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. Author manuscript; available in PMC: 2022 Sep 22.
Published in final edited form as: J Reprod Infant Psychol. 2019 Aug 9;39(1):100–110. doi: 10.1080/02646838.2019.1652257

Neonatal Negative Emotionality and the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) in Middle Childhood

Allison M Momany 1, Beth Troutman 2
PMCID: PMC9494752  NIHMSID: NIHMS1835902  PMID: 31397592

Abstract

OBJECTIVE:

Determine whether an association exists between neonatal negative emotionality and childhood emotional dysregulation.

BACKGROUND:

The Child Behavior Checklist-Dysregulation Profile (CBCL-DP) has been used as a measure of emotional dysregulation in childhood. Although there is now good evidence that the CBCL-DP predicts later psychopathology, little is known about what factors predict elevations on the CBCL-DP.

METHODS:

30 mother-child dyads who previously participated in a study of neonatal temperament were recruited to a follow-up study of emotional dysregulation during middle childhood. The Neonatal Behavior Assessment Scale and the Infant Characteristics Questionnaire were utilized as observer and maternal measure of neonatal negative emotionality, respectively. Maternal post-partum depression was also measured during the neonatal period using the Edinburgh Post-Partum Depression Scale. The Child Behavior Checklist-Dysregulation Profile (CBCL-DP) was used as a measure of childhood emotional dysregulation.

RESULTS:

The ICQ fussy-difficult scale was significantly correlated with the CBCL-DP score (r = .46, p = .010), and this correlation remained significant after controlling for maternal EPDS score (CBCL-DP r = .51, p = .01). The NBAS irritability score was not associated with the CBCL-DP score.

CONCLUSIONS:

This association provides preliminary results that neonates rated as having high negative emotionality may indeed experience chronic difficulties with emotional dysregulation.

Keywords: Disruptive Mood Dysregulation Disorder, neonatal negative emotionality, post-partum depression, CBCL-DP

Introduction

Disruptive Mood Dysregulation Disorder (DMDD) is a relatively new disorder, introduced with the publication of DSM-5 in 2013, and is characterized by two core symptoms of emotional dysregulation, severe temper outbursts and chronic irritability (American Psychiatric Association, 2013). The symptoms of DMDD must be evident before age 10 and a diagnosis must be made between ages 6 and 18 (American Psychiatric Association, 2013), speaking to the developmental nature of the dysregulation. Prior to DSM-5, children who displayed persistent irritability were often diagnosed with and treated for Bipolar Disorder, yet many of these children never experienced an episode of mania or hypomania (Goldstein & Birmaher, 2012). Thus, concerns arose that youth experiencing persistent emotional dysregulation were being improperly diagnosed and treated (Goldstein & Birmaher, 2012; Roy, Lopes, & Klein, 2014), and DMDD was added to the DSM-5 to recognize the emotional dysregulation observed in some youth without requiring a diagnosis of bipolar disorder.

Since the introduction of DMDD, there has been contentious debate surrounding the validity of the disorder because the majority of children with DMDD are diagnosed with one or more other disorders, most commonly Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder/Conduct Disorder, and mood disorders (Copeland, Angold, Costello, & Egger, 2013; Dougherty et al., 2014; Meyers, DeSerisy, & Roy, 2017). Given the high rate of comorbidity of DMDD and other disorders, some researchers have suggested that DMDD may be better understood as a transdiagnostic construct indicating difficulties with self-regulation, a component of temperament, that begins at an early age (Meyers et al., 2017). Indeed, previous work has found that child temperament at 3 years of age (higher negative emotional intensity, higher surgency, and lower effortful control) is predictive of DMDD at 6 years of age (Dougherty et al., 2014).

