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The development of maternal representations of the child during pregnancy guides a mother’s thoughts, feelings, and behavior toward her child. The association between prenatal representations, particularly those that are disrupted, and toddler social-emotional functioning is not well understood. The present study examined associations between disrupted prenatal representations and toddler social-emotional functioning and to test disrupted maternal behavior as a mediator of this association. Data were drawn from 109 women from a larger prospective longitudinal study (N=120) of women and their young children. Prenatal disrupted maternal representations were assessed using the Working Model of the Child Interview disrupted coding scheme, while disrupted maternal behavior was coded 12-months postpartum from mother-infant interactions. Mother-reported toddler social-emotional functioning was assessed at ages 12 and 24 months. Disrupted prenatal representations significantly predicted poorer toddler social-emotional functioning at 24 months, controlling for functioning at 12 months. Further, disrupted maternal behavior mediated the relation between disrupted prenatal representations and toddler social-emotional problems. Screening for disrupted representations during pregnancy is needed to facilitate referrals to early intervention and decrease the likelihood of toddler social-emotional problems.

This chapter begins by describing the approach used in the Taming Sneaky Fears program to explain the abstract concept of cognitive distortions to four- to seven-year-old children, i.e., by externalizing anxiety (calling it Sneaky Fears) and by referring to the Tricks (or cognitive distortions) that Sneaky Fears play (Not Telling the Truth, Exaggerating, and Only Showing the Bad Things). It describes how cognitive coping strategies traditionally used with older children are adapted to accommodate the cognitive abilities of four- to seven-year-old children, i.e., by learning How to Be the Boss of My Brain and using the Stop sign and the Trick Stoppers (Ignore Sneaky Fears, Think Brave Thoughts, and Talk to an Adult). The chapter provides step-by-step guidelines on how to communicate these abstract concepts and cognitive coping strategies to four- to seven-year-old children and their parents in one parent session (P-Session 2) and two child sessions (C-Sessions 3 and 4).

This chapter offers a historical timeline of the various phases of development and refinement of the Taming Sneaky Fears program, a group Cognitive Behavior Therapy program developed specifically for four- to seven-year-old children diagnosed with an anxiety disorder, and their parents. The chapter describes the development of the parent and child components of the Taming Sneaky Fears program. It summarizes the various research endeavors and the research evidence documenting the efficacy of the Taming Sneaky Fears program in the treatment of various anxiety disorders, including social anxiety disorder and selective mutism, in four- to seven-year-old children. The chapter proposes future directions for research to further refine the Taming Sneaky Fears program.

This chapter provides an overview of anxiety disorders in young children. It discusses the concept of anxiety versus anxiety disorder and describes classification and associated features of the different anxiety disorders commonly seen in young children. The chapter presents information on epidemiology of anxiety disorders in young children, as well as evidence for the comorbidity of anxiety disorders with other anxiety and non-anxiety disorders, with a special emphasis on the comorbidity between selective mutism and social anxiety disorder. Given that few data are available to document prevalence rates of anxiety disorders in four- to seven-year-old children, the chapter summarizes the evidence in children of all ages with anxiety disorders and provides specific information pertaining to four- to seven-year-old anxious children whenever such data are available. The chapter also reviews the etiological risk factors for the development of anxiety disorders, with a special emphasis on selective mutism.

This chapter describes intervention and management programs for which empirical evidence is available to treat four- to seven-year-old children with anxiety disorders, excluding the Taming Sneaky Fears program, which is described at length in subsequent chapters. The primary focus of intervention in most of extant treatment studies is on the caregivers of young anxious children and/or dyadic approaches involving the young anxious children and their caregivers. The chapter reports on the somewhat limited empirical evidence supporting these approaches and highlights their strengths and shortcomings. A special emphasis is placed on interventions that focus on the management of selective mutism and social anxiety disorder in four- to seven-year-old children. Finally, the chapter offers suggestions for further empirical exploration.

