greater maternal responsiveness and sensitivity with less autonomous coping was not anticipated. In fact, this finding would appear to contradict the perception of autonomous child behaviors as being adaptive in nature or of maternal responsiveness and sensitivity as indications of positive parenting traits. However, if mothers are attuned to children’s emotional states, such as sadness or disappointment, sensitive behavior will involve helping to regulate the child’s emotions and will lessen the need for the child to engage in independent regulatory behaviors. However, if the child is engaged in autonomous behavior, such as self-distraction from the unpleasant situation, the child is already self-regulating and thus sensitive parenting may be less in demand. Thus, an interpretation of these unexpected results is that maternal responsiveness and sensitivity were elicited by a greater need of the child for parent intervention during this problem-solving task, rather than as reflections of how parenting affects children’s emotional development.

Associations of Child and Parent Characteristics as Measured Outside the

Laboratory Tasks with Emotion Regulation

Several child characteristics measured by parent report were related to child emotion regulation. Although the groups were not significantly different on any of the three scales of the CBQ, some of these scales were related to emotion regulation for the total sample. For the Disappointing Gift task, greater effortful control was associated with more autonomous coping, and greater negative affect on the CBQ was associated with greater child negative affect. These associations help to validate the observational 57

measures and suggest that at least some of the child behaviors codes reflect stable child traits rather than task specific responses. On the BASC-2, more internalizing problems predicted less autonomous coping for the Disappointing Gift task, which is consistent with previous literature on the associations of internalizing problems with fewer adaptive emotion regulation strategies, such as attentional regulation (Eisenberg et al., 2001).

One finding from the current study that is difficult to explain was the association of greater externalizing problems on the BASC-2 with less negative affect on the Locked

Box task. Although some investigations document direct associations between negative emotionality and externalizing problems (e.g. Stice & Gonzales, 1998), other studies suggest a less direct link between externalizing problems and negative affect that involves factors such as self-regulation and parenting influences (Lipscomb et al., 2012).

For example, Eisenberg et al. (2000) found that behavioral dysregulation in 2-year-olds was related to both high and low negative emotionality several years later (Eisenberg et al., 2000). Thus, additional research is needed to examine behavioral correlates of emotion regulation in young children during mildly distressing tasks such as those used in this study.

While maternal education was not associated with child emotion regulation or maternal behaviors observed during either of the tasks, higher maternal education was associated with more reciprocal behavior on both tasks, suggesting that better educated parents were more likely to display this desirable characteristic. This finding is consistent with literature documenting socioeconomic status as a protective factor and predictor of better outcomes in a variety of developmental domains (Bradley & Corwyn,

2002). 58

Methodological Considerations

The findings of this study need to be interpreted in light of several methodological considerations. One issue raised about the design of the current study is the appropriateness of the PARCHISY observational codes for the two experimental tasks developed for this study. PARCHISY has been used in empirical studies with a preschool population (Deater-Deckard, Pike, Petrill, Cutting, Hughes, & O’Connor, 2001). As in the current study, these researchers selected particular variables from the larger coding system. In contrast to the present study procedure, they averaged the ratings of these codes across two separate tasks, one of which was a joint problem-solving task. To our knowledge, PARCHISY has not been used to code observations from either the

Disappointing Gift or Locked Box task. Some of the codes, particularly for dyadic interactions, may be more appropriately suited for an interactive task. For example, on the Disappointing Gift task, dyads are not given any particular instructions or goals, thus minimizing opportunities for cooperation and conflict. Similarly, the tasks were designed to elicit frustration and disappointment in the child, but not in the mother. Given that maternal negative affect is typically assessed by PARCHISY codes on interactive tasks designed to be frustrating for both mothers and children (Deater-Deckard, Sewell, Petrill,

& Thompson, 2010), the lack of similar demands on mothers in the Disappointing Gift and Locked Box tasks likely accounts for the absence of codes reflecting negative maternal emotions.

Although the explicit task demands remained the same across child-only and child-with-mother conditions for both tasks, having the mother present likely influenced the nature of the tasks and may have contributed to differences in task demands. 59

Specifically, the effect of maternal presence was likely more salient for the Locked Box task than for the Disappointing Gift task. When the child’s mother entered the room, the former task was likely viewed as an interactive, problem-solving challenge, possibly introducing a new set of demands. In contrast, there was no interactive challenge involved in carry out the Disappointing Gift task. Consistent with this possibility, children’s expressiveness and negative affect were significantly correlated across the child-only and child-with-mother conditions for the Disappointing Gift task, whereas no significant cross-task correlations were found for the Locked Box task. Similarly, while the child-with-mother conditions for both tasks provided opportunities for interactions such as those assessed by the reciprocity dyadic variable, only the Locked Box required explicit cooperation. As might have been expected based on these observations, reciprocity was correlated across the two tasks while cooperation was not. Finally, inter- task correlations for the child-only condition were found for both negative affect and expressiveness, suggesting some stability of emotional reactions and regulatory strategies across the two tasks when the children were alone. In contrast, no significant inter-task correlations were found for child behaviors in the child-with-mother condition. Thus, consideration of differences in the structure and demands of the two tasks and of how these demands are affected by the presence of the mother are important in interpreting the findings.

