Predicting Preschool Behavior Problems From Temperament and Other Variables in Infancy

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Predicting

Preschool

Behavior

Problems

From

Temperament

and

Other

PEDIATRICS Vol. 91 No. I January 1993 113

Variables

in

Infancy

Frank Oberklaid, MBBS, FRACP, DCH*; Ann Sanson, PhD, MAPsS; Robert Pedlow, MSc, MAP5S*; and

Margot Prior, PhD, MAPsS

ABSTRACT. There is uncertainty about the relationship

between difficult temperament in infancy and reported

problem behaviors later in childhood. In this study data

from a large, representative community cohort (total N

studied = 1583) were used to determine whether

pre-school behavior problems (at age 4 to 5 years) could be

predicted from difficult temperament and other variables

in infancy. Maternal ratings of difficult temperament on

the Revised Infant Temperament Questionnaire

pre-dicted only 17.5% of those with preschool behavior

prob-lems, a percentage not significantly greater than the 14%

of the total sample rated as having problems. There was

some improvement in prediction when difficult

temper-ament was added to other variables such as male sex

(28%). However, mothers’ overall rating of temperament

was a more powerful predictor of preschool behavior

problems, both alone (26.0%) and in combination with

other variables such as perinatal stress (36.8%), male sex (29.5%), and non-Australian parent (29.4%). Similarly,

maternal reports of infant behavior problems was a more

powerful predictor of preschool behavior problems both

alone (21.8%) and in combination with male sex (24.6%),

low socioeconomic status (26.1%), non-Australian parent

(21.8%), and nurse’s overall rating of temperament (21.

8%). The best consistent predictor of later problems was

the combination of mothers’ overall rating of

tempera-ment and maternal reports of infant behavior problems

(27.0%), especially when combined with other infant variables such as perinatal stress (35.3% ), male sex (31.

5%), and non-Australian parent (30.0%). It is concluded that difficult temperament in infancy, as traditionally

conceptualized and measured on the Revised Infant

Tem-perament Questionnaire, is not on its own significantly

associated with behavior problems at 4 to 5 years of age.

Of far greater importance for clinicians is the significant

relationship between preschool behavior problems and

maternal perceptions of difficult temperament and

be-havior in infancy. Pediatrics 1993;91:113-120;

tempera-ment, behavior problems, infant, preschool child.

ABBREVIATIONS. RITQ, Revised Infant Temperament

Question-name; SES, Socioeconomic status; PBQ, Preschool Behaviour

Ques-tionnaine.

While temperament in infants and young children

is seen increasingly by clinicians as both a useful way

From the *Department of Ambulatory Paediatnics, Royal Children’s

Hospi-tal, Melbourne; $fsychology Department, University of Melbourne; and

§Psychology Department, La Trobe University, Bundoora, Australia.

Received for publication Oct 17, 1991; accepted Jun 22, 1992.

Presented, in part, at the Plenary Session of the 31st Annual Meeting of the

Ambulatory Pediatric Association, April 1991, New Orleans, LA.

Reprint requests to (F.O.) Dept of Ambulatory Paediatrics, Royal Children’s

Hospital, Parkville, Victoria 3052, Australia.

