Infants with colic: Their childhood characteristics

Infants With Colic: Their Childhood Characteristics Madalynn Neu, RN, PhD JoAnn Robinson, PhD The purpose of this study was to compare 40 six- to eight-year-old children, 20 with prospectively ascertained infantile colic and a matched sample of 20 without colic, on characteristics of emotional regulation and on parent stress. Children completed tests of cognitive ability, and mothers completed childhood behavioral questionnaires and a parenting stress assessment. Children with colic had maternal ratings suggestive of more difficulty with emotional regulation than their noncolic matches and displayed a more impulsive cognitive style. However, the mean scores of both groups were in the normal range. Copyright 2003, Elsevier Science (USA). All rights reserved. I NFANTILE COLIC OCCURS in 5% to 30% of the infant population (Canivet, Hagander, Jakobsson, & Lanke, 1996; Lehtonen & Korvenranta, 1995; Lucassen, Assendelft, Eijk, Douwes, & van Geldrop, 2001) and is characterized by inconsolable crying that usually begins at 1 to 2 weeks of age, continues for 2 to 4 months, and occurs without an obvious physiologic cause (Brazelton, 1962; Wessel, Cobb, Jackson, Harris, & Detwiler, 1954). Parents respond to the relentless crying of their infant by desperately trying a myriad of interventions, often to no avail, and remember the colic period long after the crying has ceased (Neu & Keefe, 2002; Thompson, Harris, & Bitowski, 1986). Despite the obvious distress experienced by the infant and family during the colic episode, little research regarding long-term sequelae of colic has been reported. The emotional regulation difficulty demonstrated by infants with colic may be a precursor of childhood difficulty From the School of Nursing and Department of Psychiatry, University of Colorado, Denver, CO. This research was supported by the National Institute of Nursing Research as a National Research Service Award (NR07010-02), as well as a grant from Sigma Theta Tau Honor Society. The authors wish to thank Maureen Keefe for her consultation and Phyllis Green for her assistance with data collection. Address correspondence and reprint requests to Madalynn Neu, RN, PhD, Box C 288, University of Colorado, 4200 E. Ninth Ave., Denver, CO 80262. Copyright 2003, Elsevier Science (USA). All rights reserved. 0882-5963/03/1801-0003$30.00/0 doi:10.1053/jpdn.2003.3 12 with emotional regulation involving arousal, activity, and attention and may have continued impact on the parents. This hypothesis was explored in a study of children who were prospectively identified as having had infant colic. The goal was to compare 6- to 8-year-old children who had infant colic with children who did not have colic on child behaviors and cognitive abilities associated with difficulty in emotional regulation and on parent stress. DEFINING COLIC Infant crying normally increases in the second month to an average of 2.5 hours per day and decreases to an average of 1 hour per day at 12 weeks of age (Brazelton, 1962; Hunzikar & Barr, 1986). The crying of infants with colic conforms to the same pattern as that of other infants, but infants with colic spend more time per day in crying states (Hill et al., 1992; Lehtonen & Korvenranta, 1995; Wessel et al., 1954) and have longer crying bouts (Barr, Rotman, Yaremko, Leduc, & Francoeur, 1992). Some researchers use Wessel’s criteria that infants cry for more than 3 hours a day, more than 3 days per week, for more than 3 weeks, to identify colic, but many require that a healthy infant cry inconsolably for more than 3 hours a day for at least 3 days in just 1 week. Other definitions include crying that bothers the parent or crying that is accompanied by certain behaviors such as clenching fists, grimacing, or flexing legs over the abdomen. In addition to a physical examination to rule out an obvious physiologic cause for the crying, a parent diary is the most systematic method of Journal of Pediatric Nursing, Vol 18, No 1 (February), 2003 INFANTS WITH COLIC assessing infant colic. Studies cited in this article use the following criteria for colic unless otherwise stated: crying that occurs for at least 3 hours a day, at least 3 days a week, for 1 week or more, as assessed by parent diary. Lehtonen, Gormally, and Barr (2000) estimated that only 5% of colic cases are caused by organic disease. The small percentage of colic cases caused by organic problems, the extended crying bouts that are not amenable to soothing, and the increased