Exploring an integrative model of infant behavior: What is the relationship among temperament, sensory processing, and neurobehavioral measures?

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Abstract

Traditionally, developmental psychology, occupational/physical therapy, and behavioral pediatrics view similar infant behaviors from temperament, sensory processing, or neurobehavioral theoretical perspectives. This study examined the relations between similar and unique summary scores of three infant assessments (Early Infancy Temperament Questionnaire – EITQ, the Infant Sensory Profile – ISP, and the NICU Network Neurobehavioral Scale – NNNS) in a healthy sample of 100, one-month-old infants. A Principal Components Analysis of selected subscale scores derived from the three assessments suggested a three-factor model. Temperament and sensory summary scores had the strongest relations on two factors: Sensory-Affective Reactivity and Engagement. A third factor had strong relations between state regulation and motor competence. This new integrative model also validates an existing model and expands explanation of infant behavior across disciplines and methods which have significant implications for assessment, intervention, and management practices.

Research highlights

► Examined overlap among subscales of infant measures from three disciplines: EITQ, ISP, and NNNS. ► PCA of selected subscale scores derived from the three assessments revealed a three-factor model. ► Temperament and sensory subscales showed strongest relations on two factors: Sensory-Affective Reactivity and Engagement. ► A third factor had strong relations between state regulation and motor competence. ► New integrative model offers an expanded cross-discipline interpretation of infant behavior. ► Model supports use of specifically tailored interventions to support infant development and attachment.

Introduction

Clinicians and researchers from different disciplines must deal with the challenge of conducting rapid and discriminative infant assessments for clinical diagnoses or research purposes, yet no unified, integrated measurement system exists for evaluating infant behavior. The purpose of infant assessment is to identify at-risk infants and provide evidence-based early intervention services that promote positive infant development and healthy parent–infant relationships (Lipkin et al., 2008, Love et al., 2002, Stern, 2006). There are multiple extant measures of infant behavior used in different disciplines, which serve apparently different purposes. Yet the items included in these instruments appear to have a significant degree of empirical and conceptual overlap, both within and across measures. For instance, in the disciplines of developmental psychology, occupational/physical therapy, and behavioral pediatrics, researchers and clinicians have attempted to identify “types” of infants from different frames of reference, including, temperament, sensory processing, or neurobehavior perspectives. These discipline-specific assessments identify different foundations for describing the same infant behaviors, i.e., temperament, sensory processing, or neurobehavior. However, the conceptual separation of these constructs remains unclear and may yield a different interpretation of the same behaviors. Further confounds stem from whether the assessment reflects an objective examination or parental report.

The primary goal of this study, was to examine the extent to which three widely used, state-of-the-art infant assessments, from these three disciplines, assess similar versus unique features of infant behavior: The three assessments include: The Early Infancy Temperament Questionnaire (EITQ), the Infant Sensory Profile (ISP), and the NICU Network Neurobehavioral Scale (NNNS). We expect to find substantial similarity among these measures, which may challenge the current use of multiple concepts of infant behavior and may contribute to a new integrative model of identifying conceptual “types” of infants. In turn, the development of a more integrated behavioral assessment approach for infants could potentially give clinicians and researchers in these disciplines a better understanding of infant behavior and help identify possible problems and pathologies more effectively.

Although the disciplines of psychology, occupational/physical therapy, and developmental pediatrics view infant behaviors differently, the theoretical concepts used in each of these disciplines may be linked. For instance, developmental psychologists often present theories that focus on the psychobiological underpinnings of temperament, with the most prominent emphasis highlighting the association between sensory reactivity of the nervous system and infants’ subsequent capacity for self-regulation (Rothbart, Ahadi, & Hershey, 1994). These neural-based foundations (i.e., reactivity and regulation) have more recently been associated with the later emergence of effortful control and executive attention processes (Rueda & Rothbart, 2009). Temperament theorists also argue that innate characteristics of the newborn (e.g., sensory response thresholds, soothability, and frequency/duration of a response), may lead to variations in regulation of attention, emotions, and motor reactivity (Lewis, Worobey, & Thomas, 1989). Psychologists have long incorporated sensory reactivity and self-regulation into their constructs of temperament such as the “difficult child” (Bates, 1980, Bates et al., 1979, Thomas et al., 1961) or “inhibited child” (Kagan, Reznick, & Snidman, 1984). Both difficult temperament and behavioral inhibition are linked to an increased risk for later behavioral and emotional problems (Kagan & Snidman, 1999).