This chapter provides an overview and rationale for using the concepts of feeling recognition and management early in the Taming Sneaky Fears program, i.e., during one parent session (P-Session 1) and three child sessions (C-Sessions 1, 2, and 5). It offers detailed, step-by-step guidelines on how to implement these sessions and teach four- to seven-year-old children and their parents: (1) feeling recognition (or How to Be a Feeling Catcher by doing a Body Scan in P-Session 1 and C-Sessions 1 and 2 and by using the Feeling Thermometer in P-Session 1 and C-Session 5); and (2) relaxation strategies (or How to Be the Boss of My Body by using Spaghetti Arms and Toes in P-Session 1 and C-Session 1 and Balloon Breathing and Imagery in P-Session 1 and C-Session 2). The chapter suggests adaptations for four- to seven-year-old children with selective mutism and social anxiety disorder and their parents.

This chapter describes five new screening and assessment tools developed or refined by our group to assist clinicians and researchers working with four- to seven-year-old anxious children. The Preschool Screen for Child Anxiety Related Emotional Disorders (Pre-SCARED) is a parent report to screen and identify anxiety symptoms in four- to seven-year-old children that is derived from the Screen for Child Anxiety Related Emotional Disorders (SCARED). The Mutism Accommodation Scale is another parent report questionnaire that assesses the degree to which parents could unintentionally accommodate their children’s mutism. The chapter also describes three new clinician-administered tools our group created to help clinicians and researchers distinguish between selective mutism and social anxiety disorder in four-to seven-year-old children: the Talking Behavior Assessment Tool, the Selective Mutism Versus Social Anxiety Disorder Criteria Checklist, and the Steps to Talking. The chapter presents the currently available research evidence in support of these screening and assessment tools, including psychometric properties of the instruments where available.

This chapter describes the theoretical framework, requirements for implementation, and overview of the Taming Sneaky Fears program. It discusses adaptations of traditional Cognitive Behavior Therapy concepts and strategies to accommodate the cognitive abilities of four- to seven-year-olds. Feeling recognition becomes How to Be a Feeling Catcher with the Body Scan and Feeling Thermometer; progressive muscle relaxation and diaphragmatic breathing become How to Be the Boss of My Body with Spaghetti Arms and Toes and Balloon Breathing (with Imagery as an additional relaxation strategy); anxiety is externalized as Sneaky Fears; cognitive distortions become Tricks that Sneaky Fears play (children learn How to Be a Trick Catcher and catch those Tricks: Not Telling the Truth, Exaggerating, and Only Showing the Bad Things); cognitive coping strategies become How to Be the Boss of My Brain with the Stop sign and Trick Stoppers (Ignore Sneaky Fears, Think Brave Thoughts, and Talk to an Adult); and progressive desensitization becomes How to Climb Bravery Ladders.

This chapter focuses on how clinicians and researchers can help parents of four- to seven-year-old children advocate for daycare and school supports. It offers suggestions on how clinicians and researchers can work with daycare and school professionals to support young children with anxiety disorders and their parents. It emphasizes that although all young children with anxiety disorders can benefit from strong support from professionals working in daycare and school settings, those with separation anxiety disorder, selective mutism, and social anxiety disorder may especially benefit. The chapter provides suggestions for the type of information and training clinicians and researchers might provide to daycare and school professionals to equip them with the necessary knowledge and skills to help young anxious children and their parents implement within the daycare or classroom setting the strategies they learn in the Taming Sneaky Fears program. The chapter also provides suggestions on how to engage and support daycare and school professionals while they implement Bravery Ladders within daycare, classroom, or school settings.

This chapter describes how the Taming Sneaky Fears program explains to four- to seven-year-old children and their parents the abstract concept of progressive desensitization or gradual exposure (i.e., How to Climb Bravery Ladders to overcome fears). The concept is discussed with parents in one parent session (P-Session 3) and reviewed extensively in subsequent parent sessions while it is described to the children in two child sessions (C-Sessions 6 and 7). The chapter proposes specific adaptations for selective mutism and social anxiety disorder and emphasizes the usefulness of Bravery Ladders when working with young children with these disorders. The chapter also reviews the approach presented to parents (P-Session 3) on the management of excessive worries in young children.