Methodological Strengths and Limitations

Strengths of the study include observation of VLBW children and NBW controls during two different negative-emotion-eliciting tasks, with children observed in each task first alone and then with the mother present. Child and maternal behaviors were 60

systematically coded to examine a range of different child emotion regulation behaviors.

Mother behaviors in the child-with-mother condition were also coded to explore group differences in maternal behaviors during the tasks and to investigate potential associations of different maternal styles with variations in child emotion regulations.

Finally, child and maternal characteristics were assessed, including child behavior and temperament as rated by the mother, the child’s level of receptive vocabulary, and maternal distress.

Despite these strengths, there were also several important limitations. First, other child characteristics that may have been associated with emotion regulation were not assessed, such as child attachment and children’s executive functioning. For example, children’s behavior changed when they were alone compared to when they were with their mothers. In view of evidence that attachment is a significantly associated with emotion regulation both in early childhood (Gilliom et al., 2002) and in school age children (Contreras et al., 2000), this change may have been partially explained by their attachment styles. Similarly, although group differences were not found in ratings of children’s effortful control on the CBQ, emotion regulation behaviors may have been associated with more formal measures of executive functions, such as tests of working memory capacity and ability to inhibit responses.

Additional limitations relate to methodological features of the study. While codes for verbalization were included in examining child behaviors in this study, the quality of these verbalizations was not assessed. Additionally, the duration of each task was only one minute in the child-only condition and one minute in the child-with-mother condition. This may have limited the both intensity of frustration and disappointment 61

that the children experienced as well as their need to utilize different regulatory strategies. While the rationale for the short time frame included consideration of the children’s age as well as the vulnerability of the VLBW population, allowing the children more time to respond to disappointment or frustration may have revealed higher rates of both negative affect and emotion regulation. A related issue was that the tasks were only mildly negative in nature. Tasks that elicited more intensive disappointment and frustration or that included mothers more in the context of these emotions, may have placed more demands on emotion regulation, resulting in a more powerful test of study hypotheses. Other studies have found age differences in emotionality and use of emotion regulation strategies when comparing 3- and 4-year-olds (Cole et al., 2011). The fact that results from the current study did not yield age differences provides additional evidence that the tasks were not sufficiently distressing to elicit the types of emotion regulation strategies and developmental changes in these strategies that might be observed in children’s daily lives.

Despite the fact that the two groups were well matched on demographic factors and evidence for group differences that are typical in comparing the VLBW and NBW children, an additional limitation is that the sample may not have been representative of the broader VLBW population. As evidence for a potential recruitment bias, it was difficult to recruit families who were both willing and able to participate, and there was a high no-show rate of families who were initially scheduled to participate. For example, the sample participants may have been biased toward families with more resources (e.g. were able to rearrange their schedules reliably and had access to transportation) and higher functioning parents relative to the broader VLBW population. In addition, 62

although the sample was representative of the VLBW population in geographic area there was the study was conducted, there was limited ethnic diversity, which also limits the generalizability of the study’s findings.

A final limitation was that the sample was small. This limited the power for detection of effects, and it should also be taken into consideration when interpreting results. The small sample size also precluded examining associations of emotion regulation with factors associated with greater risk for poor developmental outcomes in

VLBW children, such as lower birth weight or gestational age or neonatal medical complications.

Future Directions

The current study is only a first step in research on the effects of preterm birth on emotion regulation in young VLBW children and the effect of parenting behavior on their early emotional development. While the current study explored several domains of psychological functioning that are associated with emotion regulation, including temperament and behavior problems, future studies may benefit from the inclusion of assessments of executive functioning to determine the role of specific cognition abilities in emotion regulation in VLBW children. Another domain that is worth further empirical exploration is the role of language in emotion regulation. Although receptive language skills were assessed using the PPVT-4, expressive language skills, such as mean length of utterance and aspects of expressive language associated with emotion regulation would have provided additional insight into the role of cognitive and developmental factors in emotion regulation (e.g. Stansbury & Zimmerman, 1999). In addition, research has demonstrated that emotion-related speech, particularly by parents is associated with 63

increased emotion regulation skills in children (Dunn, Brown, Slomkowski, Tesla, &

Youngblade, 1991; Jenkins, Turrell, Kogushi, Lollis, & Ross, 2003). The current study assessed the valence of parent language through the variables of positive and negative content. However, because other non-language parent behaviors, such as physical intrusiveness, also contributed to these observational codes, there was no pure measure of parent emotional language.