Research examining the identification, aetiology, and longitudinal outcomes of DMDD have greatly expanded given its recent addition to the DSM-5 (Copeland et al., 2013; Dougherty et al., 2014). A number of these studies use the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) as a means of identifying children and adolescents with emotion dysregulation, a core component of DMDD (Althoff et al., 2012). The CBCL-DP profile is characterized by high values on the Anxious/Depressed, Attention Problems, and Aggressive Behavior scales of the Child Behavior Checklist (CBCL; Althoff, Verhulst, Rettew, Hudziak, & van der Ende, 2010). Notably, this profile was originally identified as a scale for paediatric bipolar disorder (Biederman et al., 2009; Faraone, Althoff, Hudziak, Monuteaux, & Biederman, 2005; Mick, Biederman, Pandina, & Faraone, 2003). However, just as DMDD has been suggested as an alternative to bipolar disorder, the CBCL-DP scale has been suggested as a measure of emotional dysregulation (Ayer et al., 2009; Diler et al., 2009; Mbekou, Gignac, MacNeil, Mackay, & Renaud, 2014; Meyer et al., 2009; Volk & Todd, 2007). Indeed, numerous studies have found that children with high CBCL-DP scores are more likely to continue to experience emotional and behavioural difficulties throughout childhood, adolescence, and into adulthood indicating that emotional dysregulation evident in childhood may extend throughout the lifespan (Althoff et al., 2010; De Caluwe, Decuyper, & De Clercq, 2013; Holtmann et al., 2011; Kim et al., 2012; Masi, Muratori, Manfredi, Pisano, & Milone, 2015; Masi, Pisano, Milone, & Muratori, 2015).

Although there is now good evidence that the CBCL-DP profile predicts later psychopathology, little is known about what factors predict elevations on the CBCL-DP profile. One hypothesis is that childhood dysregulation is indicative of individual differences appearing early in life, specifically temperament (Gjone & Stevenson, 1997; Poustka et al., 2015; Sayal, Heron, Maughan, Rowe, & Ramchandani, 2014; Stringaris, Maughan, & Goodman, 2010). Moreover, negative emotionality, which is the propensity to express negative affect, is a facet of temperament that has been examined in relation to childhood dysregulation (Paulussen-Hoogeboom, Stams, Hermanns, & Peetsma, 2007). Caring for an infant with a high level of negative emotionality is an extremely frustrating and difficult task for many parents (Cutrona & Troutman, 1986; Troutman, Moran, Arndt, Johnson, & Chmielewski, 2012). Thus, high levels of negative emotionality in infancy may be associated with later problems with dysregulation due to individual differences in emotional regulation and because the child’s negative emotionality may undermine the caregiver’s attempts to help them regulate their emotions and behaviour. That is, caregivers may become less responsive because their previous attempts to soothe the infant were not successful. Additionally, post-partum depression may exacerbate a caregiver’s frustration or feelings of inadequacy (Beck, 1995; A. D. Cox, Puckering, Pound, & Mills, 1987).

Negative emotionality in young children has previously been associated with adverse childhood behaviour outcomes (e.g., Eisenberg et al., 2005; Eisenberg et al., 2009; Gjone & Stevenson, 1997; Grant, Bagnell, Chambers, & Stewart, 2009); however the empirical support for this hypothesis has not extended to temperament during the neonatal period (first four weeks of life). Thus, an examination of the association between neonatal negative emotionality and emotional dysregulation in childhood is warranted. The current study aims to examine the association between neonatal negative emotionality and emotional dysregulation in middle childhood while controlling for post-partum depression. Neonatal negative emotionality was assessed via a standardized behavioural paradigm (the Neonatal Behavioral Assessment Scale) and by maternal rating (ICQ) at four weeks of age, post-partum depression was measured with the Edinburgh Post-partum Depression Scale at 4 weeks post-partum, and childhood emotional dysregulation was measured by the CBCL-DP at 10–12 years of age. We hypothesize that infant negative emotionality, as measured by the NBAS and the ICQ, will be positively associated with scores on the CBCL-DP at 10–12 years of age after controlling for maternal post-partum depression score.

Methods

Subjects

Participants for the longitudinal study of emotional dysregulation were recruited from 111 infants who had participated in a study of infant neonatal negative emotionality at 3 and 4 weeks of age. Briefly, advertisements and local birth records were used to identify and recruit neonates and their mothers. Neonates who were hospitalized for more than 10 days following birth were excluded. Two in-home neonatal assessments were completed with 111 infants and their mothers at 3 and 4 weeks of age. At the in-home assessment, the Neonatal Behavioral Assessment Scale (NBAS) was administered, and mothers completed the Infant Characteristics Questionnaire (ICQ; both measures described below). Participants reflected a range of socioeconomic backgrounds (Hollingshead IV classifications ranged from 1 to 5) but the majority (90%) were professional households (Hollingshead IV classifications 4 and 5). Infants’ (52% girls, 48% boys) race/ethnicity was 92% White, 6% African American/Black, 6% Hispanic, 4% Asian, and 1% Native American.

