Focusing on Young Children in Pediatric Psychology Research: Introduction to the Special Issue on Young Children

Abstract

Introduction

Infancy and early childhood represent critical periods of development in which rapid and large biological, psychological, and social changes occur. The field of pediatric psychology spans young children through young adults with chronic medical conditions and/or in health care contexts, yet the vast majority of the pediatric psychology literature focuses on school age and older children.

Given the need for developmentally sensitive research, why has pediatric psychology focused more on school-aged children and adolescents to the exclusion of younger children? One reason may be that studying younger children may present methodological challenges such as the need to rely on caregivers for assessment of functioning, conducting detailed behavioral coding, lack of standardized assessment tools for this age group, presence of major developmental changes over short time periods, and difficulty using objective measures (e.g., cooperation with preschoolers wearing accelerometers; see Cohen et al., 2020 and Meltzer & Mindell, 2014 for discussions of assessment in young children). Behavioral interventions targeting young children can also present challenges and may or may not include the young children themselves in intervention delivery, and may instead be directed toward the caregiver.

Given the importance of understanding the psychosocial impact of the health care context and early behavioral processes for young children, this special issue sought research focusing on young children and their families. There are several unifying themes to the articles which we highlight below including papers using innovative research designs and assessment strategies and making use of the electronic health record and large datasets. Several studies apply novel applications to interventions, and six of the papers in this special issue focus on diverse populations, helping to further our understanding of health disparities among young children.

Broadening the focus from school-aged children and adolescents allows examination of potential developmental differences and understanding trajectories from early childhood. The information gleaned from studying younger children (ages 5 and under) helps inform prevention efforts and provides important treatment targets. De Young et al. (2021) provide a topical review of medical trauma during early childhood. Early childhood is a high-risk period for injury and traumatic medical events, yet the focus in the extant literature has been on older youth, possibly due to the reliance on self-report to capture the individual’s appraisal of the potentially traumatic event. In their review, they delineate important terms (including medical trauma), and summarize the existing literature complemented by developmental considerations for infants, toddlers, and preschoolers. De Young et al. (2021) offer a stepped care framework to inform clinical practice and outline directions for future research.

Holbein et al. (2021) examined pediatric health-related quality of life (HRQOL) and gastrointestinal symptoms in children with very early-onset inflammatory bowel disease (VEO-IBD). Understanding the functioning and symptom presentation in children with VEO-IBD is important as they appear to show different characteristics than youth diagnosed at a later age. Complemented by measures of disease activity, the research team utilized the caregiver reports of gastrointestinal symptoms and HRQOL of 51 children under age 6 years with VEO-IBD and compared with 54 caregiver reports for a healthy control group. Findings suggested that the two groups were similar in many respects and that over half of children with VEO-IBD were rated as having very good or excellent HRQOL. However, the VEO-IBD group did show significantly lower HRQOL than their healthy peers; the relation between diagnostic status and HRQOL was mediated by gastrointestinal symptoms. The measure utilized in this study was a brief, 7-item measure of HRQOL which may show promise in future research with other early childhood pediatric populations as well.

Methodological Considerations

There are multiple methodological considerations in the study of young children and their families. Chief among these decision points is the issue of assessment. The paper by Lund et al. (2021) demonstrates integration of a mixed method design using a combined performance, self-report, and interview assessment to answer a research question that cannot be answered through a single method. Using a sample of N = 110 4-year-old children and their parents, Lund et al. (2021) describe the role of parent–child reminiscing about past pain experiences on children’s executive functioning. The methods included using performance measures to measure executive functioning and episodic memory, and a structured narrative elicitation task wherein parents were asked to recall a unique autobiographical event involving pain that their child experienced in the past month. The child–parent narrative about the past pain experience was coded for structure and content. Their findings indicate that parents who reminisce using more elaboration and explanation had children who demonstrated greater performance on memory tasks.

Using a secondary data analysis, Hails et al. (2021) also relied on performance-based measures in examining a randomized controlled trial of two interventions, Video Interaction Project and the Family Check Up. The authors aimed to explore the impact of breastfeeding practices and parenting behaviors as relating to rapid weight gain in the first year of life. This sample is unique as it focused on low-income predominantly Black and/or Latinx mother–infant dyads (N = 403) recruited from two sites in urban centers in the northeast. The study authors watched video-taped interactions between the infant–mother in their interventions with the parent, and they coded these interactions for parenting behaviors. Breastfeeding and parental intrusiveness behaviors both related to infant weight trajectory. The authors discuss that well-being and parenting stress relate to breastfeeding and responsive feeding behaviors; however, there are disparities in parenting stress and well-being due to structural disadvantages related to racism and discrimination. Their findings that mothers with higher income-to-needs ratios were more likely to breastfeed infants for longer and engaged in more responsive parenting behaviors contributes to the literature connecting social determinants of health with child health outcomes.

