Which theorists developed a temperament classification system in which most children are considered to be easy difficult or slow

Child Temperament

As evidenced by the effects of family structure, culture/ethnicity, and economics, parenting does not occur in isolation. The child also brings to the parent–child relationship their own personality, ortemperament, a collection of traits that stay relatively constant over time (seeChapter 18). Nine traits have been identified in child temperament: activity level, predictability of behavior, reaction to new environments, adaptability, intensity, mood, distractibility, persistence, and sensitivity. Most infants (65%) fit into 1 of 3 groups: easy (40%), difficult (10%), and slow to warm up (15%), and these patterns are relatively stable over time. Although variations in temperament traits are part of normal human variations, certain behavioral difficulties have been associated with certain temperament types. For example, a difficult temperament has been associated with the development of externalizing behavior (e.g., acting-out, disruptive, and aggressive behavior) and not surprisingly, a slow-to-warm-up temperament with internalizing behavior (e.g., anxious and moody behavior).

Temperament traits are relatively stable, but how the child functions is affected by the environment, especially by parenting and the “goodness of fit” between the parent and child. Children with difficult temperament characteristics respond more negatively to neglectful parenting, and children of all temperament groups respond positively to responsive and sensitive parenting. Moreover, childhood traits such as low adaptability, impulsivity, and low frustration tolerance may lead some parents to engage in more negative parenting practices. These findings illustrate the interactive nature between parent and child, with parental behavior shaping child behavior, and vice versa.

How Do We Measure Temperament?

Temperament assessments in early childhood often rely on structured observations of temperament-related behavior or information collected from the caregiver. Observational measures of newborns and young infants include assessments of reactivity to multiple modes of stimulation, whereas observations of older infants, toddlers, and preschoolers also permit evaluation of attention-based regulatory capacity. Observations of young children are frequently carried out in the laboratory, following a structured set of procedures; however, such observations can also be conducted in the child’s home or the hospital. Caregiver report methodology consists of asking parents, or other care providers, questions about the frequency of behaviors related to child temperament characteristics. A variety of questionnaires, based on caregivers’ observations, have been developed for this purpose, providing researchers with tools for assessing temperament from birth into the preschool period and beyond.

At least three major goals have been pursued in the assessment of temperament in early childhood. One has been to measure individual differences in reactivity and self-regulation under controlled conditions, typically through observation in a laboratory setting. More recently, it has involved the development of laboratory marker tasks, tests that assess variability in children’s behavior in the laboratory that has been associated in adult imaging studies with the activation of specific brain regions or networks. A second goal has been to identify the structure of temperament via parental responses to paper-and-pencil questionnaires addressing multiple child attributes. Information provided by caregivers is sometimes presented together with data from additional sources (e.g., home observations or other temperament measures) because caregiver report possesses both unique strengths and potential weaknesses, as do other methods (elaborated on in the next section).

The third goal has been to adapt temperament measures to clinical uses. Clinical adaptations have included the informal use of questionnaires or observations in clinical diagnosis and treatment, as well as a means to encourage parents to pay attention to their children’s behavior patterns. Measures of temperament have also been used in studies of the development of behavior problems, and have been linked to adjustment in adulthood. Measures developed for the assessment of temperament in early childhood have not yet achieved the measurement qualities necessary for predicting future problems for specific individuals, but they have been helpful in our general understanding of the development of behavior problems.

Recent studies have begun to include physiological measures such as assessments of children’s vagal tone, cortisol levels, and hemispheric asymmetry, yielding results of interest in relation to caregiver reports and observations of children’s temperament-related behavior. The use of these methods along with other temperament assessment approaches (e.g., caregiver-report) may allow validation of each method, and provide valuable information regarding the processes involved in the development of temperamental individual differences. Consistent patterns of findings across different measurement modalities would also provide conclusive validation for each of the approaches involved. The use of physiological tools in concert with behavioral measures provides an added benefit of allowing researchers to identify mechanisms underlying individual differences in temperament.

