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Vulnerability and resilience in the development of children at risk: the role of early mother­child interaction

Manfred Laucht1 Günter Esser2 Martin H. Schmidt3

Recebido: 15/01/2002 Aceito: 15/01/2002

ABSTRACT The developmental outcome of infants born with biological risk (obstetric complications) and psychosocial risk (family disadvantage) was followed up in a prospective longitudinal study from birth into school age. In a sample of 362 children motor, cognitive, and social-emotional development were assessed at the ages of three months, two, four-anda-half, and eight years. In the search for factors that moderate the effects of early risks, the role of early mother-child interaction was examined. Results indicated that the sequelae of early risk factors remained evident up to school age. Biological and psychosocial risk factors had equally adverse effects, but were specific to the functional areas they affected. Outcome of at-risk children displayed a large heterogeneity. The impact of early risks varied as a function of mother-infant interaction quality. Both, maternal and infant interactional behaviour were found to moderate the effects of very low birth weight and of postnatal maternal depression on child outcome at school age. It was hypothesized that the quality of the early relationship may set the stage for the development of vulnerability or resilience. These findings stress the importance of early mother-child interaction in the behavioural adjustment of at-risk children. Keywords: Family adversity; Obstetric complications; Child development; Longitudinal study; Early mother-child interaction. RESUMO Vulnerabilidade e capacidade de recuperação no desenvolvimento da criança de alto risco: o papel das relações mãe­filho em estágios iniciais O desenvolvimento de crianças expostas a fatores de risco biológicos (complicações obstétricas) e psicossociais (ambiente familiar desfavorável) foi acompanhado por meio de estudo prospectivo longitudinal, desde o nascimento até a idade escolar. Em uma amostra de 362 crianças, foram feitas avaliações do desenvolvimento motor, cognitivo e socialemocional nas idades de 3 meses, 2 anos, 4 ½ anos e 8 anos. O relacionamento mãe­filho foi examinado com o intuito de identificar fatores modificadores dos riscos presentes. Nossos resultados sugerem que seqüelas relacionadas a fatores adversos precoces permanecem evidentes até a idade escolar. Tanto fatores psicossociais como biológicos estão associados a conseqüências adversas, mas mostraram-se específicos para os domínios funcionais sobre os quais exercem seus efeitos. A evolução das crianças expostas a esses fatores foi heterogênea, e o impacto dos fatores de risco precoces variou em função da qualidade das interações mãe­filho. O comportamento interativo, tanto da mãe como da criança, foi capaz de atenuar os efeitos do baixo peso ao nascimento e da ocorrência de depressão puerperal materna no desenvolvimento em idade escolar. Considera-se a hipótese de que a qualidade das interações precoces mãe­filho pode tornar a criança vulnerável ou resistente à ação de fatores nocivos ao desenvolvimento, modificando sua capacidade adaptativa. Unitermos: Adversidade familiar; Complicações obstétricas; Desenvolvimento infantil; Estudo longitudinal; Interações mãe­filho.

1 2 3

PhD, Central Institute of Mental Health ­ Mannheim, Germany. PhD, Professor of Clinical Psychology, University of Potsdam ­ Germany. MD, PhD, Professor of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health ­ Mannheim, Germany. Correspondence to: Dr. Manfred Laucht Central Institute of Mental Health, Department of Child and Adolescent Psychiatry and Psychotherapy P.O. Box 122120, 68072 Mannheim, Germany Phone: +49-621-1703-948 Fax: +49-621-23429 E-mail: [email protected]