In the field of occupational therapy, clinicians and researchers have focused primarily on sensory processing theory, which also emphasizes the neural foundations of behavior. Specifically, this perspective proposes that the ability to take in, sort, and discriminate sensory information is an integral skill needed to support regulation, attention/interaction, and adaptive functioning. During assessment, occupational therapists examine specific sensory systems in order to understand how different sensory stimuli (i.e., tactile, visual, auditory, or vestibular) contribute to behavior. In turn, clinicians and researchers in the field of developmental and behavioral pediatrics focus primarily on regulation theories including polyvagal (Porges, 1992) and synactive theories of development (Als, 1982). These approaches reflect the interrelated nature of central nervous system functions with respect to arousal state, alertness/interactive capacity, and motor systems. Collectively, the perspective espoused in each of these disciplines share a similar tenet, namely the importance of understanding the underlying neural processes that govern infant behavior and development. For instance, characteristics of “sensory reactive infants” and “behaviorally inhibited toddlers” coined from the psychology discipline (Kagan, 1994), show striking similarities to children labeled by occupational therapists as having a Regulatory Disorder (DeGangi & Breinbauer, 1997) or Sensory Modulation Disorder (McIntosh, Miller, Shyu, & Hagerman, 1999). In each perspective, identification of disorders is based on sensory processing and regulation theories (Als, 1982, Ayres, 1979, Porges and Greenspan, 1991). Such theories propose that the sensory-reactive infant's nervous system is inefficient in coordinating internal and external sensations which can result in greater than typical irritability and jeopardize parent–infant interactions (DeSantis, Coster, Bigsby, & Lester, 2004). Moreover, sensory and regulatory disorders may reflect variations in specific sensory thresholds and habituation responses which have been linked to a highly sensitive characteristic (Dunn and Brown, 1997, McIntosh et al., 1999), emotional/behavioral regulation difficulties (Kagan et al., 1999), and/or motor difficulties across the lifespan (DeGangi, Breinbauer, Doussard-Roosevelt, Porges, & Greenspan, 2000). The associations among sensory and temperament processes revealed in this body of research (Blum et al., 2002, Canivet et al., 2000, DeSantis et al., 2004) further underscore the confusion and potential for shared underlying constructs in these fields. The sensory mechanisms (e.g., sensory thresholds) that underlie these behaviors are often subsumed within the construct of temperament in developmental psychology or pediatrics (Blum et al., 2002, Rothbart, 1989, Thomas and Chess, 1977), but may need a greater representation on measurement tools from other disciplines to characterize the full range of infant behavior regulation.

Conversely, sensory processing is a neglected area of infant assessment in developmental psychology or pediatrics, and behaviors associated with sensory processing in these disciplines are often interpreted as temperament. For example, assessment of vestibular processing which governs processes such as position in space, head orientation, muscle tone, and emotional security with gravity, is often neglected/misunderstood when observed through the lens of developmental psychology or pediatrics. Repeated movement of an infant with a hypersensitive vestibular system (e.g., tipping the baby back during caregiving activities, or as part of the newborn neurobehavioral assessment) may result in the production of infant behaviors that are interpreted as irritability and intensity on temperament instruments, rather than as indicative of vestibular processing difficulties. For example, a temperament instrument's item “Fusses when placed on back to change diaper” may be similar to a vestibular item on a sensory measure “My child fusses whenever I try to move him/her” or a tactile item “My child fusses during diaper change.” Recognition of the behavioral expressions of vestibular or tactile processing difficulties assessed in these items may offer a clearer understanding of individual infant's behavioral differences and subsequent intervention strategies.