Acad-emy of Pediatrics. 1993

of conceptualizing individual differences and a

valu-able assessment tool for numerous clinical

situa-tions,1 researchers continue to debate many aspects

of the theory and measurement of temperament

in-cluding its conceptual framework,2 the validity of

maternal ratings of temperament,5-5 and the

psycho-metric properties of the questionnaires.6

Despite the unresolved questions in this debate,

the idea that infants and children have a set of

sty-listic attributes that influence the way they interact

with the environment, which in turn affects the way

they are perceived by care givers, is a compelling

one. Clinicians who work in pediatric settings are

involved frequently with common developmental

behavioral problems that are likely to be related to

temperament.7

The most widely used measure of infant

tempera-ment is the Revised Infant Temperament

Question-naire (RITQ),8 which has algorithms for categorizing

infants as exhibiting an easy, difficult, or

slow-to-warm-up temperament. Infants with a difficult

tern-perarnent have been described as those with

“irreg-ularity in biological functions, negative withdrawal

responses to new stimuli, non-adaptability or slow

adaptability to change, and intense mood

expres-sions which are frequently negative.”9

Difficult temperament in infancy has been shown

to have strong concurrent relationships with

com-mon behavioral problems such as colic and excessive

crying, sleep difficulties, and night waking.1#{176}12

Tern-perament concepts and profiles are frequently used

clinically to assist in developing practical advice

and guidance in the management of behavior

prob-lems.13’14 In addition, specific clinics and programs

have been established to provide guidance to

par-ents about problems that are believed to stem

pri-manly from their child’s temperament

character-istics7’15 with some reports of the efficacy of this

16,17

While the importance of considering the

contribu-tion of infant temperament to concurrent clinical

problems is widely accepted, far less clear is the

im-portance of infant temperament in the genesis of

problems later in life. How does a clinician answer

the commonly posed question as to whether a

tem-peramentally difficult infant will have behavior

problems later in childhood? Thomas and Chess9

as-serted that difficult temperament early in life was

associated with a significant subsequent risk of

be-havioral adjustment problems, and many years later

they wrote “. . . there is consistent evidence from a

number of samples for a significant relationship

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tween ratings of difficult temperament and later

be-havioral difficulties and pathology.”18

However, the results from other studies have been

more equivocal. Mclnerny and Chamberlai&9 found

that difficult infants had more subsequent problems,

but their follow-up period was only 18 months.

Carey et al2#{176}found that difficult temperament in

in-fancy was associated with poor school adjustment,

but some children who had an easy temperament

also had poor adjustment, so early difficult

temper-ament did not discriminate between the groups.

Cameron21 found that temperament in the first year

of life predicted mild behavior problems at 3 years of

age, but moderate to severe behavior problems were

found only when difficult temperament was

associ-ated with inappropriate parental handling of their

children. He concluded that “it appears . . .

insuffi-cient for predictive clinical purposes to determine

early the child’s initial temperament.”21 Wolkind and

DeSalis22 found an association between difficult

tern-perament in infancy and behavior problems at 42

months, but their results were difficult to interpret

because they defined difficult temperament on the

basis of a scale obtained from a semi-structured

in-terview using 40 of the items from the original Infant

Temperament Questionnaire.23 Lambert4 found that

early temperament patterns differentiated between

hyperactive and control children but data were

ob-tamed retrospectively and depended on parental

re-call. Wasserman et al25 showed in a recent study that

mothers’ ratings of temperament in infancy did not

predict mother- or teacher-rated behavior problems 6

years later.

Clinicians are also aware of the importance of

other variables in the transaction between the child

and environment in contributing to outcome.26 The

actual temperament of a child is said to be less

im-portant than the “goodness of fit” between the

child’s characteristics and parenting style.9’13’18’21’26

Furthermore, apart from temperament, there are

other child-related factors, such as gender and

pre-maturity, which can be considered to be risk factors

for the development of later problems, just as there

are risk factors related to the environmental context

in which the child is reared, such as socioeconomic

status.27’28

It has been argued that difficult temperament

might have as much to do with parental perceptions

as it does with actual characteristics of the child.29’30

While some studies suggest that ratings are affected

by maternal variables4’5’31 others claim that, to a

greater or lesser extent, they do reasonably

accu-rately assess characteristics of the child.32 The

par-ents’ global perception of the infant’s temperament,

as opposed to ratings on a detailed questionnaire, is

another important issue to consider. Several authors

have argued that maternal perceptions of difficulty

may be just as important in a clinical context as

actual ratings,13’35 and it has been suggested that

differences between ratings and perceptions of

tern-perament provide important clinical clues to a

dys-functional parent-child Furthermore,

parental overall perception that an infant has

behav-ior problems, such as colic or excessive crying, is

clinically significant, whether or not the infant fulfills

objective criteria for such behaviors.

The association between difficult temperament in

infancy and subsequent behavior problems is thus

far from clear, and it appears to be complicated by a

host of other factors. In this study we looked at the

relationship between difficult temperament and

other variables in infancy and parent-reported

be-havior problems in the preschool period. We

hypoth-esized that difficult temperament in infancy (as

cat-egorized from maternal ratings of temperament on

the RITQ) would not be more likely to lead to an

increased risk of preschool behavior problems but

that maternal perceptions of difficulty in infancy

would be more likely to give rise to subsequent

prob-lems and that combinations of risk factors in infancy

would be stronger predictors of subsequent

prob-lems than individual variables.

Subjects

METHODS

The study cohort were children from a longitudinal study of

temperament and behavior, the Australian Temperament

Pro-ject)2’5’-37 The initial sample was a stratified random sample of

2443 infants aged 4 to 8 months who came from families whose

sociodemognaphic characteristics closely resembled those of the

Australian population as a whole.36 The study design called for

yearly sampling of either the whole cohort or randomly selected

subsamples to control for the possible contaminating effect of

repeated administration of identical questionnaires in consecutive

years.3-37 The subjects for this study (N = 1583) were those for

whom complete data were available in infancy (4 to 8 months) and

preschool (4 to 5 years). This sample of 1583 children was not

significantly different from the full sample (N = 2443) on sex,

birth order, gestational age, or parental sociodemographic

chanac-tenistics.