As previously discussed, the lack of negative emotions elicited by the tasks may be attributable in part to their short duration. Thus, additional research should extend the duration of each task, particularly in the child-only condition, to allow for a greater range of negative affect and thus more time to implement regulatory strategies. In addition, longitudinal research that extends the findings of the current study across development would also provide a more sensitive design for assessing age-related changes in emotion regulation and for determining if problems in emotion regulation using tasks such as the current ones may be more evident at some ages than at others. Another domain worth considering in the emergence of self-regulation skills is the impact of environmental factors, such as preschool attendance, on early socialization. In the current study, preliminary correlations did not reveal any associations of preschool status with emotion regulation variables, and thus it was not included as a covariate in statistical analyses.

Failure to find an association, however, may have been due to the small sample and the fact that most of the children in the study were attending preschool. In future studies it may be useful to examine characteristics of preschool attendance, such as the amount of time spent in preschool and quality of instruction. Other environmental factors to 64

consider would be the attachment of the mother to the child and associated parenting characteristics.

In addition, the study examined 3-and 4-year olds at a single time point.

However, there is substantial development of emotion regulation skills during this age, and the nature of the parent-child relationship also shifts during this developmental period, particularly as children develop autonomy by attending preschool and functioning in the absence of their parents. Although the current study did not find significant effects of age and preschool status across participants, longitudinal research is needed to identify the trajectory of emotion regulation strategies and the nature of parent behavior and parent-child interactions. Furthermore, given the long-term cognitive and behavior sequelae that are known to persist in VLBW children across development, it is particularly important that future studies aim to identify whether impairments in emotion regulation skills emerge in school-age children, as social and emotional demands increase and become more complex.

Finally, this study included only mothers given their common role as primary caregiver, but future studies should also assess the impact of fathers, as their roles and approaches to parenting often differs from that of mothers’ roles. For example, there is evidence that fathers of preterm babies demonstrate more positive interactions and provide more caregiving compared to fathers of full-term babies, whereas mothers are less positive with preterm babies than term babies (Harrison, 1990). Similarly, greater ethnic diversity may provide a more complete picture of the nature of emotion regulation, as emotional expression, parent practices, and family emotional climate may differ by ethnicity. 65

Implications and Conclusion

The current study was somewhat exploratory in nature, as it adapted an existing coding system and applied it to tasks that have not been used in previous research. The tasks were adapted from two well-established emotion regulation tasks to measure the impact of social context, i.e. the child alone or the child with his mother, on emotion regulation. In adapting these tasks to this structure, the duration of the typical

Disappointing Gift and Locked Box tasks were changed. Thus, this study adds to the existing literature by providing a novel context for examining the observable emotional and interactive behavior of mothers and young children.

The findings have implications for clinical interventions as well as for scientific study of emotion regulation in young children. They confirm the importance of parent- oriented interventions for improving emotion regulation, such as those described by

Landry and colleagues (2008). These researchers have documented positive effects of training in parent responsiveness on social competence in young children with VLBW.

Although they have not focused specifically on emotion regulation, similar parent training methods may be useful in fostering emotional development in this population. In the current study, the finding that VLBW children showed less expressiveness than their

NBW peers underscores the need for prevention/intervention programs designed to improve communication, emotional understanding, and emotional expression. The trend for VLBW children to exhibit less expressiveness even in the presence of their mothers that NBW controls also suggests that, without intervention, these children may be less likely to rely on others to help modulate their emotions. Finding ways to encourage them to do so, perhaps by training parents to be more responsive to potentially distressing 66

situations, may thus be useful in helping them modulate their emotions. In addition, child expressiveness was associated with maternal responsiveness across both groups, providing support for the rationale of parenting interventions, such as Landry’s work (e.g.

Landry et al., 2008), on improving social competence in children regardless of birth weight. Finally, the fact that no dyadic group differences were found is encouraging in light of these interventions, as it suggests that although emotion regulation may be impaired in young VLBW children, mother-child interactions at this age are not.