activity level and inability to fall asleep observed in infants with colic have led some researchers to suggest that colic may indicate a variance in central nervous system functioning (Barr, Young, Wright, Gravel, & Alkowaf, 1999; Lehtonen et al., 2000) or a problem of emotional regulation (Keefe, 1988). EMOTIONAL REGULATION Emotional regulation is the flexible heightening or suppression of physiologic or behavioral arousal to focus attention or interact with others (Cole, Michel, & Teti, 1994; Thompson, 1994). Attentional persistence is an important modulator of emotional arousal in which the individual appropriately inhibits reactivity (Rothbart & Ahadi, 1994; Shoda, Mischel, & Peake, 1990). The behavior of infants with colic, in particular, suggests difficulty in suppressing an arousal response. Studies addressing child characteristics of emotional regulation and maternal-child relationships that might be affected by excessive infant arousal have been conducted during the period of colic, for several months afterward, or into early childhood. In the following studies, the presence of colic was ascertained during the first 3 to 4 months of life when the infant cried excessively. Although results of these studies reveal much similarity in development and behavior, they also ascertained differences between children who had colic and those who did not. Results of a study that examined fetal behaviors before birth showed that type of fetal movement was associated with amount of crying at 1, 6, and 12 months of age (St JamesRoberts & Menon-Johansson, 1999). In another study, infants who were classified as colicky by their parents at 1 month of age were more active and more attentive to stimuli in the first few days of life than other infants (Keefe, Froese-Fretz, & Kotzer, 1998). During the colic period, mothers rated their infants as more intense, negative in mood, nonpersistent, and distractible (Lehtonen, Korhonen, & Korvenranta, 1994), but more alert, active, demanding and less likely to use self-sooth- 13 ing behaviors than infants without colic (Keefe, Kotzer, Froese-Fretz, & Curtain, 1996). Infants with colic also were found to sleep less than other infants (White, Gunnar, Larson, Donzella, & Barr, 2000). In interactions with their mothers, infants with colic were observed to be less responsive than infants without colic. Their mothers reported feeling more distress, frustration, and inadequacy and demonstrated fewer social and emotional growth– fostering behaviors toward their infants than other mothers (Keefe et al., 1996). At 5 months of age, after resolution of colic, infants continued to cry more and were rated as more difficult in temperament by their mothers than other infants. Although mothers of infants with colic displayed as much sensitivity and affection toward their infants as other mothers, they responded less to the crying of their infants and had higher depression scores (St James-Roberts, Conroy, & Wilsher, 1998). Stifter and Bono (1998) reported that mothers of infants who had colic perceived themselves as less competent mothers and reported more separation anxiety than other mothers when infants were 5 months of age. However, Stifter and Braungart (1992) reported no differences in maternal responsiveness, maternal ratings of infant temperament, infant negativity, and infant mental development between mother and infant dyads experiencing colic and other dyads at 5 and 10 months of infant age. As in the infant studies, results of the few studies of behavior, development, and parent-child relationships of toddlers and young children who had infant colic showed much similarity between children with infant colic and those without it, but they also revealed differences. Stifter and Bono (1998) found that mothers of infants with colic, who had low self-efficacy scores and were less sensitive toward their infants at 5 months of age, had children who were insecurely attached at 18 months, suggesting an important role of maternal characteristics in the response to the infant with colic. In another study, no differences in maternal ratings of temperament and sleeping patterns through 36 months of age were found, but mothers of infants with colic stated that they perceived that their infants were more difficult than other infants (Lehtonen et al., 1994). Neu and Keefe (2002) found that mothers’ perceptions of their children at 5 to 7 years of age generally were positive. However, mothers of children who had colic in infancy related a higher activity level and more