The original cohort was recruited from maternal and child

health centers which are located throughout the state of Victoria,

in both urban and rural areas. They are staffed by maternal and

child health nurses, who achieve contact with more than 94% of

livebinths and who provide ongoing monitoring of growth and

development as well as providing counseling and advice to

par-ents about aspects of child health, development, and behavior.

Measures

At the time of enrollment, when the infants were aged 4 to 8

months, a parent (usually the mother) completed the following

measures:

. The Australian revision2 of the RITQ of Carey and McDevitt,8

consisting of 95 items rated by parents on a 6-point scale

rang-ing from “almost never” to “almost always.” Difficult

temper-ament was conceptualized according to the algorithm

devel-oped by Carey and McDevitt,8 which in turn was derived from

the original dimensions described by Thomas and Chess.9 This

algorithm was used to categorize difficult temperament from

ratings on the RITQ.

. A global temperament scale, in which infants were rated as

being either “much easier than average,” “easier than average,”

“average,” “more difficult than average,” or “much more

diffi-cult than average.” This was thought to reflect the mother’s

overall perception of the infant’s temperament, as opposed to

the detailed and specific ratings derived from the RITQ.

Moth-ens who scored their infant as “more difficult” or “much more

difficult” on this global temperament scale were considered to

perceive their infant as having a difficult temperament.

. A separate three-item questionnaire (colic, sleeping problems, excessive crying) in which parents globnlly rated their infant’s

behavior on a 4-point scale ranging from “none” to “severe.” Infants were classified as having behavior problems if their

score on a summed composite of ratings on these three items

placed them in the top quartile of total scores for the sample.

The parents also provided sociodemographic information, from

which was derived the following:

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ARTICLES 115

S Socioeconomic status (SES). A composite measure of SES was

developed by rating occupation and educational status for both

mothers and fathens.” Low SES was defined as falling into the

lowest quartile for this measure.

I Country of birth of mother and father. If either parent was not

Australian-born, this was considered a potential risk factor for

behavior problems as demonstrated by our previous research in

the Australian Temperament Pnoject.

The maternal and child health nurse, at the time of the

enroll-ment of the infant into the study, provided additional information:

I Peninatal stress. Maternal and child health nurses rated this as

being present or absent on the basis of hospital records, a

sum-many of which is passed onto them from the hospital where the

infant was born.

. Prematurity. This was defined as a gestational age of 36 weeks

or less and was also obtained from hospital records.

. Nurses’ overall perception of temperament of the infant

com-pared with that of the average infant, using the same 5-point

scale as used by the mother to nate maternal overall perception

of temperament. This was based on the nurse’s observation of

the infant’s temperament during center visits as well as from

maternal reports. A nurse’s overall perception of temperament

was categorized as difficult if she felt the infant’s temperament

was “more difficult” on “much more difficult.”

. Nurses’ rating of problems in the mother-baby dyad. The

ma-tennal and child health nurse rated this relationship, using a

5-point scale, on the basis of hen observations and impressions

derived from the frequent contacts she had with them. This

reflected both the infant’s behavior and an assessment of how

the mother was coping. Problems were considered to be present

if the nurse related the relationship as having “some” or

“seni-ous” problems.

Behavior in the preschool period was derived from parental

ratings on the Preschool Behaviour Questionnaire (PBQ).39 This

was completed when the children were 4 to 5 years old. The PBQ

is a widely used measure of behavior with 30 items rated on a

3-point scale from 1 (does not apply) to 3 (certainly applies) and

was developed as a parallel scale to the Childhood Behaviour

Questionnaire,40 with a similar factor structure. A total score,

ob-tamed by the sum of ratings on all 30 items, was obtained.

