Neil W. Boris

Infant Development and Developmental Risk: A Review of the Past 10 Years

OBJECTIVE To review critically the research on infant developmental risk published in the past 10 years. METHOD A brief framework on development in the first 3 years is provided. This is followed by a review of pertinent studies of developmental risk, chosen to illustrate major risk conditions and the protective factors known to affect infant development. Illustrative risk conditions include prematurity and serious medical illness and infant temperament, infant-caregiver attachment, parental psychopathology, marital quality and interactions, poverty and social class, adolescent parenthood, and family violence. RESULTS Risk and protective factors interact complexly. There are few examples of specific or linear links between risk conditions and outcomes during or beyond the first 3 years of life. Infant development is best appreciated within the context of caregiving relationships, which mediate the effects of both intrinsic and extrinsic risk conditions. CONCLUSIONS Complex and evolving interrelationships among risk factors are beginning to be elucidated. Linear models of cause and effect are of little use in understanding the development of psychopathology. Refining our markers of risk and demonstrating effective preventive interventions are the next important challenges.

Research on resilience to child maltreatment: empirical considerations.

OBJECTIVE To review the current research literature on resilience to maltreatment in childhood and adolescence. METHOD First, this paper addresses the methodological issues applicable to this area of research. Second, it reviews the empirical literature on the protective factors believed to contribute to resilience to maltreatment and offers commentary on specific issues raised in each study. RESULTS The current findings are summarized and an integrated descriptive picture, based on the extant literature of the processes and factors contributing to the development of resilience to childhood maltreatment is outlined. CONCLUSION Based on this extensive review and critique of the current empirical literature on resilience to maltreatment, suggestions for future investigations in this area are recommended.

Practitioner review: clinical applications of attachment theory and research for infants and young children.

Study of attachment in the 1970s and 1980s focused on operationalizing and validating many of the tenets of attachment theory articulated in Bowlby’s landmark trilogy, Attachment and Loss (Bowlby, 1982, 1973, 1980), robustly underscoring the central role of child to parent attachment in the child’s development and mental health. Attachment theory and its implications have long interested clinicians, though determining how best to translate complex theoretical constructs and research methods into the clinical arena has been challenging. Nevertheless, well-defined landmarks in early childhood attachment are clinically useful, and the emergence of interventions drawn from systematic research is promising. The purpose of this paper is to summarize salient issues from attachment theory and research and discuss how these issues inform clinical work with infants and young children. We recognize that there is a range of clinical settings in which child–parent attachment will be important. Likewise, among practitioners serving young children and their families, there is a broad range of familiarity with and expertise in attachment principles and attachment-based treatment. We assert that all clinical services for young children and their families will be enhanced by providers’ understanding of attachment theory and research. We further assert that in some clinical contexts understanding child–parent attachment is essential. We begin by reviewing developmental research on attachment to describe how attachments develop, how individual differences in selective attachments manifest, and the characteristics of clinical disorders of attachment. Next, we turn to assessment of attachment in clinical settings. Then, we describe selected specialized clinical contexts in which assessing attachments are uniquely important. Finally, we describe four interventions for young children and their families, all of which are closely derived from attachment theory, supported by rigorous evaluations, and designed to support directly the developing child–parent relationship.

Comparing Criteria for Attachment Disorders: Establishing Reliability and Validity in High-Risk Samples.

OBJECTIVE To determine whether published subtypes of attachment disorder can be reliably identified by trained clinicians reviewing data from high-risk populations and to investigate the relationship between disorder classification and standardized measures of attachment behavior. METHOD Twenty or more children aged 18 to 48 months and their primary caregivers were recruited from three sites: a treatment team for maltreated young children (n = 20), a homeless shelter (n = 25), and Head Start centers (n = 24). All dyads completed a semistructured clinical assessment and laboratory and home-based attachment measures. RESULTS All but one type of attachment disorder could be identified reliably by clinician raters (kappa range = 0.62-0.74, depending on subtype). Children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups (p <.001). As predicted, children without an attachment disorder were more likely to be classified as securely attached than those with an attachment disorder (p =.03); however, children classified as having disorganized attachment were not more likely to receive an attachment disorder diagnosis. CONCLUSIONS Attachment disorders can be reliably diagnosed in young children, though research on refining disorder criteria should precede intervention trials.

Psychosocial support and marginalization of youth-headed households in Rwanda.

Abstract This research aims to characterize the psychosocial aspects of well-being among youth-headed households (YHH) in Gikongoro, Rwanda, through examination of social support and marginalization. Data is presented on perceived availability of support from relatives, an unidentified adult, peers, and other community members and an index of social marginalization. A total of 692 interviews were completed with YHH age 13–24 who are beneficiaries of a basic needs program. Sixteen percent of youth reported there was no one they felt they could go to with a problem. In times of need, only 24% felt relatives would help them, while 57% felt neighbors would offer assistance. Most youth reported significant caring relationships: 73% reported access to trusted adult who offers them advice and guidance, and most indicated close peer relationships. However, many youth also perceived a lack of community support, with 86% feeling rejected by the community and 57% feeling the community would rather hurt them than help them. Social support is a low-cost critical resource for the care of vulnerable youth and an understanding of existing social support networks would enhance the design and implementation of psychosocial and community-based care initiatives.