emotional lability in their children than mothers of other children. Mothers of the children with colic also 14 NEU AND ROBINSON mentioned problems with discipline and some residual feelings about the colic period. Mothers of other children did not mention these problems or direct the conversation back to the infancy period. Thus results of previous studies show differences between colic and noncolic samples in maternal behavioral ratings and mother-infant interactions. Studies assessing maternal perceptions of children aged 3 to 7 years after resolution of colic indicate that mothers perceive that difficulties in the child persist. Maternal perception that an infant is difficult has been associated with later behavioral problems (Oberklaid, Sanson, Pedlow, & Prior, 1993). Little research has been conducted on the association between infant colic and maternal and child characteristics during school age. In the present report, children were assessed between 6 to 8 years of age, to investigate whether child difficulties or maternal perception of difficulty persists to the school-age period. This exploratory group comparison study focused on maternal ratings of child difficulty in emotional regulation and parent stress, as well as direct assessment of child cognitive style and ability. We tested the general hypothesis that when compared with a matched noncolic sample, 6- to 8-year-old children who had colic as infants would show more indications of emotional-regulatory difficulties, including less attention regulation, and have parents who are more stressed. METHODS Sample The sample consisted of 40 children. In the colic group (n ⫽ 20), the children had participated as infants in the Etiology and Management of Irritable Infant Study (Maureen Keefe, PhD, National Institute of Health (NIH), National Institute for Nursing Research (NINR) No. R29NR01620 Keefe et al., 1996, Keefe et al., 1998). Half of the original sample could not be located, and 4 parents (8%) refused to participate. Children who were in the Irritable Infant Study were originally recruited from a low-risk newborn nursery and local pediatricians’ offices. Families were visited every 3 weeks when the child was between 4 and 16 weeks of age. During each visit, the mother was interviewed and both parents completed a Fussiness Rating Scale that rated the infant’s unexplained fussy behavior during the past week and included amount of fussiness, intensity of fussiness, hours of fussiness per day, and number of fussy episodes per week. Infants who cried and/or had unex- plained periods of fussiness for at least 2.8 hours per day (mean, 3.9 hours) for at least 3 days at 1 month of age were ascertained as having colic (Keefe et al., 1996). Independent mother/father ratings correlated from r ⫽ 0.71 to r ⫽ 0.91 (Keefe et al., 1998). Children who had colic as infants were compared with a group of 20 infants who were drawn from a pool of 150 participants in the Infant Growth and Nursing Care Study (Marilyn Stember, PhD, NIH NINR No. RO1 NR1670), a pool of 200 research subjects from a local university, and local advertisements. Ten children were recruited from the Infant Growth study, two from the university pool, and eight from local advertisements. Mothers on the lists of the university subject pool and the Infant Growth and Nursing Care Study were randomly chosen. During the recruitment telephone call, these mothers as well as mothers who responded to the advertisements were informed that the focus of the study was investigation of characteristics of children with and without infant colic. Mothers who expressed interest in participating were asked to describe their children’s crying patterns in infancy. The immediate and unambiguous response of mothers in the noncolic group indicated the absence of any notable crying during infancy. If a mother’s response required probing, or suggested uncertainty about the amount of infant crying, the child was not included in the study. Children were 6 to 8 years of age at the time of the study. The two groups were carefully matched according to socioeconomic status, age, sex, and ethnicity (Table 1). Socioeconomic status was determined by the Hollingshead Four-Factor Index of Social Status (1978) on the basis of parents’ educational levels and occupations. Each child in the colic group was tested first and demographic information obtained. A matched subject was then chosen from the lists of comparison children who had low levels of crying in infancy, and that child was then