This chapter provides a description of screening and assessment tools that researchers have used with four- to seven-year-old children who present with various anxiety symptoms. The chapter summarizes the psychometric properties, advantages, and limitations of these instruments. It highlights the need to use some of the instruments described in this chapter with caution with young children in clinical settings due to the somewhat limited empirical evidence to justify their use. The chapter emphasizes the importance of assessing anxiety symptoms in four- to seven-year-old children using age-appropriate interviews and tools, with a special focus on the current assessment approaches that pertain to selective mutism and social anxiety disorder. The chapter highlights the need for further empirical exploration of age-appropriate screening and assessment tools of anxiety symptoms in young children.

The aim of the current study was to increase understanding of how victimization history impacts the longitudinal course of depression and anxiety in a sample of 55 adolescents emerging into parenthood. Adolescents were interviewed about their victimization experiences during their second trimester of pregnancy, and interviews were subsequently classified according the Maltreatment Classification Scale (Barnett, Manly, & Cicchetti, 1993). Adolescents reported on their symptoms of depression and anxiety prenatally and 6 and 12 months postpartum. Growth curve modeling revealed that, on average, there was a steady linear decline in depression and anxiety symptoms across the transition to parenthood, with a rate of change of 25% and 20%, respectively, from the prenatal assessment to 12 months postpartum. Sexual abuse history attenuated the likelihood of a decrease in depressive symptoms over time. Neglect history was associated with higher prenatal levels of anxiety, as well as a steeper decline in anxiety symptoms over time. Future research is needed to determine the role of poly-victimization in predicting the onset and change of depression and anxiety symptoms. Findings from the current study have the potential to aid in the design of preventative and intervention efforts to reduce risks of mental health difficulties in adolescent parents.

Pregnant adolescents are a group at high risk for exposure to traumatic experiences. The present study aimed to examine if Trauma-Focused Cognitive Behavior Therapy (TF-CBT) typically applied to Posttraumatic Stress Disorder (PTSD), could also be applied to unresolved states of mind in a sample of socially at-risk pregnant adolescents. Forty-three adolescents who were in their second trimester of pregnancy and who also had positive indices of unresolved states of mind or symptoms of PTSD were randomly assigned to either the treatment as usual (parenting classes) or intervention (parenting classes + TF-CBT) group. Adolescent mother-infant dyads were then re-assessed at infant ages 6 and 12 months on a broad range of measures, including those specific to attachment, as well as to PTSD, and adolescent behavioral adjustment. Twenty-six of the 43 (60%) recruited subjects completed all components of the study protocol. Although there were no significant effects of the TF-CBT intervention on maternal attachment, infant attachment, PTSD diagnosis and adolescent behavioral adjustment, several study limitations restrict our ability to draw firm conclusions about the efficacy of TF-CBT for use in pregnant adolescents with complex trauma. The discussion offers insight and guidance for clinical work and future intervention research efforts with this vulnerable population.

Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition, measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security, assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship adjustment beyond the domains of the FFM.

To examine the characteristics and outcomes of children with gastrostomy and gastrojejunostomy tubes inserted before age three years, and to identify the factors that predict removal of the enterostomy tubes within 12 months of insertion.Case review of a consecutive sample of 325 medical records.A tertiary care paediatric hospital that is situated in a large metropolitan area.All outpatients and inpatients from birth to 36 months of age who had an enterostomy tube inserted from 1994 to 1996.No direct intervention was provided. In the subgroup of 203 patients with a follow-up period of at least 12 months after tube insertion, children whose tubes were removed within 12 months of insertion were compared with children who continued to receive tube feedings for 12 months or longer.At the time of tube insertion, the median age of patients was six months; 47% of the children for whom data were available were failing to thrive. Although 66 (21%) of 321 patients for whom data were available had their tubes removed, only 25 of the 203 (12%) patients with a follow-up period of 12 months or more had their tubes removed within 12 months of insertion. Children whose tubes were removed less than 12 months after insertion differed from children whose tubes were not removed with respect to medical diagnosis (no children with cerebral palsy had their tubes removed versus 33% of children with cancer who had their tube removed). Most children with failure to thrive at the time of tube insertion were also failing to thrive at the time of tube removal.Children with cerebral palsy are not likely to have enterostomy tubes removed within one year of insertion.