Also employing performance measures, Morgan et al. (2021) explored the impact of superhero media on child risk-taking behaviors. The authors measured the lifetime superhero exposure and preferences of N = 59 5-year-old children. Participants were randomized to watch either a superhero show or age-appropriate comparable show, and then completed three laboratory-based performance tasks to measure risk taking behaviors: a play-based activity, picture sorting task, and vignette. Neither immediate superhero exposure nor lifetime superhero engagement had a strong influence on children’s risk taking. The researchers’ use of a multi-modal method of assessment is novel and informative to the field of methods to quantify young child behavior.

Willard et al. (2021) investigated the social-emotional functioning of 4- to 6-year-old children with brain tumors (N = 23) compared to children with solid tumors (N = 20) using a multimethod design. On average, children were 8 months post-treatment. Children completed the challenging situations task of the NEPSY-II and caregivers completed a number of questionnaires. No significant differences were found between groups on the measures although the pattern of effect sizes was suggestive of increased difficulties in children with brain tumors. This work presents novel information in the post-treatment phase for young children with cancer.

In studies of young children and families, the use of physiological measures can also be a useful assessment strategy. There is increasing recognition of the effects of trauma exposure on chronic conditions and risk behaviors throughout life. Cicilolla et al. (2021) extended this line of work by examining the effects of maternal childhood adversity on risk for perinatal complications and neonatal intensive care unit (NICU) hospitalization. The authors used a prospective longitudinal design to examine the association between adverse childhood events and obstetric complications during pregnancy and childbirth (N = 164). The sample was 41% White, 29% Black, 16% American Indian/Alaska Native, and 12% Hispanic; they used self-report measures, medical chart data, and saliva samples to measure nicotine exposure. They found that mothers with high adverse childhood event scores had higher odds of at least one adverse infant outcome, NICU admission, and maternal perinatal outcome.

Kalkastabakken et al. (2021) explored the contributions of continued follow-up from the NICU by testing the predictive value of a developmental measure on early childhood intellectual functioning. Two hundred nine participants were evaluated two times between ages 1–2 using the Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III), and again evaluated between ages 3–6 using the Wechsler Preschool and Primary Scale of Intelligence Fourth Edition (WPPSI-IV). The Bayley-III at age 1 was a predictor of Bayley-III at age 2, and Bayley-III performances at ages 1 and 2 were moderate predictors of WPPSI-IV performance. Efforts to identify those who were at risk for poorer intellectual performance based on evaluations from ages 1–2 years were not conclusive, solidifying support for continued assessment in children in order to optimize identification of those in need of services.

Harnessing the Power of the Medical System by Using Systems-Level Interventions or Large Scale Designs

In the Honaker et al. (2021) article, the authors aimed to understand the best method for screening for problematic sleep in infants within primary care visits. The screening method used a two-step process of parent and primary care provider endorsement of sleep difficulties for N = 3271 infants (ages 5–19 months), as the latter is typically a critical decision-point about if families receive recommendations and interventions. The sample was diverse with regards to race (50.1% Black), ethnicity (31.7% Hispanic), and economic background (63.3% living in economically distressed communities) and fills an important gap about sociocultural differences in parental perceptions of sleep difficulty for infants. Results demonstrated that there was a lower reported incidence of sleep problems than previously reported in the literature; a finding that could be explained by the diversity of the sample. Conclusions also focus on the need to pay attention to the specific wording used when assessing sleep. The authors present results about the prevalence of sleep difficulties in this diverse sample, and co-endorsement between reporters, which can used by other researchers and healthcare systems to develop the most effective screening strategy based on their own goals.

In another study using a large data set, Allan et al. (2021) examined medical charts of 21,520 preschool children with unintentional injuries to explore the association between attention deficit hyperactivity disorder (ADHD) and injuries. The authors provide detailed injury data on younger children that can inform models of early intervention and prevention efforts. Their findings highlighted the importance of the developmental trajectory, as at age 3, youth with ADHD demonstrated fewer injury visits than those without ADHD, while at age 6 children with ADHD had many more injury visits than those without ADHD.