The findings of this study also highlight the importance of conceptualizing child emotion regulation in VLBW children though bidirectional pathways, such as in the transactional model that incorporates different environmental stimuli (Sameroff, 2009), or the mutual regulation model that highlights the interactive role of parent and child emotion regulation on each other’s behavior (Tronick et al., 1986). Failing to observe parental behavior or the child’s behavior in a social context would have provided a less complete picture of the interpersonal factors that influence emotion regulation. While there are still many aspects of emotion regulation and competence in VLBW children yet to be understood, the study helps to provide a foundation upon which future studies can be developed.

67

Table 1 Participant Characteristics

Variables Group VLBW NBW p n=21 n=21 Child age, M (SD) 3.91 (.55) 3.80 (.63) .54 Males, n (%) 11 (53) 13 (62) .54 Years of Maternal Education 14.90 (2.41) 16.05 (2.58) .15 Caucasian/White, n (%) 10 (48) 14 (67) .22 Black/African American, n (%) 11 (52) 7 (33) .20 Currently enrolled in preschool, n (%) 18 (85.7) 17 (80.5) .45 Birth Weight in grams, M (SD) 902.43 (267.91) Gestational Age in weeks, M (SD) 26.24 (2.19)

68

Table 2a Frequencies of Observed Child Variables, Child-only Condition

Variable Disappointing Gift Locked Box Rating VLBW NBW Total VLBW NBW Total Positive Affect 0 17 19 36 19 19 38 1 2 1 3 1 2 3 2 1 1 2 0 0 0

Negative Affect 0 15 15 30 17 18 35 1 2 4 6 2 1 3 2 2 0 2 1 2 3 3 1 2 3 0 0 0

Self-Initiated Distractions 0 7 10 17 15 14 29 1 2 8 10 4 6 10 2 6 1 7 1 1 2 3 5 2 7

Comfort Seeking 0 13 14 27 17 18 35 1 6 6 12 3 3 6 2 0 1 1 0 0 0 3 1 0 1 0 0 0

Self Soothing 0 17 13 30 1 3 6 9 2 0 1 1 3 0 1 1

Verbalizations 0 17 15 32 17 18 35 1 2 5 7 3 2 5 2 1 1 2 0 1 1

69

Table 2b Frequencies of Observed Child Variables, Child With Mother Condition

Variable Disappointing Gift Locked Box Rating VLBW NBW Total VLBW NBW Total Positive Affect 0 15 13 28 18 16 34 1 0 3 3 1 2 3 2 4 3 7 1 2 3 3 1 2 3 0 1 1

Negative Affect 0 13 15 28 15 20 35 1 2 2 4 4 0 4 2 2 1 3 1 1 2 3 3 3 6 0 0 0

Self-Initiated Distractions 0 13 14 27 18 21 39 1 4 1 5 2 0 2 2 2 5 7 0 0 0 3 1 1 2 0 0 0

Comfort Seeking 0 15 19 34 9 11 20 1 1 1 2 10 10 20 2 2 1 3 1 0 1 3 2 0 2 0 0 0

Self Soothing 0 17 19 36 1 2 1 3 2 1 1 2

Verbalizations 0 3 0 3 4 0 4 1 9 10 19 13 11 24 2 4 7 11 1 7 8 3 4 4 8 2 3 5

70

Table 2c Frequencies of Observed Maternal Variables

Variable Disappointing Gift Locked Box Rating VLBW NBW Total VLBW NBW Total Positive Affect 0 8 9 17 17 15 32 1 7 10 17 3 4 7 2 4 1 5 0 2 2 3 1 1 2 0 0 0

Positive Content 0 13 12 25 11 13 24 1 4 6 10 6 7 13 2 2 2 4 3 1 4 3 1 1 2 0 0 0

Negative Content 0 15 19 34 1 3 2 5 2 2 0 2 3 0 0 0

Responsiveness 0 0 0 0 0 1 1 1 1 4 5 4 4 8 2 8 8 16 9 9 18 3 11 9 20 7 7 14

Sensitivity 0 14 17 31 9 17 26 1 3 3 6 8 3 11 2 1 0 1 3 1 4 3 2 1 3 0 0 0

Verbalizations 0 0 0 0 0 1 1 1 4 7 11 8 7 15 2 10 6 16 12 7 19 3 6 8 14 0 6 6

71

Table 2d Frequencies of Observed Dyadic Variables

Disappointing Variable Gift Locked Box Rating VLBW NBW Total VLBW NBW Total Reciprocity 0 2 1 3 5 4 9 1 6 8 14 8 8 16 2 7 7 14 6 6 12 3 5 5 10 1 3 4

Cooperation 0 16 20 36 5 8 13 1 3 1 4 9 11 20 2 1 0 1 4 2 6 3 0 0 0 2 0 2

Note: Empty cells are for variables with insufficient frequency that were not considered in analyses. 72