“Be-havion problems” for this study was defined as a score of greaten

than I SD above the mean for the total sample, providing a

prey-alence rate of behavior problems for this sample (approximately

14%) very similar to that reported in other community studies of

parent-rated behavior pnoblems.4

Analyses

Concordance between nurses’ and parents’ global rating of

temperament in infancy was calculated using the

x2

statistic. For

each of the variables, a priori criteria were established as described

above. To assess whether the various infancy measures described

affected behavioral outcome in the preschool age, the following

procedure was followed. For each infancy measure, those infants

who met the defined criteria were compared with the total cohort

on the PBQ using a 2 x I

x2

statistic.42 For example, the percentage

of infants with a difficult temperament who were subsequently

rated I SD above the mean on the PBQ was compared with the

percentage of the total cohort who scored greater than I SD above

the mean on the PBQ. Thus a significant

x2

value in the tables

indicates that the percentage of children in the specified group

exhibiting behavioral problems is significantly greaten than that of

our population as a whole. The same procedure was repeated for

each of the infancy variables individually, and then for

combina-tions of variables as indicated in the tables.

RESULTS

When the criterion of greater than 1 SD above the

mean on the PBQ is used to define behavior

prob-lems in the preschool period, 13.9% of our cohort

were rated by their parents as having problems. This

is then used as the comparison point for all other

results.

There was a significant correlation between the

mothers’ and nurses’ overall perception of the

in-fant’s temperament

(x2

= 805.1, df 16, P = .000). There

was a significant correlation between temperament

category as derived from the RITQ and maternal

overall perception of her infant’s temperament

(x2

-289.41, df 16, P < .001).

Each of the individual infancy variables was

ex-amined to determine whether its existence in infancy

increased the risk of behavioral maladjustment in the

preschool period. The results are detailed in Table I.

As predicted, a difficult temperament in infancy did

not predict preschool behavioral problems. Although

the percentage of preschoolers with behavior

prob-lems was slightly higher in the difficult temperament

group compared with the total sample (17.5% vs 13.

9%), this difference was not significant. Male sex, low

SES, behavior problems in infancy, and maternal

overall perception of difficult temperament in

in-fancy were all significantly associated with an

in-creased risk of behavior problems. As predicted,

pa-rental perception of difficulties in infancy (behavior

problems and maternal perception of difficult

tern-perarnent) were each more powerful predictors of

preschool behavioral maladjustment than actual

rat-ings of temperament.

The second hypothesis, that risk factors in infancy

were cumulative, was tested by studying children

who had combinations of risk factors. Initially

tern-perament was added sequentially to other individual variables, ie, only those children who had a difficult

temperament in infancy in addition to another

van-able were studied. The results are portrayed in Table

2. It can be seen that while this combination

in-creased the predictive power with several variables

(eg, 28% of boys with a difficult temperament had

TABLE 1. Difficult Temperament and Other Risk Factors in Infancy as Predictors of Preschool Behavior Problems: Individual Variables

(Total N = 1583)

Infancy Variable No. No. (%) With t Significance*

Subsequent

Problems

Difficult tempenament 189 33 (17.5) 1 .84 NS

Behavior problems 358 78 (21.8) 16.56 P < .001

Prematurity 80 15 (18.8) 1.42 NS

Peninatal stress 249 37 (14.9) 0.20 NS

Male sex 833 141 (16.9) 5.90 P < .05

Low socioeconomic status 333 71 (21.3) 13.65 P < .001

Non-Australian parent 472 68 (14.4) 0.36 NS

Maternal overall perception of difficult temperament 100 26 (26.0) 10.78 P < .005

Nurse’s overall perception of difficult temperament 150 29 (19.3) 3.33 NS

Nurse’s rating of problems in the mother-baby dyad 158 26 (16.5) 0.87 NS

*NS, not significant.

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TABLE 2. Difficult Temperament in Combination With Other Individual Risk Factors as Predictors of Preschool Behavior Problems

(Total N = 1583)

Difficult Temperament Plus No. No. (%) With x Significance*

Subsequent Problems

Behavior problems 96 21 (21 .9) 4.53 P < .05

Prematurity 11 4 t

t-Peninatal stress 30 5 (16.7) 0.18 NS

Male sex 85 24 (28.2) 12.83 P < .001

Low socioeconomic status 41 10 (24.4) 3.35 NS

Maternal overall perception of difficult temperament 43 9 (20.9) 1 .59 NS

* NS, not significant.

t Numbers too small to include in analyses.

preschool behavior problems), overall it made little

significant difference.

Because maternal perception of difficult

tempera-ment and of behavior problems in infancy had each

been significantly associated with an increase in

pre-school behavior problems, it was decided to then

combine each of these respectively in combination

with other variables; the results are detailed in Tables

3 and 4. Maternal overall perception of difficult

tern-perarnent in combination with other variables

re-sulted in an impressive increase in prediction for

every single variable, with five of the nine

cornbina-tions being significant at P<.05 or better. Similarly,

the combination of maternal perception of behavior

problems plus other variables also increased the

pre-dictive power (Table 4), with six of the nine being

significant. In both instances, perception of difficult

temperament and of behavior problems in

combina-tion with other variables were far more powerful

than ratings of difficult temperament on the RITQ in

predicting subsequent behavioral maladjustment.