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

21 Introduction Over the past twenty years a large body of risk research has indicated that a wide range of characteristics of a child and his/her family are associated with increased rates of various mental, behavioural, and emotional disorders. Findings from this burgeoning literature are of special clinical interest, because early intervention has been considered as an optimal strategy to prevent later mental health problems. Identified risk factors include biological and psychological characteristics of the individual such as genetic susceptibility, severe obstetric complications, CNS injury, temperamental characteristics, or specific language impairments (Rutter et al., 1999; Werner & Smith, 1982). The list of environmental factors related to higher levels of child psychopathology encompasses characteristics of the child's family such as parental mental illness, family discord, poverty, or poor parenting (Jenkins & Smith, 1991; Murray & Cooper, 1997; Garmezy, 1988). However, although a host of variables has been nominated as setting children at risk, none have yet been identified that are both highly sensitive and specific for the prediction of later disorders (Pellegrini, 1990). The poor predictive significance of single risk factors is reflected in a consistent finding of risk research which reveals a large heterogeneity of developmental outcomes in groups at risk (Cicchetti & Garmezy, 1993; Garmezy, 1988). Although some children exposed to potent risk factors develop serious disabilities or persistent disorders, others will not have a negative outcome (Werner & Smith, 1982). Since the recognition of this diversity of outcomes investigators have been in search for possible explanations. One attempt to improve prediction has led to a growing interest in the factors that might enhance or reduce vulnerability or even protect individuals at risk from having a negative outcome. Thus, the focus of research has shifted from risk factors to risk and protective mechanisms and the process of "negotiating risk situations" (Rutter, 1990). A crucial concept which emerged in this context is the construct of resilience. It refers to the "process of, capacity for, or outcome of successful adaptation despite threatening circumstances" (Masten et al., 1990). Many factors have been identified that lead to resilience amongst high risk individuals. According to Garmezy (1985) individual resilience could be traced to three sources of competence: (a) dispositional attributes of the child such as positive temperament, sociability, and positive self-esteem; (b) attributes of the family including a supportive relationship, family cohesion, and adequate rule setting; and (c) attributes of the extra-familial social environment such as peer relations, and availability of social support. Concerning early child development, a number of researchers highlight the significance of the early relationship between child and caregiver as an important source of resilience in children (Egeland et al., 1993; Masten et al., 1990). Since the coping abilities of infants seem to be limited, the availability and behaviour of caregivers should play a decisive role with respect to children's adaptation to stressful experiences. This function of the caregiver may be especially important for the infant born with biological or psychosocial risk. Thus, the question arises whether early caregiving may serve a moderating function in the development of infants born with different risks. These issues concerning the differential development of infants at risk were addressed in the present investigation using perinatal complications (biological risk) and family disadvantage (psychosocial risk) as risk factors and the quality of early mother-child interaction as a possible moderator of risk effects. The specific aims of this investigation are to determine the influence of early biological and psychosocial risk factors on the developmental outcome during childhood and to explore the role of early caregiving in predicting differential developmental courses. Method

Subjects Subjects for this investigation are participants in the Mannheim Study of Risk Children, an ongoing longitudinal study of infants at risk for later psychopathology currently being conducted in Mannheim (Germany). To be included in the study, parents and infants had to meet criteria intended to enrich and to control the risk status of the sample. Depending on pregnancy and birth history and on family background infants were assigned to one of nine groups resulting from a two-factorial (3x3) design with factor I representing the degree of biological risk (pre- and perinatal complications) and factor II the degree of psychosocial risk (family adversity). Each factor was scaled as no risk, moderate or high risk. All groups had about equal size with a slight oversampling in the high risk combinations and with sex evenly distributed in all subgroups. A total of 362 infants born between February 1986 and February 1988 were recruited from two obstetric and six children's hospitals of the Rhine-Neckar-Region of Germany. Developmental assessments were conducted at the ages of three months, two, four-and-a-half, and eight years. At school age a total of 348 children of the original sample were followed up (i.e. retention rate = 96.1). Further details on sampling and sample characteristics are given in Laucht et al. (1997). Biological risk was defined by the degree of preand perinatal complications. 118 infants who were born