This study tests the hypothesis that infants with failure to thrive (FTT) are at risk for a clinical disturbance of attachment (defined as a combination of: (1) nonautonomous caregiver state of mind with respect to attachment, measured by the Adult Attachment Interview (AAI); (2) nonbalanced caregiver representation of the infant, measured by the Working Model of the Child Interview (WMCI); (3) problematic play interactions; and (4) problematic feeding interactions). Participants were 57 infants (30 FTT, 27 non-FTT) and their primary caregivers, recruited from outpatient pediatric clinics. Caregivers were interviewed with AAI and WMCI and observed interacting with their infants during play and feeding. Results show that more infants with FTT than infants without FTT met some of the criteria for risk for a clinical disturbance of attachment —nonautonomous AAI and nonbalanced WMCI classifications, and less dyadic reciprocity during feeding. However, there were no group differences in play. Future directions for research are discussed.

L'objectif de cette etude est de veritier si des problemes de comportements alimentaires specifiques, chez les nourrissons souffrant de troubles d'alimentation post-traumatiques, laissent prevoir les resultats du traitement. Dans cette serie de cas, vingt-quatre enfants âges entre sept semaines et trente-quatre mois ont ete traites en trois etapes pour leurs troubles alimentaires post-traumatiques. Les trois composantes du traitement etaient constitutees (1) de changements physiologiques et environmentaux pour regulariser les cycles de faim-satiete et promouvoir de bonnes routines et habitudes alimentaires, (2 ) d'un suivi nutritionnel et (3) d'une therapie du comportement (gavage). Les nourrissons souffrant de troubles alimentaires post-traumatiques qui demontraient un refus passif d'avaler la nourriture mise dans leur bouche en ne mastiquant pas, ne sucant pas ou ne bougeant pas la nourriture dans leur bouche pendant plus de cinq secondes etaient moins susceptibles de respondre au traitment que les nourrissons souffrant de ces troubles qui ne presentaient pas ces comportements. De plus, un plus grand nombre de nourrissons souffrant de troubles alimentaires qui n'ont pas reagi au traitement presentaient des problemes anatomiques et mecaniques des voies aeriennes superieures, telle que la fistule tracheo-oesophagienne, ou de maladies pulmonaires telle que la dysplasie broncho-pulmonaire que les nourrissons souffrant de troubles d'alimentation post-traumatiques qui ont reagi positivement au traitement. Les decouvertes ont un impact direct sur l'evaluation et le traitement des troubles post-traumatiques alimentaires dans la petit enfance.

The stability and predictive validity of Classifications of mothers' representations of their infants as determined by the Working Model of the Child Interview (WMCI) were examined. Concordance between mothers' representations of their infants assessed prenatally and again one year later and infant Strange Situation (SS) attachment classifications at 12 months was also examined. WMCI classifications were stable over 12 months in 80% of mothers, compared to 51 % expected by chance alone. Pregnancy WMCIs predicted infant SS classifications in 74% of cases, compared to 54% expected by chance. Concordance between 11-month WMCI and 12-month SS classifications was 73 % (vs. 55% expected by chance). Problems with the skewed distribution of the sample, the low concordance between pregnancy and 11 months for one of the three classifications, and future directions for research are discussed.