The Role of Mental Health Factors, Behavioral Factors, and Past Experiences in the Prediction of Rapid Repeat Pregnancy in Adolescence

PURPOSE This study investigates the predictors of rapid repeat pregnancy (subsequent pregnancy within 24 months of previous pregnancy outcome) in a sample of urban adolescents. METHODS Adolescents aged 12-19 years (N = 354) who were predominantly African-American (94.1%) completed individual interviews during pregnancy and at 24 months postpartum. Logistic regression was used to determine the relationship among mental health factors, behavioral factors, and negative life experiences in the prediction of rapid repeat pregnancy. RESULTS Of the adolescents, 42% (n = 147) of adolescents reported a rapid repeat pregnancy. Baseline reports of later age at menarche (12.43 vs. 11.91; p = .003) and a greater likelihood of aggression were significantly associated with having a rapid repeat pregnancy within 24 months. Age at menarche and self-reported aggression contributed independently to the prediction of a closely spaced second pregnancy (p < .05). CONCLUSIONS It is suggested that pubertal onset and individual mental health as it relates to measures of aggression should be considered when developing programs targeting adolescents at highest risk for rapid repeat pregnancy.

Attachment Disorders of Infancy

John Bowiby’s influential theory of attachment (1969/1982, 1973, 1980) grew out of concern among clinicians and researchers in the early to mid-twentieth century about problems of young children raised in contexts of less-than-adequate caregiving, with difficulties in social relatedness (Bowlby, 1951; Call, 1980; Goldfarb, 1945; Kempe, Silverman, Steele, Droegemueller, & Silver, 1962; Rutter, 1972; Skeels, 1966; Spitz, 1945, 1946; Tizard & Tizard, 1971). The formal classification of clinical disorders of attachment, however, is a relatively recent development. In fact, there has been almost no systematic research devoted to clinical disorders of attachment, and until recently, these disorders have been cited in the literature only rarely. In this chapter, we begin by reviewing research demonstrating some of the deviant and unusual attachment behaviors evident in young children raised in extraordinary caregiving contexts. Afterward, we review several different approaches to defining and classifying disorders of attachment. Then, we turn to what is known about the etiology, epidemiology, differential diagnosis, and course and prognosis. We conclude by describing issues salient to assessment and treatment of attachment in infants and toddlers. Throughout, we emphasize the importance of the integration of theory, research, and clinical application.

Risk for maternal depression and child aggression in Early Head Start families: A test of ecological models

Current literature indicates that risk for maternal depression is substantial in low-income families. A large body of research also indicates that when mothers are depressed, children are at risk for a number of developmental difficulties. While mutual influence between child and parental difficulties has been noted, few studies examine risk factors for both depression and child aggression within ecological models. The present cross-site study examined the unique and additive contributions of contextual factors, including SES and family functioning, on maternal depression and child aggression in Early Head Start families. A multiethnic sample of parents and their children, between the ages of 12 and 43 months, participated in this study. Families came from five Early Head Start programs across the United States, representing both urban and rural areas. Structural equation models (SEM) demonstrate mutual links between depression and aggression, mediated at least in part by ecological factors. SEM indicated that 36.4% of the variance in child aggression is accounted for in a model linking aggressive behavior to parent depression, stress, and couple-level functioning, as well as other family interaction variables. A second model focusing on maternal depression revealed that 44.5% of the variance in maternal depression was accounted for through family factors, including couple-related support and satisfaction and parenting stress. In this second model, child aggression was indirectly linked to maternal depression. These data have important implications for programs serving at-risk families.

Nurse home visiting: Perspectives from nurses

Nurses working in the Nurse Family Partnership (NFP) program provide intensive home-visitation services for first-time, low-income mothers. The goals are to improve maternal health outcomes, child health and development outcomes, and to enhance maternal life-course development; however, many of the families face significant psychosocial and mental health issues that can impede progress achieving their goals. Because of the importance of the nurse-client relationship in achieving positive outcomes, these non-mental-health nurses must shift their approaches and techniques from a medical to a psychosocial model. In this article, we examine the role of the nurse in the NFP and present results of focus groups with experienced NFP nurses regarding their perspectives, challenges, and rewards in conducting this work.

Depressive Symptoms in Youth Heads of Household in Rwanda Correlates and Implications for Intervention

OBJECTIVE To examine the level of depressive symptoms and their predictors in youth from one region of Rwanda who function as heads of household (ie, those responsible for caring for other children) and care for younger orphans. DESIGN Cross-sectional survey SETTING Four adjoining districts in Gigonkoro, an impoverished rural province in southwestern Rwanda. PARTICIPANTS Trained interviewers met with the eldest member of each household (n = 539) in which a youth 24 years old or younger was caring for 1 child or more. MAIN EXPOSURE Serving as a youth head of household. MAIN OUTCOME MEASURES Rates and severity of depressive symptoms using the Center for Epidemiologic Studies Depression scale; measures of grief, adult support, social marginalization, and sociodemographic factors using scales developed for this study. RESULTS Of the 539 youth heads of household, 77% were subsistence farmers and only 7% had attended school for 6 years or more. Almost half (44%) reported eating only 1 meal a day in the last week, and 80% rated their health as fair or poor. The mean score on the Center for Epidemiologic Studies Depression scale was 24.4, exceeding the most conservative published cutoff score for adolescents. Multivariate analysis revealed that reports of depressive symptoms that exceeded the clinical cutoff were associated with having 3 basic household assets or fewer, such as a mattress and a spare set of clothes (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.70), eating less than 1 meal per day (OR, 1.68; 95% CI, 1.09-2.60), reporting fair health (OR, 1.32; 95% CI, 0.76-2.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.73-4.13), having at least 1 parent die in the genocide as opposed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; 95% CI, 1.17-3.12). There was an interaction between marginalization from the community and alcohol use; youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report symptoms of depression (OR, 3.07; 95% CI, 1.73-5.42). When models were constructed by grouping theoretically related variables into blocks and controlling for other blocks, the emotional status block of variables (grief and marginalization) accounted for the most variance in depressive symptoms. CONCLUSIONS Orphaned youth who head households in rural Rwanda face many challenges and report high rates of depressive symptoms. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.