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

22 full-term, had normal birth weights, and no medical complications were assigned to the nonrisk group. The moderate risk group of 119 infants had preterm births (gestational age < 37 weeks) or preterm labours (tocolytic treatment or cerclage) or EPH-gestosis of the mother but no severe complications. The 125 infants of the high risk group met one of three criteria: a) very low birth weight (< 1500 g), b) clear case of asphyxia with special care treatment, c) neonatal complications such as seizures, respiratory distress syndrome or sepsis. An obstetric adversity score was obtained by counting the presence of 9 adverse conditions during pregnancy, delivery, and postnatal period (for more details see Laucht et al., 1997). Psychosocial risk was derived from a family risk index measuring the presence of 11 adverse family factors. The items of this index, which is an "enriched" family adversity index as proposed by Rutter and Quinton (1977), cover developmentally unfavourable characteristics of the parents (e.g. mental disorder), the partnership (e.g. marital discord), and the family environment (e.g. chronic difficulties) (for more details see Laucht et al., 1997). Families with a score of 0 on the index formed the nonrisk group (n=120), with a score of 1 or 2 the moderate risk group (n=111), and with a score of 3 or more the high risk group (n=131). Scale, Burgemeister et al., 1972; 8 years: Culture Fair Test CFT 1, Weiss & Osterland, 1977). To assess behaviour problems the Mannheim Parent Interview (MEI) (Esser et al., 1989a) was conducted. The MEI is a standardised structured interview which is administered by trained interviewers. Parental reports about their children are rated on 3-point scales according to severity for a number of symptoms. Between toddlerhood and school age and the behavioral ratings of trained raters in four standardized settings in both familiar (home) and unfamiliar (laboratory) surroundings. At the age of three months behavioral problems included feeding, sleeping and digestive disorders as well as 13 adverse temperamental characteristics such as irritability, distractability or dysphoric mood which were derived from the nine temperament scales of Thomas, Chess and Birch (1968). a broad range of symptoms (23 at 2 years, 29 at 4 ½ years and 40 at 8 years) was evaluated comprising among others temper tantrums, hyperactivity, attention problems, oppositional behaviour, aggressive behaviour, separation anxiety, social inhibition, dysphoric mood, sleeping problems, tics, and stereotypies. At all assessments the number of problem behaviours was summed up leading to a total problem score, a score of internalizing problems (such as separation anxiety, dysphoric mood, and social inhibition)2 and4 ½ years); and a (3)score of externalizing behavioral problems (such as hyperactivity, aggressive and oppositional behaviour)2 and 4 ½ years). Mother-child interaction measures. An observational procedure was used to assess the quality of mother-infant interaction. Mother-infant dyads were observed and videotaped during a 10-min semistructured diaper and play session at 3 months of age. The videotaped interactions were rated with the Mannheim-Rating-System for Mother-Infant Interaction MRS-MII (Esser et al., 1989b). The rating system included eight 5-point scales for maternal behaviour (emotion, physical affect, vocalisation, lack of verbal restrictions, congruency, variability of behaviour, reactivity and stimulation). Ratings on each scale were made every minute resulting in a total of 130 ratings per dyad. Raters were blind as to parental and child risk status. Mean interrater reliability for two trained raters and 32 dyads was rs = 0.83. Results

Assessments Assessments conducted at each wave covered three domains: 1) child developmental outcome comprising different areas of functioning from neurophysiological up to social-emotional development, 2) family stress and resource factors including characteristics of the parents (e.g. mental health), their partnership (e.g. marital conflict), and the family environment (e.g. chronic difficulties), and 3) parentchild relationship including parenting characteristics (child rearing behaviour and attitudes) and patterns of interaction assessed by microanalysis of behaviour observations. Child measures. Assessments of fine and gross motor skills were obtained using the Psychomotor Developmental Index (PDI) of the Bayley Scales of Infant Development (Bayley, 1969) at 3 and 24 months and the Motor Quotient (MQ) of the Test of Motor Abilities MOT 4-6 (Zimmer & Volkamer, 1984) at 4 1/ 2 years and of the Body Coordination Test KTK (Kiphardt & Schilling, 1974) at 8 years of age. Cognitive development was measured by the Mental Developmental Index (MDI) of the Bayley Scales at 3 and 24 months. At 4 1/2 and 8 years a composite score was formed providing a measure of verbal reasoning (Sentence Completion of the Illinois Test of Psycholinguistic Abilities, Kirk et al., 1968) and of nonverbal reasoning (4 ½ years: Columbia Mental Maturity

The long-term outcome of children at risk The sequelae of early risk factors remained evident up to school age. Organic and psychosocial risk factors exhibited equally negative effects, but were specific as to the areas they affected. Psychosocial risks primarily influenced cognitive and social-emotional functioning