Parental perceptions and subjective experience of infants have long been considered important in clinical work with infants and families. Using three different samples of infants, we compare mothers' represen- tations of their infants in clinically referred and nonreferred groups, using the Working Model of the Child Inter- view (WMCI). Twenty-four mothers of infants with failure to thrive (and 25 matched controls), 17 mothers of toddlers with sleep disorders (and 20 matched controls), and 13 mothers of infants seen in a general infant psy- chiatry clinic participated. Compared to their nonclinical counterparts, mothers of infants with clinical problems had representations of their infants that were significantly more likely to be classified distorted or disengaged. Infant gender, age, and birth order were independent of maternal classifications. We conclude that the WMCI is a useful structured interview to categorize mothers' perceptions and subjective experience of their infant and re- lationship with the infant. Mothers' WMCI classifications are associated with the clinical status of the infant. RESUMEN: Las percepciones de la madre y la experiencia subjetiva de los infantes han sido consideradas im- portantes, desde hace tiempo, en cuanto al trabajo clinico con infantes y familias. En este estudio, presentamos los resultados de una entrevista clinica acerca de las representaciones que las madres tienen de sus infantes y las comparamos con las representaciones de otras madres de infantes que no pertenecen al mismo grupo. Partici- paron veinticuatro madres de infantes con problemas de crecimiento (y sus 25 parejas de control), 17 madres de infants con trastornos para dormir (y sus 20 parejas de control), y 13 madres de infantes que habian sido vistos en una clinica de siquiatria infantil general. Comparados con sus contrapartes no clinicas, las madres de infantes

Empirical research supporting the contention that insecure attachment is related to internalizing behaviors has been inconsistent. Across 60 studies including 5,236 families, we found a significant, small to medium effect size linking insecure attachment and internalizing behavior (observed d = .37, 95% CI [0.27, 0.46]; adjusted d = .19, 95% CI [0.09, 0.29]). Several moderator variables were associated with differences in effect size, including concurrent externalizing behavior, gender, how the disorganized category was treated, observation versus questionnaire measures of internalizing behavior, age of attachment assessment, time elapsed between attachment and internalizing measure, and year of publication. The association between avoidant attachment and internalizing behavior was also significant and small to moderate (d = .29, 95% CI [0.12, 0.45]). The effect sizes comparing resistant to secure attachment and resistant to avoidant attachment were not significant. In 20 studies with 2,679 families, we found a small effect size linking disorganized attachment and internalizing behavior (observed d = .20, 95% CI [0.09, 0.31]); however, the effect size was not significant when adjusted for probable publication bias (d = .12, 95% CI [-0.02, 0.23]). The existing literature supports the general notion that insecure attachment relationships in early life, particularly avoidant attachment, are associated with subsequent internalizing behaviors, although effect sizes are not strong.

Some of the controversies surrounding the definition and classification of failure to thrive (FTT) are briefly described. Phenomenologic aspects of FTT are reviewed as well. In addition, treatment methods reflecting the considerable heterogeneity of clinical presentation with respect to the infants with FTT, their mothers, their families, and the FTT infant-mother relationship are described. Finally, methodologic problems limiting studies currently available are reviewed, and future directions for research are suggested.

The current meta-analysis examines the links between unresolved representations of attachment, anomalous parental behavior, and disorganized attachment relationships in 12 studies including 851 families. We found moderate effect sizes for the associations between unresolved states of mind and anomalous behavior (r = .26), unresolved states of mind and infant disorganized attachment relationships (r = .21), and anomalous behavior and disorganized attachment relationships (r = .34). Sample characteristics, observational context, and observational measure were not associated with differences in effect sizes. Only a small part of the association between unresolved states of mind and disorganized attachment relationships was explained by the mediation of anomalous parental behavior (.26* .34 = .09). Other factors yet to be uncovered must mediate the influence of unresolved states of mind on infant disorganized attachment; thus, further exploration of infant, parental, ecological, and genetic factors are warranted.

Millions of infants worldwide are victims of some form of maltreatment (e.g., physical, sexual, and emotional abuse; neglect; exposure to interpersonal violence), and often multiple forms. Accurate incidence and prevalence rates are difficult to ascertain because of the absence of universally accepted definitions and because of inconsistent reporting, investigative, and recording practices in various jurisdictions. This article provides a review of infant, caregiver, and environmental risk factors for maltreatment, in addition to a description of the impact of maltreatment on the infant’s brain, development, and behavior. Finally, principles of assessment of maltreated infants and their families and interventions are described.