Table 3 Item Loadings in Principal Components Analyses for Child Variables

Disappointing Gift Task Component 1 2 3 Self-Initiated Distractions .87 Comfort Seeking -.64 Self Soothing .70 Verbalizations .68 Positive Affect .64 Negative Affect .90 Eigenvalues 1.62 1.33 1.04

Locked Box Task Component 1 2 3 Verbalizations .89 Positive Affect .80 Self-Initiated Distractions -.79 Comfort Seeking .67 Negative Affect .96 Eigenvalues 1.71 1.15 1.00

73

Table 4 Group Comparisons of Child and Maternal Characteristics

Variables Group VLBW NBW p PPVT standard score (M, SD) 101.62 (21.26) 114.33 (16.06) .04 BSI Global Severity Index 52.24 (9.14) 46.14 (8.52) .03 BASC-2, T-score (SD) Adaptive Skills 56.05 (8.25) 48.43 (8.76) .01 Internalizing 54.62 (8.84) 45.10 (8.21) .001 Externalizing 52.95 (8.99) 45.19 (5.34) .002 <.00 Behavioral Symptom Index 54.00 (7.98) 45.05 (6.12) 1 CBQ-Very Short Form, M (SD) Surgency 5.03 (1.78) 4.58 (.98) .32 Negative Affect 5.56 (3.03) 4.24 (2.4) .13 Effortful Control 7.51 (4.51) 5.80 (2.15) .13 *p<.05, **p<.01, ***p<.001

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Table 5a Intercorrelations of Observed Child Factors

Disappointing Gift, Child-only Condition Autonomous Negative Coping Expressiveness Affect Autonomous Coping - .03 -.06 Expressiveness - -.07 Negative Affect -

Disappointing Gift, Child With Mother Condition Autonomous Negative Coping Expressiveness Affect Autonomous Coping - .14 -.52** Expressiveness - -.20 Negative Affect - ** p<.01

Locked Box, Child-only Condition Autonomous Negative Coping Expressiveness Affect Autonomous Coping - -.05 -.05 Expressiveness - .15 Negative Affect -

Locked Box, Child With Mother Condition Autonomous Negative Coping Expressiveness Affect Autonomous Coping - .06 -.08 Expressiveness - -.05 Negative Affect -

75

Table 5b Correlations of Observed Child Factors Across Conditions

Disappointing Gift Autonomous Coping, Expressiveness, Negative Child with Child with Affect, Child Mother Mother with Mother Autonomous Coping, Child only .07 .13 -.19 Expressiveness, Child only .02 .39* -.31 Negative Affect Child only -.41** -.21 .72**

*p<.05 **p<.01

Locked Box Autonomous Coping, Expressiveness, Negative Child with Child with Affect, Child Mother Mother with Mother Autonomous Coping, Child-only -.01 .10 -.24 Expressiveness, Child-only .07 .22 -.01 Negative Affect Child-only -.11 .09 .19

76

Table 5c Correlations of Observed Child Factors Across Tasks

Disappointing Gift with Locked Box, Child-only

Locked Box Autonomous Negative Disappointing Gift Coping Expressiveness Affect Autonomous Coping .04 .10 -.004 Expressiveness -.10 .63** .38* Negative Affect -.03 -.004 .38*

*p<.05 **p<.01

Disappointing Gift with Locked Box, Child with Mother

Locked Box Autonomous Negative Disappointing Gift Coping Expressiveness Affect Autonomous Coping -.16 .24 -.01 Expressiveness -.17 .26 .07 Negative Affect .20 -.24 .15

77

Table 5d Intercorrelations of Observed Maternal Variables

Disappointing Gift

Positive Positive Affect Content Responsiveness Sensitivity Verbalizations

Positive Affect - -.32 -.13 .05 -.17

Positive Content - .38* .40** .45**

Responsiveness - .32* .68**

Sensitivity - .21

Verbalizations - *p<.05 **p<.01

Locked Box

Positive Positive Negative Affect Content Content Responsiveness Sensitivity Verbalizations

Positive Affect - -.11 -.04 -.004 -.14 -.003

Positive Content - .10 .28 .45** .38*

Negative Content - .01 .13 .09

Responsiveness - .10 .59**

Sensitivity - .01

Verbalizations - *p<.05 **p<.01

78

Table 5e Correlations of Observed Maternal Variables Across Tasks

Disappointing Gift with Locked Box

Locked Box

Positive Negative Disappointing Gift Positive Affect Content Content Responsiveness Sensitivity Verbalizations

