Mary D. Klinnert

Maternal emotional signaling: Its effect on the visual cliff behavior of 1-year-olds.

Facial expressions of emotion are not merely responses indicative of internal states, they are also stimulus patterns that regulate the behavior of others. A series of four studies indicate that, by 12 months of age, human infants seek out and use such facial expressions to disambiguate situations. The deep side of a visual cliff was adjusted to a height that produced no clear avoidance and much referencing of the mother. If a mother posed joy or interest while her infant referenced, most infants crossed the deep side. If a mother posed fear or anger, very few infants crossed. If a mother posed sadness, an intermediate number crossed. These findings are not interpretable as a discrepancy reaction to an odd pose: in the absence of any depth whatsoever, few infants referenced the mother and those who did while the mother was posing fear hesitated but crossed nonetheless. The latter finding suggests that facial expressions regulate behavior most clearly in contexts of uncertainty.

EMOTIONS AS BEHAVIOR REGULATORS: SOCIAL REFERENCING IN INFANCY

This chapter deals with three broad issues: Whether emotions are epiphenomenal, how emotions play a crucial role in determining appraisal processes, and what the mechanisms are by which emotions may influence interpersonal behavior. We present evidence from studies indicating that emotions play a crucial role in the regulation of social behavior. Social regulation by emotion is particularly clear in a process we call social referencing—the active search by a person for emotional information from another person, and the subsequent use of that emotion to help appraise an uncertain situation. Social referencing has its roots in infancy, and we propose that it develops through a four-level sequence of capacities to process emotional information from facial expression. We discuss whether the social regulatory functions of emotion are innate or socially learned, whether feeling plays an important role in mediating the effects of emotional expressions of one person on the behavior of another, and whether stimulus context is important in accounting for differences in reaction to the same emotional information.

Prediction of early-onset asthma in genetically at-risk children.

The W.T. Grant Foundation Asthma Risk Study was designed to prospectively examine children who were considered at a genetically increased risk for the development of asthma. The respective contributions of 11 potential risk factors, both environmental and biological, were assessed in order to determine their relative roles in affecting the early onset of asthma. This is a report of an inception cohort of children born to asthmatic mothers and followed for a 3‐year period. All 150 families were recruited from the general community and living within 2 h of the National Jewish Center for Immunology and Respiratory Medicine (Denver, CO). Mothers in the index risk sample had been previously diagnosed with asthma and were recruited during their pregnancy through physician referrals and media solicitation. The index sample of 150 families was 92% Caucasian and predominantly middle class.

Early Asthma Onset: Consideration of Parenting Issues

This report examines the relationship between early parental behavior and the later onset of asthma in a cohort of 150 children who were genetically at risk for developing asthma. Judgments of both parenting problems and maternal coping were made during a home visit when the infant was 3 weeks old. A clinical interview with the mother was developed and reliably coded. The sample was divided into two groups based on the presence or absence of concerns about coping and parenting. During the following 2 years, the respiratory status of the children was monitored. Four categories of respiratory status were defined: (1) asthma; (2) recurrent infectious wheezing; (3) a single isolated wheezing episode; or (4) no wheezing. Early problems in coping and parenting were associated with the later onset of asthma (p less than 0.001). Furthermore, parents of children who developed asthma were more likely to have been having difficulties at the 3-week visit than those whose children developed infectious wheezing (p less than 0.005).

Early Asthma Onset.

: It has been repeatedly noted by clinicians that psychological stressors appear to be associated with the expression of asthma in individuals who have a genetic vulnerability for developing the disease. While retrospective evidence has supported this clinical observation (Levitan 1985; Teiramaa 1986), the association between emotional stressors and illness onset can only be convincingly demonstrated using a longitudinal design (Mrazek 1988; Steinhausen et al. 1983). In 1985 the W. T. Grant Asthma Risk Study was designed to identify which physiological and psychological risk factors for asthma were most highly associated with eventual expression of the disease. Young infants who were genetically at risk for asthma were evaluated and their development was prospectively monitored. The primary objective of the longitudinal study was to identify risk factors for illness expression. If this were possible, these risk factors could then be targeted for intervention efforts designed to delay the initial onset of asthmatic symptoms. The ultimate objective of an effective intervention would be that for some children, the illness could be prevented completely.

Early Asthma Onset: Risk of Emotional and Behavioral Difficulties

The relationship between age of asthma onset and behavioral adjustment was analyzed using data from a longitudinal prospective investigation of 150 children identified prenatally as at genetic risk for developing asthma (the W. T. Grant Asthma Risk Study). The childrens development and asthma status were monitored regularly for 6 years. Mothers were interviewed yearly using the Behavioral Screening Questionnaire (BSQ). Children who had an early onset of asthma (by 3 years of age) had significantly more behavior problems at age 4 than children who developed asthma later (between 3 and 6 years of age). Furthermore, the early-onset group had significantly more problems at age 6 than both children who developed asthma later and children who never developed asthma. Children with early asthma onset were compared to children who were asthma free on individual problem items of the BSQ, revealing a profile of behavior problems that included waking at night, depressed mood, and some indication of increased fearfulness. This profile is consistent with an earlier report of behavior problems among severely asthmatic preschool children (Mrazek, Anderson, & Strunk, 1984), who displayed the same internalizing behavior problems on the BSQ. These results suggest that early asthma onset may have predictable negative influences on behavioral adjustment over a wider range of asthma severity than has previously been reported.