Of the original 111 infants in the neonatal study, the authors attempted to contact the 106 infants who completed two Brazelton assessments. Contact information from the original study was initially used to attempt to recruit subjects; however, given the period of time that had elapsed since the original study (approximately 10 years), it was anticipated that participant contact information may not be accurate for many of the participants. An online search engine specifically for addresses and phone numbers (whitepages.com) was used in attempt to find updated contact information for participants who had moved.

For the childhood assessment, mothers completed the Achenbach System of Empirically Based Assessments (ASEBA) Child Behavior Checklist (CBCL) for children 6–18 years and the CBCL-DP was calculated from this (described below). Study methods were approved by the relevant Institutional Review Board (IRB). Written informed consent was obtained from mothers at the infancy and childhood assessments. Assent was obtained from the children at the childhood assessment.

Measures

Neonatal negative emotionality

Maternal rating.

The Infant Characteristics Questionnaire (ICQ; Bates, Freeland, & Lounsbury, 1979) is a widely used assessment of infant temperament and has been used with infants as young as 1 month in previous studies (Hsu & Lavelli, 2005; Papousek & vonHofacker, 1998; Pearce & Ayers, 2005; Porter & Hsu, 2003; Van Egeren, 2004). The 6-item fussy-difficult scale of the ICQ (Bates, 1992) was used to obtain maternal ratings of overall negative emotionality at four weeks of age. Mothers rated each item on a 7-point Likert scale and summed to create a total fussy-difficult score. This scale is comprised of the following items: (1) How easy or difficult is it for you to calm or soothe your baby when he/she is upset; (2) How many times per day, on the average, does you baby get fussy and irritable—for either short or long periods of time?; (3) How much does you baby cry and fuss in general; (4) When your baby gets upset, how vigorously or loudly does he/she cry and fuss?; (5) How changeable is your baby’s mood?; (6) Please rate the overall degree of difficulty your baby would present for the average mother. The internal consistency of the ICQ fussy-difficult scale for the current study (Cronbach’s alphas = .82 to .88) is comparable to that found in previous studies (Cronbach’s alphas = .79 to .87; Bates et al., 1979; Van Egeren, 2004).

Observer rating.

The Neonatal Behavioral Assessment Scale (NBAS; Brazelton, 1973) is a standardized assessment administered by a trained examiner that samples a range of neonatal behaviours (e.g., reflexes, state changes, arousal, and regulation). A neonatal irritability factor developed by Kaye (1978) identifies neonates who are more prone to express neonatal negative emotionality (Cassidy, Woodhouse, Sherman, Stupica, & Lejuez, 2011; Crockenberg, 1981; Kaye, 1978; Keenan, Grace, & Gunthorpe, 2003; van den Boom, 1989). The neonatal irritability factor is calculated by summing scores on the peak of excitement, rapidity of build-up, and irritability scales. In the current study, the NBAS (Brazelton, 1973) was administered at three and four weeks post-partum by the second author, who was trained and certified as reliable at the Brazelton Institute, Harvard University. The neonatal irritability factor was calculated for both NBAS assessments and averaged to create a continuous measure of neonatal negative emotionality.

Maternal post-partum depression

The Edinburgh Post-partum Depression Scale (EPDS) is a self-report measure that was developed to screen mothers for post-partum depression (J. L. Cox, Holden, & Sagovsky, 1987; Murray & Carothers, 1990). The EPDS is commonly used in empirical studies of post-partum depression and has good internal consistency (Cronbach’s alpha = .87; J. L. Cox et al., 1987). The EPDS is comprised of 10-items that assess symptoms of depression. Respondents are asked to rate each item on a 4-point Likert scale based on the previous seven days. The EPDS was completed by mothers at three weeks post-partum and a total score was computed.

Childhood emotional regulation

Mothers completed the Child Behavior Checklist (CBCL; Achenbach, 1991) when children were eight to eleven years old. The CBCL is a 118-item scale that can be scored for a Total Scale, Internalizing Score, Externalizing Scale, and 8 syndrome subscales (Withdrawn, Somatic Complaints, Anxious/depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior). For the current study, the CBCL-Dysregulation Profile (CBCL-DP) was used to assess childhood emotional regulation. The CBCL-DP is scored by summing the T-scores from the Attention Problems, Aggressive Behavior, and Anxious/depressed subscales (Holtmann et al., 2011).

Analytic plan

Assessment of selection bias.