Positive Affect .28 .27 .10 -.12 .08 -.09

Positive Content -.13 -.06 -.29 .10 .12 -.06

Responsiveness -.20 .28 -.16 .52** .22 .39*

Sensitivity -.08 .23 -.10 .12 .39* .18

Verbalizations -.22 .12 .02 .31 -.02 .38*

*p<.05 **p<.01

79

Table 6 Group Differences, Disappointing Gift Task

Mixed Design ANOVAs

Autonomous Coping Expressiveness

F (df) p F (df) p

Age .32 (1,37) .57 1.02 (1,37) .32

Maternal Education .37 (1,37) .55 .32 (1,37) .58

Group .003 (1,37) .96 1.64 (1,37) .21 41.85 Maternal Presence 2.06 (1,39) .16 (1,37) <.001

Group x Maternal Presence 3.66 (1,39) .06 .03 (1,39) .88

Generalized Estimating Equations

Negative Affect

beta(SE) Exp (B) (95% CI) p

Age .28 (.54) 1.32 (.46,3.79) .61

Maternal Education .02 (.12) 1.02 (.81,1.28) .90

Group -.21(.73) .81 (.19,3.40) .77

Maternal Presence <.001 (.33) 1.27 (.66,2.44) .48

Group x Maternal Presence .48 (.67) 1.62 (.44,6.02) .47

80

Table 7 Group Differences, Locked Box Task

Mixed Design ANOVAs

Autonomous Coping Expressiveness

F (df) p F (df) p

Age 1.28 (1,37) .27 2.30 (1,37) .14

Maternal Education .18 (1,37) 68 1.20 (1,37) .28

Group .17 (1,37) .68 4.44 (1,37) .04

Maternal Presence 20.19 (1,39) <.001 108.66 (1,39) <.001

Group x Maternal Presence .05 (1,39) .83 4.07 (1,39) .051

Generalized Estimating Equations Negative Affect B(SE) Exp (B) (95% CI) p Age .03 (.62) 1.03 (.30,3.46) .97 Maternal Education .21 (.11) 1.24 (.98,1.56) .07 Group 1.10 (.67) 2.99 (.81,11.09) .10 Maternal Presence -1.22 (.86) .30 (.05,1.61) .16

81

Table 8 Group Differences of Maternal Variables

Linear Regressions

Disappointing Gift Task

Predictor B(SE) β R2 p Positive Affect -.10 (.27) -.06 .26 .26 Positive Content .05 (.28) .03 .005 .86 Responsiveness -.38 (.20) -.28 .21 .07 Sensitivity -.27 (.28) -.16 .02 .35 Verbalizations -.15 (.25) -.10 .09 .55

Locked Box Task

Predictor B(SE) β R2 p Positive Affect .22 (.18) .20 .05 .22 Positive Content -.18 (.22) -.13 -.80 .43 Negative Content -.16 (.15) -.16 .25 .29 Responsiveness -.17 (.26) -.11 .05 .52 Sensitivity -.45 (.21) -.34 .12 .04 Verbalizations .21 (.24) .14 .06 .39

82

Table 9 Group Differences of Dyadic Variables

Disappointing Gift

Linear Regression Logistic Regression

Reciprocity Cooperation

Predictor B(SE) Β R2 p B(SE) Exp (B) (95% CI) p Age .04 (.24) .03 0.87 -.02 (.97) .98 (.15,6.47) .98 Maternal Education .13 (.06) 0.35 .04 -.17 (.21) .84 (.56,1.27) .41 Group .11 (.29) 0.06 .12 0.71 1.48 (1.18) 4.41 (4.41,44.53) .21

Locked Box

Linear Regressions

Reciprocity Cooperation

Predictor B(SE) Β R2 p B(SE) β R2 p Age -.38 (.24) -.24 .12 -.44 (.21) -.32 .04 Maternal Education .13 (.06) .36 .02 .002 (.05) -.32 .96 Group -.04 (.28) -.02 .19 .88 .50 (.25) .31 .17 .051

83

Table 10a Associations of Observed Maternal Variables and Observed Child Factors, Disappointing Gift Task

Hierarchical Linear Regressions

Autonomous Coping Expressiveness

Predictor B(SE) Β R2 p B(SE) β R2 p Step 1

Age .50 (.37) .22 .18 -.09 (.47) -.03 .85

Maternal Education -.39 (.09) -.07 .67 -.04 (.11) -.05 .75

Group -.64 (.44) -.23 .09 .16 -.39 (.56) -.12 .02 .49

Step 2

Positive Affect .51 (.26) .31 .17 .06 .16 (.34) .08 .05 .64

Positive Content -.52 (.25) -.05 .19 .04 .42 (.32) .21 .06 .21

Responsiveness -1.17 (.31) -.59 .34 .001 .12 (.06) .38 .04 .046

Sensitivity -.95 (.20) -.59 .43 <.001 -.25 (.32) -.13 .03 .44

Verbalizations -.53 (.28) -.30 .17 .07 .20(.37) .10 .03 .59

84

Table 10b Associations of Observed Maternal Variables and Observed Child Factors, Disappointing Gift Task