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

23 at age 8. As can be seen from figure 1, in these areas the highest increase of disordered children was found between nonrisk and high psychosocial risk groups indicating that the rate of children with social-emotional, i.e. behavioural, problems rose from 15.4% in the nonrisk group up to 41.5% in the high risk group which is corresponding to an almost threefold risk. A similar increase was found in cognitive functioning with rates of 9.4% impaired among nonrisk children and 27.7% among high-risk children. However, no significant differences were obtained when comparing motor outcome of the at risk groups. In contrast, the impact of early organic risks concentrated on motor and cognitive functioning. As shown in figure 2, the rate of cognitively impaired children amounted to 30.5% in the high risk group as compared to 10.4% in the nonrisk group which was an increase of almost factor 3. Slightly lower in this group was the relative risk of a motor disorder and not significant the risk of a disorder of social-emotional functioning. A number of single risk factors were associated with particularly poor outcomes. Among psychosocial risks the best predictors of cognitive and socialemotional impairment at school age were teenage parenting, parental mental illness, low parental educational level, and single-parent family (showing relative risks between three and four). Among organic risks seizures and very low birth weight were most closely related to disorders of cognitive and motor functioning (with relative risks of up to 5). In general, the negative effects of organic and psychosocial risks were found to be additively related which meant that the cumulative effect of both risks corresponded to the sum of the single risk effects. This is best demonstrated when looking at cognitive outcome with 8 years (Figure 3). In all psychosocial risk groups the rate of disordered children increased similarly with growing organic risk. The small deviation in the low risk group was not significant. However, in some cases also an interactive relationship between organic and psychosocial risks was obtained indicating that child outcome may be particularly poor under multiple risk conditions. From figure 4 presenting the rates of severe developmental disorders in the nine risk groups of the study design it is evident that severe disorders culminated

Figure 1 Sequelae of early organic risks at school age Note: RR = relative risk, significant differences between high and nonrisk groups: *p < .05, **p < .01, ***p < .001

Figure 3 Cognitive outcome at school age: interplay between organic and psychosocial risks

Figure 2 Sequelae of early psychosocial risks at school age Note: RR = relative risk, significant differences between high and nonrisk groups: *p < .05, **p < .01, ***p < .001

Figure 4 Severe developmental disorders in 8-year-old with different organic and psychosocial risks

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

24 in one multiple risk group consisting of those children with the highest risk load (i.e. with both high organic and high psychosocial risk). Almost every third of the children in this group was severely impaired at age 8 which clearly exceeded the rate that could be expected when assuming an additive relationship between risks. of motor and cognitive functioning and to exhibit more behavioural and learning problems (Breslau, 1995). In accordance with the literature, our results indicated that the 40 VLBW children of this study were behind on cognitive measures at all ages. In early childhood their delay reached about 10 IQ points increasing up to 20 at school age (Figure 6). Similar deficits were found in motor functioning and in social-emotional development with VLBW displaying more emotional problems such as social anxiety and depressive mood from the age of two years on. However, as with other children at risk, the development of VLBW was in no sense unitary, but revealed a large heterogeneity. According to our results, the quality of early interaction became especially salient in this realm. Both maternal and child interactional behaviour during infancy appeared to modify the adverse impact of VLBW on later development. Among maternal behaviour, a high variability of interaction with the infant seemed to be especially important for the cognitive development (i.e. verbal intelligence) in VLBW children: at 8 years these children profited from a variable maternal stimulation, while they suffered if maternal stimulation was poor. In contrast, in NBW children maternal variability showed no comparable effect (which was reflected in a significant statistical interaction) (Figure 7). A similar relation emerged between maternal reactivity during interaction with the infant and the number of internalizing symptoms of preterm children at eight years: VLBW children developed especially well (i.e. had fewer problems) if their mothers had shown more sensitivity and responsivity, while they exhibited higher problem scores if maternal reactivity had been low. However, not only maternal interactional behaviour appeared to be predictive of child development at school age, the same held for infant interactional behaviour (Figure 8). VLBW infants who often had been looking and smiling at their mothers had a more favourable developmental outcome (i.e. yielded higher non verbal