We then combined the two maternal perception

van-ables (temperament and behavioral problems) and

added them sequentially to other variables (Table 5).

It can be seen that these combinations were the most

powerful predictors of all. For example, 31.5% of

all boys whose mothers perceived them as having

both a difficult temperament and behavior problems

in infancy were considered to subsequently have

behavioral maladjustment in the preschool period

(P < .001).

Other combinations of infancy variables were

ex-amined to determine their value in predicting

pre-school behavior problems, but generally they were

not as powerful as those outlined in Tables 4 and 5.

Categorization of maternal ratings of difficult

tern-perament in combination with infant behavior

prob-lems, when added to other individual variables,

re-sulted in modest increases in prediction beyond each

of the variables in isolation, with percentages

rang-ing from 17.0 to 29.2 and 2 of the 8 combinations

being significant (Table 6).

DISCUSSION

The results of this study reject the suggestion that

difficult temperament in infancy, at least as

catego-nized from parental ratings on the RITQ, is per se a

risk factor for subsequent behavior problems. A

dif-ficult temperament in infancy resulted in only a 3%

to 4% increase in the proportion of children with

problems in preschool compared with the sample as

a whole, an increase not statistically significant.

Sim-ilarly, other individual biological and environmental

risk factors only marginally increased the risk of

pre-school problems, often contrary to expectations.

Prematurity on its own did not increase the

poten-tial risk for subsequent problems, a finding

consis-tent with our previous research35’43” but contrary to

earlier reports. Peninatal stress might be thought to

increase the vulnerability of a child to subsequent

problems,45 but this was not evidenced in our data, at

least not when peninatal stress was studied in

isola-tion. This may have been due to the insensitivity of

our measure (maternal and child health nurses

pro-viding a simple “yes” or “no” rating on the basis of

hospital records), but it is more likely to be due to the

TABLE 3. Maternal Overall Perception of Difficult Temperament in Combination With Individual Risk Factors as Predictors of

Preschool Behavior Problems

Maternal Perception of

Difficult Temperament Plus

No. No. (%) With

Subsequent

x Significance*

Difficult temperament 43

Problems

9 (20.9) 1.59 NS

Behavior problems 89 24 (27.0) 11.18 P < .001

Prematurity 3 1 t

Peninatal stress 19 7 (36.8) 7.32 P < .01

Male sex 61 18 (29.5) 10.93 P < .005

Non-Australian parent 34 10 (29.4) 6.01 P < .05

Nurse’s overall perception of difficult temperament 60 14 (23.3) 3.95 P < .05

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ARTICLES 117 TABLE 4. Maternal Perception of Behavior Problems in Combination With Other Individual Risk Factors as Predictors of Preschool

Behavior Problems (N = 1583)

Behavior Problems Plus No. No. (%) With Significancet

Subsequent Problems

4.53 P < .05

Difficult temperament 96 21 (21 .9)

Prematurity 17 5 (29.4) 3.02 NS

Peninatal stress 63 12 (19.0) 1.26 NS

Male sex 195 48 (24.6) 16.53 P < .001

Maternal overall perception of difficult temperament 89 24 (27.0) 11.18 P < .001 Nurse’s overall perception of difficult temperament 96 21 (21.8) 4.53 P < .05

TABLE 5. Maternal Overall Perception of Difficult Temperament Plus Behavior Problems Plus Additional Risk Factors as Predictors

of Preschool Behavior Problems

Material Perception of Difficult

Plus Behavior Problems Plus

No. No. (%) With

Subsequent

Significance*

Problems

9 (26.4) 4.04 P < .05

Difficult temperament 34

Prematurity 2 1 -F

Peninatal stress 17 6 (35.3) 5.67 P < .05

Male sex 54 17 (31.5) 12.24 P < .001

Nurse’s overall perception of difficult temperament 54 13 (24.1) 4.13 P < .05

-F Numbers too small to include in analyses.

TABLE 6. Difficult Temperament, Behavior Problems, Plus Additional Risk Factors as Predictors of

Preschool Behavior Problems

Difficult Temperament Plus

Behavior Problems Plus

No. No. (%) With

Subsequent

Significance*

5

Problems

... 1- F

Prematurity

Peninatal stress 18 4 F -F

Male sex 54 14 (26.0) 5.76 P < .05

Maternal overall perception 41 9 (22.0) 1 .98 NS

F Numbers too small to include in analyses.

fact that as a group these infants did not have

sig-nificant perinatal stress.35

It is not surprising that male sex emerges in

isola-tion as a risk factor for preschool behavior problems.