tested. Instruments Instruments selected assessed characteristics that were found in previous studies to differ between children with and without colic. These difficulties included difficult temperament, activity level, attention (distractibility and impersistence), negativity, sleep disturbances, parent distress, and dysfunctional parent-child interactions. Temperament was assessed with the Behavioral Style Questionnaire (BSQ) (McDevitt & Carey, 1978), a 100-item parent rating instrument de- INFANTS WITH COLIC 15 Table 1. Demographic Factors Used to Match Colic and Noncolic Groups Sex Male Female Age (y) 6 7 8 Ethnicity Caucasian African American Hispanic/Caucasian Socioeconomic status* I II III Colic Group [n (%)] Noncolic Group [n (%)] 10 (50) 10 (50) 10 (50) 10 (50) 6 (35) 13 (60) 1 (5) 7 (30) 12 (65) 1 (5) 17 (85) 2 (10) 1 (5) 17 (85) 2 (10) 1 (5) 9 (45) 10 (50) 1 (5) 9 (45) 10 (50) 1 (5) Note: No significant differences were found between groups. *I, Higher executives and major professionals; II, administrators, owners of medium-sized businesses, and lesser professionals; and III, managers, small business owners, and minor professionals. signed as a Likert scale ranging from 1 point (almost never) to 6 points (almost always). The 9 subscales correspond to the 9 components of temperament proposed by Thomas, Chess, and Birch (1968): mood, adaptability, intensity, approach, rhythmicity, activity, persistence, distractibility, and sensory threshold. Validity and reliability were demonstrated by McDevitt & Carey (1978), with 350 Caucasian children who were predominantly middle class. Test-retest reliability on a subsample of 59 mothers after 1 month was r ⫽ 0.89 (McDevitt & Carey, 1978). Only the subscales comprising the difficult temperament constellation (emotional intensity, approach, mood, adaptability, and biologic rhythmicity) were used in this study. Internal validity of the difficult child constellation was 0.74 in this sample. The scores for subscales in the difficult temperament constellation were summed to obtain a difficult temperament score. The difficult temperament score with subscales summed ranges from 5 to 30. Higher scores indicate more difficult temperament. The ADHD Checklist of the Diagnostic Interview for Children and Adolescents, Revised (Reich & Welner, 1988) is a parent rating scale containing 24 items derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition ADHD criteria that pertain to attention, impulsivity, and hyperactivity. The checklist, originally developed as a structured interview, uses “yes” and “no” responses. The total score is the sum of “yes” responses, with a maximum score of 20. Higher scores indicated more ADHD characteristics. Brunshaw and Szatmari (1988) reported a sensitivity of 0.69 and specificity of 0.82 for the ADHD Checklist in children aged 6 to 12 years. Scale reliability was 0.86 in this sample. The Child Behavior Checklist (CBCL) (Achenbach, 1991) is a parent rating scale that is used to examine problematic behaviors. The CBCL is widely used in research and was normed on 2800 children aged 4 to 17 years. It is a parent rating scale consisting of 118 items divided into 9 subscales and offers a 3-choice response format: 0 (behavior never occurs) to 2 (behavior occurs frequently). Three of the subscales assess internalizing characteristics (withdraw/approach, somatic complaints, and anxious/depressed), and three assess externalizing characteristics (attention problems, delinquent behavior, and aggressive behavior). The three remaining subscales are thought problems, social problems, and other problems (collection of miscellaneous behaviors including sleeping difficulties). Adequate validity was reported for children aged 4 to 17 years by Achenbach (1991). One-week test-retest reliability was r ⫽ 0.82 in a sample of 80 children aged 4 to 16 years. The internalizing and externalizing subscales were used in this study, as well as five questions pertaining to sleep in the other problems subscale. Cronbach’s ␣ internal consistency reliability coefficients for the internalizing and externalizing scales in this sample were .84 and .90, respectively. Higher scores indicate more problematic behavior. The Matching Familiar Figures Test (MFFT) (Kagan, Rosman, Day, Albert, & Phillips, 1964) was used with the children to measure cognitive style. The MFFT is a collection of 12 familiar outline figures that includes two practice figures. For each figure, the child chooses from six possibilities the one figure that is identical to the