Temperament/Coping Styles

Somatic symptoms have been found to be more common in children who are conscientious, sensitive, insecure, internalizers, and anxious, and in those who strive for high academic achievement. Somatization may also occur in children who are unable to verbalize emotional distress. Somatic symptoms are often seen as a form of psychological defense against intrapsychic distress that allows the child to avoid confronting anxieties or conflicts, a process referred to as “primary gain.” The symptoms may also lead to what is described as “secondary gain” if the symptom results in the child being allowed to avoid unwanted responsibilities or consequences.

Temperament and Adolescent Behavior

Temperament is often thought of as a person's disposition, characterized by their drive, affect, and emotion. These aspects of behavior are influenced by a biologically-based system that is fairly consistent across the life span: Measures of infant temperament tend to correlate with measures of adult temperament and personality. Temperament is also related to many of the systems implicated in bipolar disorder, including emotion regulation, arousal, and affect. Certain temperament styles may be risk factors for developing mood disorders.

One temperament framework describes four affective temperament styles – cyclothymic, hyperthymic, depressive, and irritable. Not everyone with an affective temperament will develop a mood disorder, nor do all individuals with mood disorders have an affective temperament style. However, studies have shown that the two do often cooccur and that the presence of an affective temperament may be a major risk factor for developing bipolar disorder.

Of the affective temperaments, hyperthymic and cyclothymic temperaments are most often associated with bipolar disorder. Individuals with hyperthymic temperament are often characterized as energetic and outgoing. They tend to be goal-oriented and of high energy, which may predispose them to manic states. Additionally, they are often gregarious and disinhibited. Although their somewhat socially aggressive nature may be off-putting to others, people with hyperthymic temperament are generally successful at school and work.

Cyclothymic temperament is not as adaptive as hyperthymic temperament and, as a result, has been studied more often. Individuals with hyperthymic disorder are much less likely to seek treatment, as the symptoms they experience are often conducive to personal gains. People with cyclothymic temperament tend to exhibit behavior more similar to the mood episodes seen in bipolar disorder. They are often very irritable and moody, with drastic shifts from good-natured hyperactivity to irritable depression. Cyclothymic temperament is associated with poor interpersonal skills, passive–aggressive behavior, and high emotional reactivity. People with cyclothymic temperament tend to be more prone to substance abuse and suicidality.

Cyclothymic temperament may be one of the best ways to predict future bipolar disorder. Cyclothymic temperament is highly prevalent in the offspring of parents with bipolar disorder, and the trait increases bipolar risk above and beyond that associated with heritability or temperament alone. Additionally, young people with depression and cyclothymic temperament are much more likely to convert to bipolar disorder than young people with depression alone. Identifying adolescents with cyclothymic temperament could offer a good opportunity for early intervention. Unfortunately, temperament is not typically assessed outside of research settings. Furthermore, many of the traits associated with both hyperthymic and cyclothymic temperaments are also considered ‘normal’ adolescent behavior. Depending on the individual, it could be very challenging to distinguish cyclothymic moodiness from the moodiness often brought on by hormonal shifts in adolescence. Similarly, the high energy and impulsivity seen in hyperthymic temperament may not be qualitatively different from ‘typical’ excitability and poor judgment exhibited by teenagers.

The differentiation of temperament from normal adolescent behavior is also complicated by the fact that one of the key ways for identifying bipolar disorder – episodicity – works against the identification of temperament. Temperamental traits are, by nature, more chronic. Adolescence may amplify the effects of a person's temperament, yet they will have likely ‘always’ had some or all of the behaviors of interest. So, although noticing a change in behavior can aid in the diagnosis of bipolar disorder, temperament recognition may be hard for the people who know the adolescent best.

Those with both an affective temperament and bipolar disorder are likely to have a more difficult, chronic course of illness. Individuals with uncomplicated bipolar disorder often achieve remission and experience periods of balanced mood and good functioning. In contrast, those with an affective temperament tend to experience some mood symptoms even when their bipolar disorder is in remission. Furthermore, features associated with affective temperament – such as emotion dysregulation, limited social support, and tendency toward erratic behavior – may actually trigger or prolong mood episodes. Studies in adults with bipolar disorder are finding that personality traits may influence what types of treatment people seek and how able they are to adhere to complex treatment regimens. People with bipolar disorder often have lower levels of trait conscientiousness, making it more likely that they will have difficulty following through with taking medication, keeping appointments, or completing tasks from therapy.