Logistic Regression

Negative Affect

Predictor B(SE) Exp (B) (95% CI) p Step 1 Age .29 (.60) 1.34 (.42, 4.25) .62 Maternal Education .13 (.15) 1.13 (.85, 1.52) .40 Group .38 (.71) 1.46 (.36, 5.84) .59 Step 2 Positive Affect -.89 (.54) .41 (.14,1.18) .10 Positive Content .32 (.40) 1.38 (.64,3.01) .42 Responsiveness .95 (.63) 2.59 (.75,8.96) .13 Sensitivity 1.08(.50) 2.94 (1.10,7.87) .03 Verbalizations .34 (.47) 1.4 (.56,3.51) .47

85

Table 11a Associations of Observed Maternal Variables and Observed Child Factors, Locked Box Task

Hierarchical Linear Regressions

Autonomous Coping Predictor B(SE) Β R2 p Step 1 Age .12 (.18) .11 .51 Maternal Education .01 (.04) .03 .88 Group -.04 (.21) -.03 .01 .87 Step 2 Positive Affect .20 (.19) .18 .04 .30 Positive Content .02 (.16) .02 .01 .93 Negative Content -.27 (.23) -.22 .05 .26 Responsiveness .02 (.14) .02 .01 .91 Sensitivity -.07 (.17) -.08 .02 .68 Verbalizations .05 (.15) .05 .02 .76

86

Table 11b Associations of Observed Maternal Variables and Observed Child Factors, Locked Box Task

Logistic Regressions

Expressiveness Negative Affect Predictor B(SE) Exp (B) (95% CI) p B(SE) Exp (B) (95% CI) p Step 1 Age -.61 (.60) .54 (.17, 1.76) .31 .32 (.88) 1.38 (.25, 7.76) .71 Maternal Education .18 (.15) 1.2 (.90, 1.60) .21 .17 (.23) 1.10 (.75, 1.88) .46 Group -1.39 (.71) .25 (.06, 1.01) .05 2.03 (1.21) 7.60 (.71, 81.63) .09 Step 2 Positive Affect 1.09 (.82) 2.97 (.60,14.72) .18 -18.81 (10936.83) .000 (.000,-.) .999 Positive Content -.19 (.55) .83 (.28,2.45) .74 -.05 (.72) .95 (.23,3.86) .94 Negative Content -.34 (.88) .71 (.13,4.01) .70 -.12 (.1.18) .89 (.09, 8.98) .92 Responsiveness .30 (.47) 1.35 (.54, 3.38) .53 .08 (.66) 1.09 (/30,4.93) .90 Sensitivity -.45 (3.37) .98 (.29, 3.26) .97 .33 (.73) 1.40 (.34, 5.94) .65 Verbalizations -.02 (.3.34) .97 (.37, 2.51) .94 -.42 (.79) .65 (.14, 3.07) .59

87

Table 12a Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Disappointing Gift Task

Hierarchical Linear Regressions

Autonomous Coping Expressiveness

Predictor B(SE) R2 β p B(SE) R2 β p PPVT standard score .004 (.01) .06 .05 .79 .001 (.002) 1.00 .10 .56 BASC-2, T-score Adaptive Skills -.003 (.03) .06 -.02 .92 .01 (.004) .13 .22 .22 Internalizing -.06 (.03) .17 -.39 .04 .10 -.13 .31 Externalizing -.06 (.03) .15 -.35 .06 <.001 (.01) .09 -.02 .93 Behavioral Symptom Index -.04 (.03) .10 -.25 .30 -.01 (.01) .12 -.19 .33 CBQ, Very Short Form Surgency -.08 (.17) .07 -.08 .64 .004 (.03) .09 .03 .87 Negative Affect -.03 (.09) .06 -.06 .74 .01 (.004) .12 .16 .33 Effortful Control -.14 (.07) .16 -.33 .04 -.02 (.01) .16 -.27 .10 BSI, Global Severity Index -.06 (.31) .14 -.33 .08 -.01 (.01) .12 -.21 .27

88

Table 12b Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Disappointing Gift Task