Another area of similarity among infant measures not explicitly examined is the impact of motor competence/muscle tone on regulatory and temperamental qualities. The diagnostic category “Regulatory Disorders” refers to infants that demonstrate difficulty in both sensory and motor systems (Zero to Three, 2005). Others have identified motor competence as a mediator of infant state and emotional regulation (Als, 1982, McIntosh et al., 1999). While empirical evidence for these models is limited, there is some support for relations among motor competence and self-regulatory behavior (Barton & Robins, 2000). Variations in muscle tone and movement quality, as examined on the NICU Network Neurobehavioral Scale (NNNS), have been associated with infant vestibular and tactile processing (Als, 1982, DeGangi and Breinbauer, 1997, McIntosh et al., 1999), but have not been documented with infant sensory measures such as the Infant Sensory Profile, ISP (Dunn, 2002a). Neonatal neurobehavioral examinations further demonstrate shared theoretical elements in that they typically include assessments of motor integrity, muscle tone, and reflexes as well as typical “temperament” dimensions such as sensory reactivity, irritability/mood, and activity level/arousal. Measures of alertness/orientation, motor integrity, and state regulation from the Neonatal Behavioral Assessment Scale (NBAS) are associated with comparable measures from the Early Infant Temperament Questionnaire, EITQ (Peters-Martin & Wachs, 1984). In the Peters-Martin and Wachs study, infants rated as behaviorally organized (i.e., exhibiting more interactive behavior, motor maturity, and state control) on the NBAS at one month of age, were more likely to be categorized as being temperamentally “easy” at 6 months. Similarly, Tirosh et al. (1992) reported that 4-month-old infants with increased competence of the motor system were more skilled at minimizing overstimulation in comparison to those who were less motorically mature.

A growing number of researchers investigating infant temperament, sensory processing, and/or neurobehavior have independently pursued the most parsimonious constructs to represent individual differences in these domains. The initial nine-dimension temperament model developed by Thomas, Chess and colleagues’ New York Longitudinal Study – NYLS (Thomas et al., 1961), later assessed by the EITQ (Medoff-Cooper, Carey, & McDevitt, 1993), has more recently been substantially revised into a refined three-dimensional model of temperament with the Infant Behavior Questionnaire-Revised (IBQ-R) (Gartstein & Rothbart, 2003). These three dimensions (Orienting/Alerting, Negative Emotionality, and Surgency/Extraversion) have been consistently confirmed in a variety of samples varying in race/ethnicity and age from 6 months to adults (Posner and Rothbart, 2007, Rothbart and Ahadi, 1994). In addition, sensory-based behavioral constructs developed by occupational therapists and psychologists are increasingly incorporated in the assessment of regulatory-disordered infants. Such constructs include, Low Threshold, Low Registration and Sensation Seeking (Dunn & Westman, 1997) and Hypersensitive (sensory reactive), Hyposensitive/Under-responsive, and Sensation Seeking/Motorically Impulsive (Zero to Three, 2005). However, these sensory-based constructs have not been cross-validated with temperament or neurobehavioral models. Finally, researchers in developmental and behavioral pediatrics propose that infant behavior may be represented by two to thirteen constructs on measures such as the NBAS or the NNNS (Azuma et al., 1991, Brazelton, 1973, Lester and Tronick, 2005), with Orientation/Attention and arousal/irritability being the most prevalent.

Another element of confusion in the field of infant assessment is the reported variability in correspondence between mothers and other observers of infant behavior and temperament. Some studies show minimal correlations between different types of raters and suggest that maternal ratings reflect the mother's subjective perceptions of the child which may be influenced by variations in personality, mental health, or cultural beliefs and values, more strongly than the child's constitutional make up or behavioral characteristics (Kagan, 1994, Seifer, 2000, Vaughn et al., 1981). However, other researchers have demonstrated moderate correlations between parental and observer ratings (Bates et al., 1994, Matheny et al., 1987, Rothbart et al., 2001a). Some have argued that parent report may reflect a combination of an objective component representing the child's true behavior, as well as a subjective component which projects parental perceptions of the child (Bates & Bayles, 1984). More recently, Stifter, Willoughby, and Towe-Goodman (2008) reported a moderate level of parent–observer correlation for infants’ positive emotionality but not for negative reactivity.