This is consistent with previously documented sex

differences in ratings of temperament and behavior

in toddlers and preschoolers.31’46 Similarly, low SES

has been shown consistently to increase the risk for

behavior problems.31 Although we had previously

demonstrated that having a non-Australian parent

was significantly associated with a higher incidence

of perceived behavior problems and ratings of

diffi-cult temperament in infancy,38 this influence had

washed out by the preschool period. This may have

been due to sampling bias, with fewer

non-Austra-han children being sampled at the later time period,

or to other environmental factors that cannot be as-certained from our data. However a non-Australian

parent did emerge as a risk factor in combination with other variables.

We might have expected a trained nurse’s

obser-vation of the infant’s temperament, and especially of

the adjustment of the mother-infant dyad, to be

pre-dictive of later problems, but this was not the case,

even though there was a significant correlation

be-tween nurses’ and mothers’ overall perception of

temperament. This may have been due to the rating

scale employed-each was a single question rated on

a simple scale and may not have been sensitive

enough to pick up problems. However, when nurses’

ratings were added to other risk factors, the

predic-tion of subsequent problems improved, indicating

that risk factors operate cumulatively.47

This then leads us to the not unexpected finding

that maternal perceptions of difficult temperament

and behavior were significantly more powerful

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dictors than categorization of difficult temperament

derived from actual ratings on the RITQ. Indeed,

even when difficult temperament was combined

with other variables (Table 2), there were only slight

increases in prediction. On the other hand, when

maternal perception variables-either overall

per-ception of temperament (Table 3) or perception of

behavior problems (Table 4)-were added to other

individual risk factors, this generally resulted in a

greatly increased risk of preschool behavior

prob-lems. Infancy variables which by themselves had

lit-tle predictive value became significant if, in addition,

there was maternal perception of a difficult infant.

These results indicate that if a mother perceives an

infant as being temperamentally difficult and having

behavior problems (colic, excessive crying, sleep

problems), then irrespective of the actual

tempera-ment category derived from the RITQ, that infant has

an almost doubling of the risk for preschool behavior

problems. Furthermore, if in addition the infant is a

boy, has experienced peninatal stress, or has a

non-Australian parent, then this risk is amplified further

(Table 5).

These results are consistent with the view that

tern-perament per se is “neutral” and that it is the

good-ness of fit between a child’s characteristics and

pa-rental and other variables that is important in

determining behavioral outcome.9 This transactional

model of development implies that any temperament

characteristic which is regarded as abrasive on

unde-sirable by the child’s caretakers is regarded as a risk

factor,48 so that child and environmental variables

must be considered together in the assessment of a

parent-child 49

Researchers continue to argue about the validity of

temperament rating scales in measuring exclusively

within-child characteristics, with a number of

au-thons suggesting that they also invariably reflect

characteristics of the rater.4’5’31 There is no doubt that

a difficult infant or child poses additional parenting

stresses, and it has been argued that if a mother

perceives her young child as being temperamentally

difficult, then she will exhibit less positive maternal

behavior toward him or her.5#{176}While this might affect

temperament ratings on the RITQ, it is more likely to

manifest itself as a global perception of difficult

tern-perament or of behavior problems in infancy. The

latter may be regarded as reflecting both real

within-child problematic behaviors but also maternal

char-actenistics.

Whether or not detailed temperament ratings are

affected by rater characteristics is of less concern in a

clinical context. The rating of an infant or child as

having a difficult temperament simply alerts the

cli-nician that there exists a possible risk factor that may

negatively influence the mother-infant transaction.5#{176}

More clinically relevant is the perception that the child

is difficult, especially if categorization derived from

the actual temperament rating does not concur with

the perception.13 If, as has been argued, maternal

ratings of temperament reflect solely, or mainly,

with-in-child characteristics, then the clinician will learn

little of the stresses and strains that the mother brings

to the relationship. Global impressions of difficulty,

on the other hand, may include maternal

psycholog-ical functioning51 as well as influences of

sociodemo-graphic and cultural factors.5’31

It is not surprising, therefore, that maternal

per-ceptions of a difficult infant are significantly more

predictive of preschool behavior problems than

categorization of temperament based on ratings. A

dysfunctional mother-infant relationship may

fore-shadow later problems either because of the

contin-uation of variables that make parenting stressful or

else because the dyssynchronous relationship

estab-lished in infancy persists as the child grows olden.