The Five Minute Speech Sample in Children with Asthma: Deconstructing the Construct of Expressed Emotion

OBJECTIVE To use the Five Minute Speech Sample (FMSS) to assess Expressed Emotion (EE) in various samples of children with asthma in order to clarify (1) developmental and validity issues for the EE construct and (2) the use of the FMSS technique, specifically, in children with chronic medical illness. METHOD Data were collected on a sample of 84 adolescents with severe, chronic asthma who had failed outpatient management. In addition, a sample of 30 children with asthma, ages 6-9. were recruited from an outpatient pediatric clinic. A comparison sample of 15 children without any chronic illness, ages 6 9, were recruited by notices posted in the community. The primary caregiver of each child was assessed using the FMSS. RESULTS FMSS interviews were reliability coded in all samples. Rates of high Criticism (FMSS CRIT), Emotional Overinvolvement (FMSS EOI), and EE were comparable to rates previously reported in child and adolescent samples. Although the validity for ratings of FMSS CRIT was well supported, the validity of FMSS EOI ratings and the overall EE construct were more problematic. CONCLUSIONS The FMSS is a useful and largely valid measure in children with asthma. Ratings of FMSS CRIT were found to have strong validity. There was little problem shifting the context of FMSS administration from chronic mental to chronic medical illness, but a variety of developmental considerations arose, especially regarding FMSS EOI ratings. Although we raise concerns about viewing EE as a valid construct, it may remain a useful predictive index.

Unraveling the ecology of risks for early childhood asthma among ethnically diverse families in the southwest

OBJECTIVES We describe the prevalence of asthma risk factors within racial/ethnic and language groups of infants participating in an intervention study for reducing chronic asthma. METHODS Low-income children aged 9 to 24 months with 3 or more episodes of wheezing illness were enrolled. Baseline information included family and medical histories, allergic status, environmental exposures, emotional environment, and caregiver psychosocial resources. RESULTS Racial/ethnic and language groups-European Americans, African Americans, high-acculturated Hispanics, and low-acculturated Hispanics-showed different patterns of risk factors for childhood asthma, with low-acculturated Hispanics showing the most distinctive pattern. CONCLUSIONS Patterns of covariation of biological and psychosocial risk factors for childhood asthma were associated with racial/ethnic and language status among urban, low-income children.

Caregiver negative affect is a primary determinant of caregiver report of pediatric asthma quality of life

BACKGROUND Quality of life has increased in popularity as an outcome measure in health research. However, the measurement of quality of life has been questioned on methodologic grounds, as it often shows little association with objective measures of disease status. OBJECTIVE For this report we studied the determinants of pediatric asthma caregiver report of quality of life and its relationship to disease burden. METHOD Ninety-eight children who were admitted to a Pediatric Day Program for an asthma evaluation were enrolled in an outcome study. A complete set of medical records for the 2-year period before and after the admission was collected and systematically coded for health care utilization. Using the Pediatric Asthma Caregivers Quality of Life Questionnaire, data were collected at baseline, discharge, and year after the admission. Caregiver negative affect (anxiety and depression), measured with the Brief Symptom Inventory, was also collected at baseline and discharge. RESULTS Caregiver report of quality of life was unrelated to health care utilization at baseline but instead was significantly related to baseline caregiver negative affect. A significant relationship between health care utilization and quality of life was present at followup. The Emotional Function scale from the quality of life measure can account for most of the relationship between quality of life and negative affect. CONCLUSIONS Caregiver affect may have a considerable influence on report of quality of life. Understanding the individual characteristics of the respondent is important when using a quality of life instrument as an outcome measure.

PedsQL eosinophilic esophagitis module: feasibility, reliability, and validity.

Objective: Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory condition with a paucity of information on health-related quality of life (HRQOL). The objective of the study was to report on the measurement properties of the PedsQL EoE Module. Methods: The PedsQL EoE Module was completed in a multisite study by 196 pediatric patients with EoE and 262 parents of patients with EoE. Results: The PedsQL EoE Module scales evidenced excellent feasibility (0.6%–3.1% missing), excellent group comparison reliability across total scale scores (patient &agr; 0.93; parent proxy &agr; 0.94), good reliability for the 7 individual scales (patient &agr; 0.75–0.87; parent proxy &agr; 0.81–0.92), excellent test–retest reliability (patient intraclass correlation coefficient 0.88; parent intraclass correlation coefficient 0.82), demonstrated no floor effects and low ceiling effects, and demonstrated a high percentage of scaling success for most scales. Intercorrelations with the PedsQL Generic Core Scales were in the medium (0.30) to large (0.50) range. PedsQL EoE Module scores were worse among patients with active histologic disease (≥5 eos/hpf) compared with those in remission (patient self-report: 63.3 vs 69.9 [P < 0.05]; parent proxy report: 65.1 vs 72.3 [P < 0.01]), and those treated with dietary restrictions compared with those with no restrictions (patient self-report: 61.6 vs 74.3 [P < 0.01]; parent proxy report: 65.5 vs 74.7 [P < 0.01]). Conclusions: The results demonstrate excellent measurement properties of the PedsQL EoE Module. Patients with active histologic disease and those treated with dietary restrictions demonstrated worse PedsQL scores. The PedsQL EoE Module may be used in the evaluation of pediatric EoE disease-specific HRQOL in clinical research and practice.