Differential development of children at risk The results presented up to now revealed only one aspect of the long-term outcome of at-risk children. A consistent finding of risk research, however, has been the large heterogeneity of developmental outcomes in groups at risk. Although some children exposed to potent risk factors developed serious disabilities or persistent disorders, others would not have a negative outcome or even developed especially favourably. The diversity of outcomes in children at risk is demonstrated in figure 5 showing the distribution of IQ scores (nonverbal intelligence assessed at 8 years) in a group with severe obstetric complications as compared to a normal group. As can be seen, even in this high risk group the IQ scores varied across the whole range of the IQ scale. As expected, higher rates of children with low IQs were obtained, however, the majority of these children had an IQ in the normal range, and there also was a small group with an IQ above average. The moderating role of early mother-child interaction To demonstrate the significance of early motherchild interaction in the development of at risk children, two risk groups were selected as examples: 1) very low birth weight infants (VLBW), and 2) children of postnatally depressed mothers. VLBW children. Children with a birth weight below 1500 g make up about 1% of all births in western countries. Numerous studies have highlighted the psychiatric sequelae of these children. VLBW children have been shown to perform more poorly on measures

Figure 5 Cognitive outcome of the high organic risk group: nonverbal intelligence at 8 years

Figure 6 Cognitive development of VLBW children from infancy into school age

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

25 intelligence and had fewer behaviour problems) than preterm children who had been less competent during interaction with their mothers. Again, for NBW infants these behaviours seemed to have no comparable predictive value. This finding may be interpreted as evidence for a transactional effect indicating that infant behaviour was of particular importance in the interaction with VLBW children. Thus, competent behaviour of preterm children might be especially rewarding for their mothers and might encourage them to engage more intensely with their infants thereby promoting their children's later development. Children of mothers with a postpartum depression. Children of postnatally depressed mothers form another risk group which has attracted current research (Murray & Cooper, 1997). Recent epidemiological studies have reported rates of 10 to 15% of mothers showing signs of a clinical depression after child birth. In agreement with the literature, our results demonstrated that maternal depressive mood during early infancy was associated with severe negative consequences for child development. The 22 children of postnatally depressed mothers in our study yielded mean IQ scores that lay 10 points below the level of a control group of children with healthy mothers. This held from two years on and pertained to verbal intelligence, in particular. The adverse sequelae of maternal depression were especially salient for the social-emotional development of these children (Figure 9). At all ages (from early infancy up to school age), they displayed higher rates of behaviour disorders. At age 8 the relative risk rose to more than threefold in comparison to the controls. In particular, the numbers of externalizing (i.e. hyperactive, oppositional and conduct) problems were increased. As for preterm children, the quality of early motherchild interaction became especially salient for later development of children with a depressed mother. Depending upon the relationship between mother and infant different developmental pathways emerged. Thus, children of mothers with a postpartum depression were developing more favourably if their mothers were able to behave "non depressively" when interacting with their infants. On the other hand, unresponsive maternal interactional behaviour was associated with more adverse consequences if shown by a depressed mother. Figure 10 demonstrates that 8-

Figure 7 Maternal interactional behaviour as a moderator of developmental outcome of VLBW children at 8 years

Figure 9 Behaviour problems in children of postnatally depressed mothers from infancy into school age

Figure 8 Infant's interactional behaviour as a moderator of developmental outcome of VLBW children at 8 years

Figure 10 Maternal interactional behaviour as a moderator of developmental outcome of children of postnatally depressed mothers at 8 years