Non is it surprising that infancy variables that by

themselves do not increase the risk for subsequent

behavior problems (Table 1) do become additional

risk factors in the face of maternal perception of

in-fant difficulty (Tables 3 through 6). For example,

pen-natal stress became associated with a higher

mci-dence of preschool behavior problems only when

maternal perception of infant difficulty was present.

Similarly, having a non-Australian parent, by itself

not associated with an increased risk of behavior

problems, became significant when there was a

per-ception of infant difficulty. These results are in accord

with the notion that risk factors are cumulative47’52

and that these biological and environmental factors

are operating as vulnerability factors only when

other stresses are also present.53 We did not attempt

to specifically calculate the relative importance of

each of the infant variables in predicting subsequent

outcome, ie, constructing an index of risk for each

infant. In another paper we intend to use multiple

logistic regression techniques to study not only such

relative risk, but also to examine factors that predict

resiliency.

It could be argued that a limitation of this study is

that most of the data were derived from mothers,

whose rating of their preschoolers as having

prob-lems is simply a continuation of their perceiving their

infants as difficult. The results of this study may

well have been strengthened by confirmatory data

from another source (eg, teachers) that the

preschool-ens have behavior problems. However, it has been

argued that mothers’ reports of their children’s

behavior are the most reliable and valid source of

data.3’33’54 Furthermore, if the child is perceived to

have behavior problems by the mother, then this is

likely to have clinical significance irrespective of its

confirmation from another source.

Another issue is to what extent these results are

determined by the way temperament was measured

and difficult temperament categorized. Several

workers have criticized this conceptualization of

temperament after subsequent empirical work which

has not supported the original nine temperament

categories.2 Furthermore, there has been criticism of

the RITQ on empirical grounds,2’6 with doubt then

being cast on the validity of the clinical categories

derived from it. We have previously argued for

tern-perament measures that have stronger psychometric

properties.2 We have suggested that there are

signif-icant weaknesses in the categorical designation of

difficult temperament, which suggests (incorrectly)

that all infants with a difficult temperament are the

same, provided they fulfill the a priori and rather

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ARTICLES 119

In another study, we conceptualized difficult

temper-ament from a continuous easy-difficult scale derived

from the Short Temperament Scale for Infants,2 and

we found that difficult temperament was a

signifi-cant but modest predictor of subsequent problems.47

The results from that study are consistent with the

data presented here, with the modest predictive

value of difficult temperament of doubtful clinical

significance.

The fact that mothers’ perceptions of difficult

tern-penarnent and behavior are more likely than ratings

on the RITQ to predict subsequent problems

sug-gests that they are measuring different things. The

RITQ provides a more “objective” assessment of the

infant’s actual temperament, while perception is

more subjective and may be affected more by

mater-nal variables.

There was a highly significant correlation between

temperament category (derived from the RITQ) and

mothers’ overall perception of temperament;

how-even, the relationship was not straightforward

clini-cally. For example, only 44% of those infants

per-ceived as more difficult or much more difficult were

categorized on the RITQ as being difficult, and

con-versely only 25% of infants categorized as difficult on

the RITQ were perceived as more difficult or much

more difficult than average. Thus despite the

signif-icant statistical correlation, the level of clinical

pre-diction from one to the other is low, reinforcing the

notion that the RITQ and maternal global perception

of temperament are measuring different things.

Behavior problems in the preschool period were

defined by a score of greater than 1 SD above the

mean, giving an arbitrary prevalence rate of 14%.

Some might argue that it may have been preferable to

use the PBQ as a continuum, rather than categorize

the group into those with problems and those

with-out. However, we were interested in a clinically

sig-nificant negative outcome and the prevalence rate of

behavior problems is consistent with other studies.41

Despite these reservations about the validity of

temperament measures and the conceptualization of

difficult temperament, pediatricians continue to use

the RITQ and the nine dimensions of temperament

originally conceptualized by Thomas and Chess and

have found profiles generated by this and related

questionnaires to be of considerable clinical utility.

These results are, therefore, particularly relevant

be-cause of the widespread clinical use of these

mea-sunes.

IMPLICATIONS

What are the implications for the clinician? These

results indicate that the measurement of

tempera-ment alone is unlikely to tell us much about whether

the infant is causing difficulties at the present time

and especially whether or not there are likely to be

behavioral problems in the future. Anticipatory

guid-ance programs based solely on temperament ratings

can be expected to be of little value and are not

warranted on the basis of these results. More valid is

the assessment of temperament in the context of

parenting styles and expectations, especially where

there is parental perception of a difficult infant.