First, given the high rate of attrition between the assessments during infancy and childhood, efforts were undertaken to ascertain whether selection bias was evident in the childhood sample. First, maternal and observer ratings of neonatal negative emotionality and maternal ratings of depression were compared for participants and non-participants in order to examine whether mothers of infants with high levels of neonatal negative emotionality or mothers who experienced more symptoms of post-partum depression were more likely to participate in the childhood assessment. Second, the mean score for the Dysregulation Profile, Externalizing Problems, and Internalizing Problems on the CBCL for children who participated in the childhood assessment was calculated to determine the extent to which participants may be experiencing more severe behavioural difficulties, and therefore, have mothers more likely to participate in the childhood assessment.

Neonatal negative emotionality and childhood emotional regulation.

Next, correlations were computed between the CBCL-DP scale, CBCL Total Problems, ICQ fussy-difficult score, and the NBAS irritability rating. Partial correlations controlling for maternal EPDS scores were also computed for each pair-wise combination.

Results

Of the original 106 participants, 38 participants could not be located and 38 did not return the questionnaires/refused to participate. This resulted in 30 children and their mothers who participated in both the neonatal and childhood assessments (mean age = 9.3, SD = 1.0).

Assessment of selection bias

Individuals who participated in the childhood assessment did not exhibit significantly different levels of neonatal negative emotionality as assessed by the NBAS (t(104) = .15, p = .88) or maternal report on the ICQ fussy-difficult scale (t(104) = −.16, p = .87). Additionally, mothers of individuals who participated in the childhood assessment did not report higher levels of post-partum depression on the EPDS (t(104) = .62, p =.54).

Descriptive statistics were calculated for the CBCL Dysregulation Profile, Internalizing Problems, and Externalizing Problems t-scores (Table 1). The mean t-score on each scale was in the normal range indicating the individuals who participated in the childhood assessment were not, on average, experiencing clinical symptomology and, therefore, did not appear to be influenced to participate in the childhood assessment because of more severe behavioural difficulties.

Table 1.

Descriptive statistics for the t-scores of Total Problems, Internalizing Problems, and Externalizing Problems scales of the CBCL for participants at the childhood assessment (n = 30).

Scale Mean SD Range
Total Problems 49.07 8.2 39 to 74
Internalizing Problems 49.77 9.57 33 to 72
Externalizing Problems 48.20 8.84 34 to 74
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Neonatal negative emotionality and childhood emotional regulation

Correlations and partial correlations (controlling for maternal EPDS score at 4 weeks post-partum) between the NBAS, ICQ fussy-difficult rating, CBCL-DP score, CBCL Internalizing Problems score, and CBCL Externalizing Problems score are presented in Table 2. With regard to neonatal negative emotionality and childhood emotional regulation, the ICQ fussy-difficult scale was significantly correlated with the CBCL-DP score and the CBCL Internalizing Problems score (r = .46, p = .010 and r = .57, p < .01, respectively), and these correlations remained significant after controlling for maternal EPDS score (CBCL-DP r = .51, p = .01 and CBCL Internalizing Problems r = .56, p < .01). However, the NBAS irritability score was not associated with the CBCL-DP score or CBCL Internalizing Problems score, with or without controlling for maternal EPDS score. The CBCL Externalizing Problems score was not correlated with either measure of neonatal irritability, regardless of whether maternal depression was covaried. Interestingly, the correlation and partial correlation for the NBAS irritability score and the ICQ fussy difficult score were not significant.

Table 2.

Correlations and partial correlations (controlling for EPDS score) between the measures of neonatal irritability and CBCL scales (n = 30).

Correlation Partial Correlation
ICQ fussy NBAS ICQ fussy NBAS
CBCL-DP r = .46 (.12, .80), p = .01 r = .17 (−.21, .55), p = .37 r = .51 (.12, .90), p = .01 r = .21 (−.20, .62), p = .29
CBCL Int r = .57 (.25, .89), p < .01 r = 0.0 (−.39, .39), p = .99 r = .56 (.23, .89), p < .01 r = .05 (−.36, .46), p = .81
CBCL Ext r = .25 (−.13, .62), p = .19 r = .01 (−.38, .40), p = .95 r = .27 (−.11, .66), p = .16 r = −.02 (−.44, .39), p = .92
NBAS r = .28 (−.09, .65), p = .13 r = .37 (0.0, .77), p = .05
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Note: NBAS = neonatal behavioral assessment scale, ICQ fussy = fussy-difficult scale of the Infant Characteristics Questionnaire; CBCL-DP = Child Behavior Checklist-Dysregulation Profile; CBCL Int = Child Behavior Checklist Internalizing Problems; CBCL Ext = Child Behavior Checklist Externalizing Problems