standard. The examiner scores the child on two scales: response time (latency to first response) and errors. Concurrent validity has been reported (Arizmendi, Paulsen, & Domino, 1981; Kagan, 1965). Studies of discriminant validity that included children aged 6 to 8 years and demonstrate differences between children who responded reflectively (slow and accurate) and those who responded impulsively (quick and inaccurate) were summarized by Arizmendi et al. (1981). The MFFT has discriminated between children with attention and arousal difficulties and other groups aged 6 to 12 years (Pennington, Grossier, & Welsh, 1993; Robins, 1992; Weyandt, & Willis, 1994). An adapted version 16 with 10 outline figures that included two practice figures was used in the current study to reduce total testing time of the children. Scales reliabilities were 0.94 for response time and 0.36 for errors. The Wechsler Intelligence Scale for Children, Third Edition (WISC-III) (Wechsler, 1991) is well normed and is used frequently in evaluations of child intelligence. The WISC-III contains 12 tests that load on four factors: verbal comprehension (verbal reasoning/language ability), perceptual organization (non-language reasoning/spatial ability), freedom from distractibility (measure of attention/mental rotation of numbers), and processing speed (speed in thinking/visual-motor coordination). The test’s reliability and validity have been documented (Wechsler, 1991). Mean 3-week testretest reliability for the four factor scores ranged from 0.74 to 0.89 in a sample of 111 children aged 6 and 7 years. Internal consistency coefficients for this sample ranged from 0.56 for freedom from distractibility to 0.81 for verbal comprehension. According to Sattler (1992), the WISC-III may not accurately measure cognitive ability for low-functioning children at 6 years of age. The Parenting Stress Index–Short Form (PSI) (Abidin, 1995) is a 36-item Likert scale with choices ranging from 1 (strongly agree) to 5 (strongly disagree). It is divided into three subscales: parent distress (role restriction, interpersonal conflict, and available social support), parent-child dysfunctional interaction (feelings of alienation between parent and child), and difficult child (self-regulatory characteristics of the child). Normative data collected from 2633 mothers of children ranging in age from 1 month to 12 years and extensive discriminant and convergent validity of the long form of the Parenting Stress Index have been reported (Abidin, 1995). No validity studies have been reported for the short form, but the correlation between the long and short forms for the parent distress subscales is r ⫽ 0.92 (Abidin, 1995). The internal consistency in this sample was 0.86. Higher scores on the PSI indicate more parent stress. NEU AND ROBINSON being tested, the mother completed the BSQ, ADHD Checklist, CBCL, PSI, and demographic form, which included information about family illness history and the health of the child. Time for parent completion of all questionnaires was 60 to 90 minutes. The child completed the WISC-III and MFFT. Total testing time was approximately 2 hours. Children were given $10 at the conclusion of testing. Data Analysis We used t tests to compare means of the following: difficult temperament score, ADHD Checklist, t scores of the externalizing (attention problems, delinquent behavior, aggressive behavior) and internalizing (withdrawal, somatic complaints, anxious/depressed) scales of the CBCL, and total sleep problems obtained from the mean of the five questions pertaining to sleep difficulties in the CBCL. Using Bonferroni correction resulted in setting ␣ for the t tests at .01. Separate multivariate analyses of variance (MANOVA) were used for the two subscales of the MFFT, the factor scores of the WISC-III, and the three subscales of the PSI, and ␣ was set at .05 for the MANOVA tests. Three children in the colic group and two children in the noncolic group had outlying scores in the MFFT. One child in the noncolic group had an outlying score on the ADHD Checklist. Outliers were removed from the analysis. RESULTS Matching of colic and noncolic subjects was successful (Table 2). In addition, there were no significant differences between the colic and noncolic groups with regard to family history of allergies/asthma, ADHD, affective disorder or the number of siblings, reported problems of pregnancy, birth weight, or breast or bottle feeding of the child in the study. Eighteen children (90%) in the colic group and nineteen