The results of this study raise the issues of

preven-tion and early intervention. If, as we have shown,

maternal perception of a difficult infant significantly

increases the risk of subsequent behavior problems,

is it feasible to intervene to prevent or ameliorate

these problems? Clearly we cannot recommend such

intervention in a general way for all such situations,

especially because prediction is still modest and the

majority of children will not have problems.

How-ever, particularly where the risk of subsequent

prob-lems is increased further by biological or

environ-mental risk factors, and especially when these factors

act in a cumulative way, then one could argue that

there is a strong case for such intervention. More

problematic, of course, is to specify exactly what sort

of intervention is likely to be effective, and for which

children. It may be more pertinent to use the concept

of temperament in a more general way to assist

par-ents in understanding individual characteristics of

their children and thus encourage them to adopt

parenting styles to promote a goodness of fit.

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3. Bates JE, Bayles K. Objective and subjective components in mothers’ perceptions of their children from age 6 months to 3 years.

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6. Hubert NC, Wachs TD, Peters-Martin P. Candour MJ. The study of early

temperament: measurement and conceptual issues. Chili! Dii’.

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7. Cameron JR. Rice DC. Developing anticipatory guidance programs

based on early assessment of infant temperament: two tests of a pre-vention model. IPediatr Psycl:ol. 1986;11 :221-234

8. Carey WB, McDevitt SC. Revision of the Infant Temperament Question-naire. Pediatrics. 1978;68:735-739

9. Thomas A, Chess S. Teinpt’ram:’nt and Dt’z’elop:nc’nt. New York, NY:

Brunner/Mazel; 1977

10. Carey WB. Clinical applications of infant temperament measures. /

Pc-diatr. 1 972;81 :823-828

11. Carey WB. Night waking and temperament in infancy. I Pt’diatr.

1974;84:756-758

12. Oberklaid F, Prior M, Golvan D, Clements A, Williamson A. Tempera-ment in Australian infants. Aust Pa:’diatr J.1984;20:181-184

13. Carey WB. Clinical use of temperament data in pediatrics. I Dci’ Be/ia:’

Pediatr. 1985;6:137-142

14. Earls F. Temperament characteristics and behaviour problems in three

year old children. INero M:’nt Dis. 1981;169:367-373

15. Turecki S. The Difficult Child Center. In: Carey WB, McDevitt SC, eds.

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The Netherlands: Swets & Zeitlinger; 1989

16. Webster-Stratton C, Eyberg S. Child temperament: relationship with

child behaviour problems and parent-child interactions. ICli;: Child

Psychol. 1982;11 :123-129

17. Little DL. Parent acceptance of routine use of the Carey and McDevitt Infant Temperament Questionnaire. Pediatrics. 1983;71 :104-106 18. Thomas A, Chess S. Korn S. The reality of difficult temperament.

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19. Mclnerny T, Chamberlain RW. Is it feasible to identify infants who are at risk for later behaviour problems? Cliii Pediatr (Phi/a). 1975;17:233-238 20. Carey WB, Fox M, McDevitt SC. Temperament as a factor in early school

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24. Lambert NM. Temperament profiles of hyperactive children. Am J

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SCEVOLE DE STE MARTHE ON THE QUALITIES OF A GOOD

WET-NURSE

Among the writers on diseases of children in the sixteenth century was the

French poet Sc#{233}volede Ste Marthe (1536-1623). In his Paedotrophia, written in Latin

hexarneters, he outlined the physical qualities to be looked for in a wet-nurse as

follows’:

Choose one of middle age, non old on young,

Nor plump, non slim, her make, but firm and strong;

Upon her cheek, let health refulgent glow,

In vivid colours, that good humour show.

Long be her arms, and broad her ample chest,

Hen neck be finely tuned, and full her breast;

Let the twin hills be white as mountain snow,

Their swelling veins with circling juices flow;

Each in a well projecting nipple end,

And milk in copious streams from these descend,

Remember, too, the whitest milk you meet

Of grateful flavour, pleasing taste, and sweet,

Is always best; and if it strongly scent

The air, some latent ill the vessels vent.

REFERENCE

1. Dewees WP. A Treatise on the Physical and Medical Treatment of Children. 10th ed. Philadelphia: Blanchard and Lea;

1853:161.

Noted by T.E.C., Jr., MD

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1993;91;113

Pediatrics

Frank Oberklaid, Ann Sanson, Robert Pedlow and Margot Prior

Infancy