Conclusions and Future Directions

Temperament-based personality traits enabling one to successfully solve conflicts between immediate emotional demands and the long-term goal of WL seem to favor BS success. These findings have important clinical implications for patients undergoing BS. In fact, although TT are constitutionally based, they are not unmodifiable; clarifying the processes and behaviors through which TT contribute to satisfactory postsurgical WL will allow researchers to identify potential areas of intervention. In this way, multiprofessional treatments that also address psychological issues could improve BS patients’ self-regulation capacities arising from the interplay of their underlying TT. This will ultimately optimize patient care and enhance surgical success.

1 A Definition of Temperament

Temperament has been defined as constitutionally based individual differences in emotional, motor, and attentional reactivity and self-regulation, demonstrating consistency across situations and relative stability over time (Rothbart and Derryberry 1998). The term ‘constitutional’ stresses links between temperament and biology. Over the long history of the study of temperament, individual differences in temperament have been linked to the constitution of the organism as it was understood at the time. The term ‘reactivity’ refers to the latency, rise time, intensity, and duration of responsiveness to stimulation. The term ‘self-regulation’ refers to processes that serve to modulate reactivity; these include behavioral approach, withdrawal, inhibition, and executive or effortful attention.

2.2 Child Temperament

Temperament theorists believe that early child temperament is of etiological significance to the later development of childhood anxiety. ‘Behavioral inhibition’ is the term used to describe one particular pattern of childhood temperament that has been most frequently linked with childhood anxiety problems. It can be defined as a relatively stable temperament style characterized by initial timidity, shyness, and emotional restraint when exposed to unfamiliar people, places, or contexts. This temperament pattern is associated with elevated physiological indices of arousal and has been shown to have a strong genetic component. Most importantly, children exhibiting a temperament style of behavioral inhibition demonstrate an increased likelihood of developing child anxiety (see Kagan 1997 for a review of this area). Other temperament theorists argue for the existence of three stable factors: positive affectivity/surgency (PA/S), negative affectivity/neuroticism (NA/N), and effortful control (EC) (Lonigan and Phillips in press). According to this theory, high NA/N combined with low EC places children at risk for the development of anxiety problems, and there is some tentative evidence to support this proposition. However, as not all children exhibiting an early temperament style of behavioral inhibition, or high NA/N combined with low EC, go on to develop an anxiety disorder, the presence of moderating or mediating variables appears to be likely. In particular, attachment style and parenting characteristics (see Sects. 2.3 and 2.4) are likely to interact with early childhood temperament to determine the development of anxiety problems.

Although the literature regarding childhood temperament is interesting, it tells us little about the exact mechanism of action. It remains to be determined whether temperament impacts upon anxiety through greater susceptibility to conditioning processes, greater emotional and/or physiological arousability to stressful events, or through cognitive processes. For example, it is feasible that ‘at risk’ temperaments have their impact though greater tendencies to detect and attend to threatening stimuli in the environment, or expectations regarding the occurrence of negative outcomes. It has been shown in several studies that anxious children are more likely than others to think about negative events and to expect negative outcomes from situations.

Temperament

Temperament is understood as the way children respond to the world around them, how they regulate their emotions and how comfortable they are with new situations, both social and others.6 It represents the earliest appearance of the child’s individual differences in emotional reactivity. Furthermore, temperament has been used in developmental psychology as a proxy for negative emotionality and has been associated with childhood psychiatric disorders later in life.7,8 Maternal depression and anxiety have been shown to affect childhood temperament (greater fussiness). Furthermore, interpersonal difficulties have been found in patients with EDs, which could affect the way mothers with EDs respond to their child’s cues, and in turn affect temperament.