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

26 year-old children of depressed mothers developed especially favourable (and did not differ from the control group in the number of externalizing problems), if their mothers had displayed more reactivity and used more babytalk during interaction with their infants. However, higher numbers of externalizing problems were presented by children whose depressed mothers had been less reactive and produced less sensitive vocalisations during infancy. In addition, infant behaviour during interaction with their depressed mothers was related to later development (Figure 11) indicating that the negative consequences of maternal depression on verbal intelligence during school age were only present in those infants who had been less visually active in interaction with their mothers. Infants, however, who had been more attentive to their mothers developed more favourably and did not differ from the control group (which was reflected in a significant interaction). This result may again be interpreted as indicating a transactional effect: infants looking at their mother might stimulate and encourage her to interact more responsively with them which then might promote child outcome. A second result which, at first glance, appeared to point towards the opposite direction was especially revealing: a seemingly unfavourable outcome of socialemotional functioning (i.e. a higher number of externalizing symptoms) emerged for infants who had been smiling longer at their depressed mothers. The explanation here lies in a specific interactional pattern prevalent in dyads with a depressed mother. Increased smiling of the infant may be interpreted as a compensatory reaction towards the passive and less responsive behaviour of a depressed mother ­ as an attempt to attract mothers attention. Externalizing behaviour of the 8-year-olds may serve a similar purpose. Thus, the infant and the 8-year-old child appeared to use the same active coping strategy in dealing with a depressed and unresponsive mother. Discussion The present investigation supports the view that infants born with obstetric complications or born into disadvantaged family environments are at risk for later developmental disorder. In a prospective study the adverse impact of early risk factors on child adjustment remained evident up to school age. This finding is well in line with a host of previous research that has documented the developmental sequelae of early risk factors. According to our results, early organic and psychosocial risks were equally unfavourable for child development, but had differential effects on outcome. While family risk factors primarily affected cognitive and social-emotional functioning, the impact of perinatal complications concerned on motor and cognitive outcome. The present findings further indicated that biological and psychosocial risks contributed mainly additively to child adjustment up to school age. In our study only scarce empirical evidence was found for an interactive relationship between family factors and obstetric complications which would be necessary to assume that the effect of one risk factor was modified by the presence of the other. Thus, both risks have to be considered as having independent adverse effects on child development. A consistent finding of risk research has been the large heterogeneity of developmental outcomes in groups at risk. Although some children exposed to potent risk factors develop serious disabilities or persistent disorders, others will not have a negative outcome or even develop especially favourably. The finding that overcoming adversity is not uncommon has led to a growing interest in the processes and mechanisms that might enhance or reduce the adverse effect of risk factors or even protect individuals at risk from having a negative outcome. A crucial concept which emerged in this context is the construct of resilience. One attempt to trace the role of resilience in child development is to study the significance of early mother-child relationship in moderating the effects of high risk conditions. Consistent with current evidence the results presented here underline the importance of a harmonious early mother-child interaction for the developmental outcome of at-risk children (Egeland et al., 1993) indicating that the quality of the early interaction modified the adverse impact of early risk factors. Responsive interactional behaviours of mother and infant were found to be of far greater importance in at-risk than in nonrisk groups. Thus, the quality of the early interaction may set the stage for an either favourable or unfavourable development. The particular importance of the early relationship for the development of at-risk children derives from its developmental function: the emotional security

Figure 11 Infant's interactional behaviour as a moderator of developmental outcome of children of postnatally depressed mothers at 8 years

Laucht, M.; Esser, G.; Schmidt, M.H.

Rev. Psiq. Clín. 29 (1):20-27, 2002

27 experienced in the interaction with the first caregiver forms the basis for the development of the child's selfconfidence and self-efficacy which are important components of the child's ability to cope with stress and adverse life events (Ainsworth et al., 1978). Therefore a successful mother-child interaction may be at the beginning of a development where resilience emerges. On the other hand, an early mother-child interaction which is determined by disturbances and misunderstandings may increase the vulnerability of atrisk children. Thus, empirical evidence is provided for early mother-child interaction as a possible source of differential development in children at risk. Understanding the causes of differential child development is crucial to the development of effective prevention and intervention programs for socially disadvantaged and biologically vulnerable children (Spiker et al., 1993). The present findings underscore the role of promoting early interaction as an effective strategy of early intervention in infants at risk. Acknowledgements The Mannheim Study of Risk Children is an ongoing study conducted at the Central Institute of Mental Health, Mannheim, Germany. The study is supported by grants from the German Society for the Advancement of Scientific Research DFG as part of the Special Research Program SFB 258 "Indicators and Risk Models of the Genesis and Course of Mental Disorders" at the University of Heidelberg, Germany. References