Variability in parent–observer correspondence might also reflect a lack of consensus in accurate classification of infant temperament. While early researchers viewed temperament as a continuous construct along an easy–difficult continuum (Thomas, Chess, Birch, Hertzig, & Korn, 1963), others have utilized a categorical conceptualization (Kagan, Snidman, Arcus, Rubin, & Asendorpf, 1993). During the past decade, a broader scope of temperament conceptualization has emerged (i.e., Orienting/Alertness, Negative Emotionality, and Surgency–Extraversion). These temperament dimensions are part of a hierarchical structure that subsumes aspects of neuroscience, adaptation, and constitutional aspects of infant behavior (Rothbart, Chew, & Gartstein, 2001). More recent interpretations have focused on the psychobiological components of infant behavior within the infant–caregiver system as essential in understanding infant behavior which includes parent, observer, and physiological measures (Hofer, 1994, Lyons-Ruth et al., 2003, Stifter et al., 2008). Given the controversy regarding both the classification of temperament and issues surrounding inconsistencies in parent and observer reports, researchers now endorse the use of multiple, repeated measures by mixed raters in varying environments, and at different time points, which are likely to make important contributions to our understanding of the complexity of infant behavior and temperament as part of the parent–infant system (Hane et al., 2006, Rothbart and Hwang, 2002, Rueda et al., 2005).

In the present study, we sought to shed further light on these issues by examining the associations among two parent-reported measures (one assessing infant temperament and the other sensory processing) and an examiner-administered infant neurobehavior assessment. Our aim was to evaluate whether it is feasible to propose a new integrated model of infant behavior in the first month of life that could incorporate these seemingly distinct, but related perspectives. Although we expected to find some variability between parent and observer raters, we also anticipated significant associations among the measures, especially in the areas of sensory processing and temperament. Moreover, given that the majority of parent–observer correspondence studies reported on infants starting at the 3-month age level, the current study of 1-month-old infants offers the possibility of providing new information on parent–observer rating correspondence at an earlier age which can extend and elaborate our understanding of infant measurement and behavior. The findings from this study may also help to clarify the associations among current theoretical and measurement constructs during early infancy, which would help clinical and research professionals in diverse disciplines: (a) articulate common domains of functioning; (b) discern typical versus atypical behaviors; and (c) coordinate clinical management.

Specifically, the current study sought to evaluate the associations among subscale scores of three widely used infant assessments (the Early Infant Temperament Questionnaire – EITQ, the Infant Sensory Profile – ISP, and the NICU Network Neurobehavioral Scale – NNNS) in a sample of term, healthy one-month-old infants. The following hypotheses were generated from research studies cited previously as well as examination of similarities among subscales and items across measures (refer to Item Categorization below for more detailed item examination). It was expected that there would be a: (1) strong association between sensory (ISP) and temperament (EITQ) subscale scores; (2) moderate association between sensory (ISP)/temperament (EITQ) subscale measures and the neonatal exam (NNNS); and (3) moderate association between neurobehavior subscale measures (NNNS muscle tone, regulation), and ISP subscale measures of tolerance/threshold to sensory stimuli.

Section snippets

Participants

A sample of 130 clinically normal mothers and infants were recruited on a daily basis from the well-child newborn nurseries at a large metropolitan teaching hospital in the northeastern United States as part of an ongoing NICHD-funded project between 1999 and 2004 (standardization of the NRN-Neurobehavioral Scale, NNNS). Mother–infant dyads were screened for eligibility to participate in the study through review of medical records and nursing reports. Inclusion criteria for the newborns

Preliminary analysis

Analysis of Demographic Data: Results of univariate and bivariate analyses revealed a normal distribution for all variables with no outliers except for mild skewness/kurtosis noted on the NNNS Regulation summary score. There was missing data on several items on the ISP and EITQ when parents reported that their 1-month-old infant did not yet have the opportunity (e.g., “looks in the mirror”) or were too young (e.g., “needs more support for sitting”) to perform the task. In that case, the mean of

Discussion

Results from this study suggest a unique three-factor model of infant behavior that offers a multi-disciplinary, integrative perspective and a comprehensive analysis of the infant. This model also suggests possible external validation in its similarity to the well-established three-factor temperament model developed from the Infant Behavior Questionnaire-Revised (Gartstein et al., 2003; Rothbart, Chew, et al., 2001). The current study's Factor One: “Regulation and Coordination of Movement,” is

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