Discussion

Given the relatively recent addition of Disruptive Mood Dysregulation Disorder (DMDD) to the DSM-5 and the use of the CBCL-DP to assess emotional dysregulation in childhood, the current study sought to determine whether emotional dysregulation evident during childhood is preceded by high levels of neonatal negative emotionality. Results indicate significant associations between maternal ratings of neonatal negative emotionality and maternal ratings of childhood emotional dysregulation. These associations persisted after accounting for maternal symptoms of post-partum depression. However, maternal ratings of neonatal negative emotionality were not associated with childhood externalizing behaviour suggesting the significant longitudinal associations may reflect the persistent emotion regulation difficulties that constitute DMDD in the DSM-5. Notably, this study contributes to the extant literature by measuring infant temperament at four weeks of age.

Previous research supports an association between elevated CBCL-DP scores and later problems. Althoff and colleagues (2010) found that individuals with elevated CBCL-DP scores experienced higher rates of anxiety, mood, disruptive behavior, and substance use disorders later in development (Althoff et al., 2010), and analyses by Doughtery et al (2014) revealed that an elevated CBCL-DP score at three years of age predicted DMDD at six years of age. Additional research in young adults supports the association between elevated CBCL-DP scores and later problems, specifically increased risk for substance use disorder, suicidality, and overall poorer functioning (Holtmann et al., 2011). Furthermore, the longitudinal association is evident when examining pathological personality traits, as opposed to disorder criteria, in children (De Caluwe et al., 2013), providing support that the CBCL-DP is measuring a chronic difficulty with emotion regulation.

Although the research to date has focused on outcomes associated with elevated CBCL-DP scores, the individual characteristics that precede elevated CBCL-DP scores I childhood are largely unknown. Thus, the current study adds to our understanding of chronic emotion regulation difficulties by examining infant temperament, specifically neonatal negative emotionality, and subsequent CBCL-DP scores. The significant associations found in the current study are especially important to consider given research showing that preschoolers who have elevated CBCL-DP scores differ from their peers who do not have elevated CBCL-DP scores in several ways including parenting behavior and parental personality, psychopathology, and marital functioning (Kim et al., 2012). Thus, parenting or parent-child interventions during infancy and early childhood for children rated as having high negative emotionality may prevent long-term adverse outcomes.

There are some limitations of the current study that are important to consider. First, it is possible that the association between the maternal rating of neonatal temperament and childhood dysregulation is an artifact of method variance. That is, maternal ratings during the neonatal assessment were associated with maternal ratings during childhood, but observer ratings during the neonatal assessment were not associated with maternal ratings during childhood. A second limitation was the large time span (8–12 years) between assessments as this resulted in high attrition and a relatively small sample size. Therefore, the current study may be underpowered. Finally, maternal depression was not controlled for at the childhood assessment.

Future efforts are required to gain a better understanding of the longitudinal association between neonatal negative emotionality and childhood emotional dysregulation. Additional research should include larger samples in order to derive a more precise estimate of the association. Also, other measures of childhood emotional dysregulation, including behavioural measures and measures from other caregivers or educators, should be utilized to determine the extent to which the association is an artefact of the same rater (mother) at both time points. Measures of emotional dysregulation should be administered at additional time points more proximal to the neonatal period to better understand the trajectory of emotional dysregulation.

The results of the current study provide preliminary evidence for an association between maternally-rated neonatal negative emotionality and childhood emotional dysregulation. Importantly, the ratings of neonatal negative emotionality in the current study are at four weeks, the earliest time point to be associated with ratings on the CBCL-DP in childhood. Moreover, this association suggests neonates rated as having high negative emotionality may indeed experience chronic difficulties with emotional dysregulation, and such neonates may develop into children who are diagnosed with Disruptive Mood Dysregulation Disorder.

Funding:

The research presented in this manuscript was supported by a grant from the National Institute of Child Health & Human Development (NICHD R03 HD037232) and the Iowa Center for Research by Undergraduates (ICRU).

Footnotes

Disclosure statement: The authors report no conflict of interest.

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