Logistic Regression

Negative Affect

Predictor B(SE) Exp (B) (95% CI) p PPVT standard score .004 (.02) 1.00 (.67,1.215) .86 BASC-2, T-score Adaptive Skills .06 (.05) 1.07 (.97,1.17) .18 Internalizing .03 (.05) 2.03 (.95,1.13) .46 Externalizing -.001 (.05) .999 (.91,1.10) .98 Behavioral Symptom Index -.003 (.05) 1.00 (.90,1.10) .97 CBQ, Very Short Form Surgency .22 (.25) 1.24 (.76,2.02) .39 Negative Affect .40 (.16) 1.50 (1.09,2.04) .01 Effortful Control .14 (.10) 1.15 (.94,1.41) .17 BSI, Global Severity Index -1.64 (3.72) 1.03 (.94,1.14) .50

89

Table 13a Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Locked Box Task

Linear Regression

Autonomous Coping

Predictor B(SE) R2 β p PPVT standard score -.002 (.01) .03 -.05 .79 BASC-2, T-score Adaptive Skills -.02 (.01) .08 -.24 .18 Internalizing -.01(.01) .04 -.09 .65 Externalizing .01 (.02) .04 .07 .72 Behavioral Symptom Index .001 (.02) .03 .02 .94 CBQ, Very Short Form Surgency .04 (.08) .04 .11 .52 Negative Affect .04 (.04) .05 .14 .42 Effortful Control -.01 (.03) .03 -.03 .89 BSI, Global Severity Index .01 (.02) .04 .09 .66

90

Table 13b Associations of Reported Behavioral and Language Characteristics with Observed Child Variables, Locked Box Task

Logistic Regressions

Expressiveness Negative Affect

Predictor B(SE) Exp (B) (95% CI) p B(SE) Exp (B) (95% CI) p PPVT standard score .03 (.03) 1.03 (.97,1.09) .32 .01 (.03) 1.01 (.96,1.06) .71 BASC-2, T-score Adaptive Skills .03 (.05) 1.03 (.93,1.15) .56 .08 (.06) 1.08 (.97,1.21) .16 Internalizing .01 (.05) 1.01 (.91,1.13) .81 -.09 (.06) .91 (.81,1.03) .15 Externalizing -.02 (.07) .98 (.86,1.12) .76 -.24 (.11) .79 (.63,.98) .03 Behavioral Symptom Index -.01 (.07) .99 (.86,1.13) .83 -.15 (.08) .86 (.74,1.00) .06 CBQ, Very Short Form Surgency .05 (.32) 1.05 (.56,1.97) .87 -.36 (.45) .70 (.29,1.70) .43 Negative Affect -.18 (.27) .83 (.50,1.40) .49 .04 (.16) 1.04 (.75,1.43) .83 Effortful Control -.17 (.22) .85 (.55,1.31) .46 -.30 (.33) .74 (.39,1.41) .37 BSI, Global Severity Index -3.07 (4.62) .96 (.85,1.08) .46 .-02 (.06) .98 (.97,1.11) .74

91

Appendix A Coding Variables

Child Codes

1. Positive Affect: smiling, laughing

2. Negative Affect: frowning, cold/harsh voice tones

3. Aggression/acting out: defiant and/or inappropriate externalizing behavior

4. Noncompliance: refusal to do what is asked of him/her, demonstrating contrary

and defiant behaviors when given a command or request

5. Self-initiated distractions: self-initiated behaviors to distract him/herself from

the distressing object/situation

6. Self-soothing: verbal or physical behaviors to comfort or reassure

7. Comfort seeking: orienting to examiner or mother to help reduce distress

8. Verbalizations: quantity of speech utterances

Mother Codes

1. Positive Affect: smiling, laughing

2. Negative Affect: frowning, cold/harsh voice

3. Positive Content: use of praise, explanation, and open-ended questions

4. Negative Content/Intrusiveness: use of physical control of child, prohibited

touching of target object, or use of criticism.

5. Responsiveness: frequency mother responds to child’s questions, comments, and

behaviors

6. Sensitivity: verbal and nonverbal support a mother provides to her child, e.g.

providing assistance to her child and encouraging a child to problem solve

7. Verbalizations: quantity of speech utterances

92

Dyadic Codes

1. Reciprocity: shared positive affect, eye contact, a “turn taking”, i.e. conversation-

like, quality of interaction

2. Conflict: presence of a disagreement, mutual or shared negative affect, arguing

3. Cooperation: explicit agreement and discussion regarding how to proceed with

and/or complete a task

Note: Coding system consists of 0-3 ratings. The coding system was based on the following scale:

0 0% or very minimal target behavior exhibited 1 target behavior displayed for 25-50% of task, or very briefly but intense display of behavior 2 target behavior displayed for 50-75% of task 3 target behavior displayed for 75-100% of task

93

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