Novel Applications

There is innovation in adapting and testing evidence-based treatments in pediatric populations for which the interventions were not originally created. Garcia et al. (2021) conducted a nonrandomized open trial of an adaptation of Parent-Child Interaction Therapy with 15 families with children ages 2–5 who had experienced a traumatic brain injury (87% Hispanic). Their findings that the intervention was largely feasible, acceptable, and demonstrated preliminary evidence of efficacy to decrease child externalizing and internalizing behavior problems is promising as a treatment for youth after this common preschool injury, and effects may prevent more significant deteriorations in the future. While this study had a small sample and an open trial design, this a promising new area and the methods used by the authors to adapt the intervention for their population including bilingual service and in-home intervention service delivery, if needed, could be useful for researchers in other fields looking to adapt and implement evidence-based treatments in new populations.

Ramos et al. (2021) harnessed peer mentoring to intervene with parents of young children recently diagnosed with food allergies. This novel pilot study (N = 10 mentees, N = 8 mentors; all mothers) utilized a 6 month intervention period with variable numbers of mentor-mentee interactions across participants. Mentee ratings were supportive of feasibility and acceptability. Preliminary estimates of effectiveness did not reach statistical significance but were in the predicted directions. Although prior to the COVID pandemic, the mentorship was flexible and often delivered remotely via telephone which holds significant promise for flexible, distance delivery in the future.

Morrongiello et al. (2021) used a novel approach to explore means of increasing preschooler’s safety awareness and reducing risky behaviors and ultimately unintentional injuries. The authors developed a storybook for preschoolers about different hazards in their home and the possible injuries that could occur (for the intervention group), and a storybook about nutrition (as the control condition). Fifty-nine children ages 3.5–5.5 years old were randomized, and mothers read the book to their child daily for 4 weeks. Compared to children in the nutrition control group, children in the storybook safety awareness group demonstrated increased safety knowledge, could identify more hazards, and demonstrated fewer risky behaviors. Implementation of developmentally appropriate education without trained facilitators, coverage of a broad range of hazards and injuries, and individualized delivery of the material via parents all demonstrate the novelty and efficacy of storybooks as resources to increase preschoolers’ safety knowledge and decrease risky behaviors.

Diverse Populations

Examining how research findings previously conducted in non-Hispanic White populations may present differently within diverse populations can help to contribute to understanding health disparities. Williamson et al. (2021) conducted a study looking at the interaction of cumulative risks, sleep problems, and child psychological outcomes in preschoolers. Two hundred five parent–child dyads (62.9% Black, 24.4% non-Latinx White, and 4.4% Latinx) completed questionnaires about sleep, family socio-demographics, and child psychosocial and executive functioning. The authors found that pediatric sleep problems were associated with increased child psychosocial problems, which were exacerbated by children’s greater exposure to cumulative risk. In particular, for those children with higher cumulative risk, insomnia symptoms were strongly associated with poor child outcomes. These findings within a diverse sample demonstrate the importance of considering parent and child experience of risk across their lifetime, which may disproportionately affect underserved families and contribute to health disparities affecting child development.

Engel et al. (2021) tested whether maternal stress was associated with child atopy in Black mothers, and whether the construct of maternal warmness served as a protective factor. The study implemented a mixed methods design including parental self-reports, parent–child observations, and physiological sampling of stress. Results demonstrated that for mothers with observed high warmth and responsive parenting, there was less of an association between maternal stress and child atopy. Though their findings did not replicate the relationship between maternal self-reports and inflammatory response on child atopy that was previously found in non-Hispanic White mothers, the data demonstrate the complexity of the relationship between maternal stress and child atopy, and the need to further investigate the impact of unique stressors experienced by Black mothers.

We thank the authors described above as well as the others who submitted their work for consideration of this special issue. We were inspired to see the range of high-quality pediatric research focused on young children from our colleagues. The field of pediatric psychology has grown with regards to insights into young children, though much work remains to be done. Creative research designs can answer important questions, including use of systems-level interventions and data collection, and in diverse populations with respects to ethnicity, socioeconomic status, family structure, and health, cognitive, or developmental status. There is also a role for more focus on the shared and unique mechanisms in behavioral interventions as researchers apply evidence-based programs developed for one population to a new one, or initially designed for older children to the preschool age group. Similarly, the advent of new assessment tools including wearable technologies may also help advance our understanding of the unique experiences of young children and their family members. Longitudinal research that follows the developmental trajectory of young children over time are also needed. There are many opportunities for new and established investigators, and findings of future research with young children will move the field forward with an aim to promote overall health and well-being for children with medical and developmental challenges.

Acknowledgments

The work of Carrie Tully, PhD and Randi Streisand, PhD on this special issue was supported in part by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK102561, PI: R.S.). We appreciate the support of Susan Wood, Editorial Assistant, as well as Hailey Inverso, Research Assistant at Children’s National Hospital.

Conflicts of interest: None declared.

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