AINSWORTH, M.D.; BLEHAR, M.C.; WATERS, E.; WALL, S. ­ Patterns of Attachment: a Psychological Study of the Strange Situation. Erlbaum, Hillsdale, NJ, 1978. B AYLEY , N. ­ Bayley Scales of Infant Development. Psychological Corporation, New York, 1969. BRESLAU, N. ­ Psychiatric Sequelae of Low Birth Weight. Epidemiol Rev 17: 96-106, 1995. BURGEMEISTER, B.; BLUM, L.; LORGE, J. ­ Columbia Mental Maturity Scale. Harcourt Brace Jovanovich, New York, 1972. CICCHETTI, D. & GARMEZY, N. ­ Prospects and Promises in the Study of Resilience. Dev Psychopathol 5: 497-502, 1993. EGELAND, B.; CARLSON, E.; SROUFE, L.A. ­ Resilience as Process. Dev Psychopathol 5: 517-28, 1993. E SSER , G.; B LANZ , B.; G EISEL , B.; L AUCHT , M. ­ Mannheimer Elterninterview. Beltz, Weinheim, 1989a. ESSER , G.; SCHEVEN , A.; PETROVA, A.; LAUCHT, M.; SCHMIDT, M.H. ­ Mannheimer Beurteilungsskalen zur Erfassung der MutterKind-Interaktion im Säuglingsalter (MBS-MKI-S). Z Kinder Jugendpsychiatr 17: 185-93, 1989b. GARMEZY, N. ­ Stress Resistent Children: the Search for Protective Factors. In: S T E V E N S O N , J.E. (ed.): Recent Research in Developmental Psychopathology. Journal of Child Psychology and Psychiatry, Book Supplement No. 4. Pergamon Press, Oxford, pp. 213-3, 1985. GARMEZY , N. ­ Longitudinal Strategies, Causal Reasoning and Risk Research: a Commentary. In: R UTTER , M. (ed.): Studies of Psychosocial Risk. Cambridge University Press, New York, pp. 29-44, 1988. JENKINS, J.M. & SMITH, M.A. ­ Marital Disharmony and Children's Behaviour Problems: Aspects of Poor Marriage that Affect Children Adversely. J Child Psychol Psychiatry 32: 793-802, 1991. KIPHARDT, E.J. & SCHILLING, F. ­ Körperkoordinationstest für Kinder (KTK). Beltz, Weinheim, 1974. KIRK, S.A.; MCCARTHY, J.; KIRK, W.D. ­ Illinois Test of Psycholinguistic Abilities. University of Illinois Press, Urbana, 1968. LAUCHT, M.; ESSER, G.; SCHMIDT, M.H. ­ Developmental Outcome of Infants Born with Biological and Psychosocial Risks. J Child Psychol Psychiatry 38: 843-54, 1997. MASTEN, A.S.; BEST, K.M.; GARMEZY, N. ­ Resilience and Development: Contributions from the Study of Children who Overcome Adversity. Dev Psychopathol 2: 425-44, 1990. MURRAY, L. & COOPER, P.J. (eds) ­ Postpartum Depression and Child Development. Guilford Press, New York, 1997. P ELLEGRINI , D.S. ­ Psychosocial Risk and Protective Factors in Childhood. J Dev Behav Pediatr 11: 201-9, 1990. RUTTER, M. & QUINTON, D. ­ Psychiatric Disorder ­ Ecological Factors and Concepts of Causation. In: MCGURK, M. (ed.): Ecological Factors in Human Development, North Holland, Amsterdam, pp. 173-87, 1977. RUTTER, M. ­ Psychosocial Resilience and Protective Mechanisms. In: ROLF. J.; MASTEN. A.S.; CICCHETTI, D.; N UECHTERLEIN, K.H.; W EINTRAUB , S. (eds.): Risk and Protective Factors in the Development of Psychopathology. Cambridge University Press, New York, pp. 181-214, 1990. RUTTER, M.; SILBERG, J.; O'CONNOR, T.; SIMONOFF, E. ­ Genetics and Child Psychiatry: II Empirical Research Findings. J Child Psychol Psychiatry 40: 19-55, 1999. SPIKER , D.; F ERGUSON , J.; BROOKS -G UNN , J. ­ Enhancing Maternal Interactive Behavior and Child Social Competence in Low Birth Weight, Premature Infants. Child Dev 64: 754-68, 1993. W E I S S , R.H. & O S T E R L A N D , J. ­ Grundintelligenztest CFT 1. Westermann, Braunschweig, 1977. WERNER, E.E. & SMITH, R.S. ­ Vulnerable but Invincible: a Study of Resilient Children. McGraw Hill, New York, 1982. Z IMMER , R. & VOLKAMER , M. ­ Motoriktest für 4-6jährige Kinder (MOT 4-6). Beltz, Weinheim, 1984.

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