Stability of adult attachment and transmission of attachment across 3 generations were examined in a longitudinal study of 96 infants, mothers, and maternal grandmothers. The Adult Attachment Interview (AAI) was used to assess attachment in mothers (during pregnancy and when infants were 11 months old) and grandmothers (any time during the study). The Strange Situation (SS) was used to assess attachment in infants at 12 months. Both the 3- and 4-category classification systems of the AAI and SS were used. Mothers' AAI classifications were stable over 12 months in 90% (3-category) and 77% (4-category) of mothers. Mothers' AAI classifications during pregnancy predicted infants' SS classifications in 81% (3-category) and 68% (4-category) of cases, and grandmothers' AAI classifications in 75% (3-category) and 49% (4-category) of cases. Using log-linear analysis, we show that a simple parent-to-child model accounts for transmission of attachment.

Psychological, family, and social characteristics relating to attachment relationships were measured in mothers of 20 sleep-disordered toddlers, comparing them with 21 mothers of toddlers without sleep problems. The groups were matched on measures of socioeconomic status, child and maternal age, maternal education, marital status, and family size. Results showed that 100% of mothers of sleep-disordered children were classified as insecure with respect to attachment, as assessed by the Adult Attachment Interview, compared with 57% of control group mothers (p less than 0.002). There were no group differences on measures of maternal defensiveness, self-esteem, marital satisfaction, and social support. These results suggest that maternal current perspectives on their relationship history, rather than general psychosocial adjustment, are crucial contributors to the onset and perpetuation of sleep disorders in early childhood.

Infants with feeding problems requiring tube feedings may remain dependent on them for long periods. Experience with behavior therapy (defined as the extinction of specific problem behaviors at meal times and the fostering of adaptive eating behaviors) suggests that this may shorten the duration of tube feeding dependency. Objective: To compare the outcome of tube feeding dependency with behavior therapy and standard therapy. This is the first randomized trial of behavior therapy in this population.Methods: Subjects were tube feeding dependent infants aged 5 to 36 months and their primary feeder (32 infants in Group 1 and 31 in Group 2). Sample size was selected to detect improvement in successes with behavioral intervention (50%) vs. control group (10%). Exclusion criteria included recent aspiration, swallowing difficulties due to neurological or anatomical problem, and inability to attend regularly. Subjects were randomly assigned to one of two interventions: Intervention A (nutritional counseling + behavior therapy) or Intervention B (nutritional counseling). There were 7 weekly treatment and 4 follow-up visits. Total duration of involvement in the trial for each patient was 6 months. The primary outcome measure (success vs. failure of treatment) was the number of infants still dependent on tube feeding at the third follow-up visit in each group (i.e., 5 months after the start of the trial). The decision to discontinue tube feeding was made by an independent judge, without knowledge of intervention and using pre-defined criteria.Results: 63 infants were enrolled. The two treatment arms were similar with respect to infant age, birthweight, birth order, gender, development delay, severity of the feeding disorder, socio-economic status and parents' age and education. Because the study is not completed yet, it is inapproriate to break the randomization code at this time. However, preliminary results on the entire sample indicate that 10 out of 33 (30%) subjects at the third follow-up visit and 13 out of 30 (43%) at the fourth follow-up visit were successes. These success rates are in line with our predictions based on sample size and much higher than the rate expected without behavioral treatment. Final results by treatment intervention will be analyzed on completion of the study (March 1998). Conclusion: We suspect that behavior therapy will be found to be efficacious.

Psychological characteristics pertaining to attachment relationships were measured in mothers of 25 hospitalized failure-to-thrive (FTT) infants and mothers of 25 hospitalized, normally growing infants. The groups were matched for race, socioeconomic status, maternal education, and infant's age and sex. Results showed that 96% of mothers of FTT infants were classified as insecure with respect to attachment, as assessed by the Adult Attachment Interview (George, Kaplan, & Main, 1985), compared to 60% of control group mothers. Lack of resolution of mourning over the loss of a loved one was found in 52% of the mothers in the FTT group and in 32% of mothers in the control group. Mothers of FTT infants reported receiving less support from their families and rated their current relationship with their partner as less satisfying. These findings provide empirical support for the widely held clinical notion that FTT in infants is often a relationship disorder between infant and caregiver.