Mothers with EDs have been shown to be more likely to describe their infant as having a difficult temperament. Compared with women with no history or current EDs, they tend to rate their children as having high levels of difficult temperament9; and perceive them as having greater negative effect, that is, demonstrating more sadness, irritability, and crying compared with controls.10 In a more recent large longitudinal study, we found that mothers with EDs were more likely to perceive their children as having a “difficult temperament” characterized by the child being less happy and active than other children of their age, more restless and as having more tantrums and as being less cautious and guarded than other children of their age.11 Many studies, however, including our own, have relied on maternal reports rather than direct observations and therefore should be considered with caution. Although it is possible that children of mothers with EDs are objectively more difficult, we should not discard the possibility that mothers with EDs perceive their children as being difficult. This could be due to their own preoccupation with the disorder, or due to difficulties processing their children’s emotional cues. However, even if the latter is true, this maternal perception of a difficult temperament might have an impact on how they respond to their child’s needs, and in turn affect their child’s temperament and later development. Interestingly, in our recent study 11 on childhood psychopathology in children of mothers with EDs, we found that child temperament partially mediated the effect of maternal bulimia nervosa (BN) on childhood psychopathology at the age of 7 years (pointing to a shared genetic and environmental effect). For maternal AN, however, the effect of the EDs on childhood psychopathology was completely mediated by temperament. Lastly, as temperament has been found to have a genetic influence,7 we cannot discard the hypothesis that children of mothers with EDs have a genetic predisposition to a difficult temperament, which in itself predisposes to later psychopathology.

1 Temperament

Temperament is basically the childhood equivalent of personality, although there is more emphasis in the temperament literature on constitutional predisposition and genetic and biological factors. The modern study of child temperament began with the New York Longitudinal Study of Chess and Thomas (1984). Children in their first 5 years of life were rated on temperamental dimensions by their parents, and these dimensions were combined into three broad categories of easy, difficult and ‘slow to warm up’ temperament. Having a difficult temperament at age 3–4 years (frequent irritability, low amenability and adaptability, irregular habits) predicted poor adult psychiatric adjustment at age 17–24.

Remarkably, Bates (1989) found that mothers' ratings of difficult temperament as early as age 6 months (defined primarily as frequent, intense expressions of negative emotions), predicted mothers' ratings of child conduct problems between the ages of 3 and 6 years. Similar results were obtained in the Australian Temperament Project, which found that children who were rated as irritable, not amenable, or showing behavior problems at age 4–8 months tended to be rated as aggressive at age 7—8 years (Sanson et al. 1993). However, when information at each age comes from the same source, it is possible that the continuity lies in the rater, rather than the child. Fortunately, other studies (e.g., Guerin et al. 1997) show that difficult temperament in infancy, rated by mothers, also predicts antisocial behavior in childhood rated by teachers.

Because it was not very clear exactly what a ‘difficult’ temperament meant in practice, other researchers have investigated more specific dimensions of temperament. For example, Kagan (1988) and his colleagues in Boston classified children as inhibited (shy or fearful) or uninhibited at age 21 months on the basis of their observed reactions to a strange situation, and found that they remained significantly stable on this classification up to age 7 years. Furthermore, the uninhibited children at age 21 months significantly tended to be identified as aggressive at age 13 years, according to self and parent reports (Schwartz et al. 1996).

The most important results on the link between childhood temperament and later offending have been obtained in the Dunedin longitudinal study in New Zealand, which has followed up over 1000 children from age 3 years and into their 20s (Caspi 2000). Temperament at age 3 years was rated by observing the child's behavior during a testing session involving cognitive and motor tasks. The most important dimension of temperament was being undercontrolled (restless, impulsive, with poor attention), which predicted aggression, self-reported delinquency, and convictions at age 18–21 years.

Temperament

Temperament may also play a role in how a child copes with painful procedures. Psychologically, temperament is classically defined as an inborn dispositional difference in behavioral style and self-regulation or variability in individual behavioral responses to external stimuli.89 Physiologically, temperament is conceptualized in terms of individual differences in reactivity to stress and focuses on, for example, cardiovascular and neuroendocrine responsiveness (heart rate, blood pressure, vagal tone, cortisol levels).90 Children with temperaments characterized by higher levels of behavioral or physiological reactivity, lower levels of adaptability, and lower thresholds for behavioral or physiological responsiveness to stimuli demonstrate higher levels of distress when confronted with medical stressors and seem to prefer coping responses that decrease their perception of the stressor (avoidance, distraction). From a physiological viewpoint, such coping responses may downregulate a child's reaction to the stressor. Children with less reactive and more adaptable temperaments, who demonstrate lower levels of distress, may be able to take better advantage of coping responses that involve direct confrontation with the stressor (information seeking, observation).29