children (95%) in the noncolic group lived with both biological parents. There were no differences in the reported frequency of neurologic and/or mental health evaluations (10%). Data Collection Procedures Testing was done either at the university per parent request (for 2 children in the colic group and 2 children in the noncolic group) or in the home of the child (for the remainder of the subjects). Mothers signed an informed consent form. Either the first author or research assistant, each trained in administration and interpretation of the instruments, conducted the testing. While the child was Table 2. Comparison of Demographic Factors Between Colic and Noncolic Groups Measure Colic Group [mean (SD)] Noncolic Group [mean (SD)] Age of child (y) Hollingshead index Father’s age (y) Mother’s age (y) 7.1 (0.7) 52.8 (9.1) 40.6 (7.7) 38.0 (5.0) 7.1 (0.6) 53.9 (7.6) 40.9 (6.0) 40.0 (6.0) Note: No significant differences were found between groups. INFANTS WITH COLIC 17 One child (5%) in the colic group and none in the noncolic group had been diagnosed with ADHD. No children in either group had been diagnosed with depression. No difference was found between groups in the difficult temperament score. Ten percent of the children in both groups had maternal ratings indicating difficult temperament. A difference was found between the two groups on the ADHD Checklist (t ⫽ 2.8, p ⫽ .010). Children with colic as infants had ADHD scores more than twice as high as children who did not have infantile colic. With use of a recommended cutoff score above nine (Brunshaw & Szatmari, 1988), 5 children (25%) in the colic group versus no children in the noncolic group had scores in the clinical range for ADHD (p ⫽ .02 [Fisher exact test]). Results showed a trend for mothers in the colic group to rate their children higher on the externalizing scale of the CBCL than mothers in the noncolic group (t ⫽ 2.0, p ⫽ .049). With regard to t scores, those above 60 are suggested as being borderline or in the clinical range (Achenbach, 1991). Two children in the colic group (ten percent) had borderline or clinical range scores in the externalizing subscales. No children in the noncolic group had scores in the clinical range. No differences were found in mean sleep problems or the CBCL internalizing scale (Table 3). A group difference also was found in the number of children who had maternal ratings that were in the clinical range (t score ⬎60 on the CBCL internalizing or externalizing scale; score ⬎9 on the ADHD Checklist, a neurologic and/or mental health evaluation, or a diagnosis of an emotionalregulatory disorder). Of the children, 10 (50%) in the colic group versus 4 (20%) in the noncolic group had a parent rating or report suggesting borderline or clinical difficulty in emotional regulation (␹2 ⫽ 4.0, p ⬍ .05). Of the 10 children in the colic group who had scores in the clinical or borderline range, 8 (80%) had only one indicator, and of the 4 children in the noncolic group with a clinical range or borderline score, 3 (75%) had only one indicator. MANOVA of cognitive style assessed by the MFFT differed significantly between colic and noncolic groups [F(2,37) ⫽ 5.1, p ⫽ .012]. Univariate comparisons of the MFFT showed that children in the colic group had faster response times [F(1,33) ⫽ 8.0, p ⫽ .017] and made more errors [F(1,33) ⫽ 6.3, p ⫽ .008] than children in the noncolic group. MANOVA of the WISC-III showed a difference between groups [F(4,35) ⫽ 2.7, p ⫽ .044]. Univariate comparisons revealed that the perceptual organization factor score of the colic group was significantly lower than that of the noncolic group [F(1,38) ⫽ 8.1, p ⫽ .007] (Table 3). No differences in the MANOVA of the PSI were found between the colic and noncolic groups. DISCUSSION A two-group comparison design was used to investigate the hypothesis that when compared with a matched noncolic sample, 6- to 8-year-old children who had infantile colic would show more indications of emotional-regulatory difficulties in- Table 3. Group Means and Univariate Comparisons of Behavior, Cognitive Abilities, and Parent Stress Between Colic and Noncolic Groups Variable BSQ difficult temperament score ADHD Checklist CBCL Externalizing scale (t score) Internalizing scale (t score) Sleep problems MFFT Response time Total errors WISC-III Verbal comprehension Perceptual organization Freedom from distractibility Processing speed PSI Colic Group [mean (SD)] Noncolic Group [mean (SD)] Effect Size p n* 16.2 (2.4) 5.6 (4.7) 15.3 (2.2) 2.0 (2.4) ⬍0.5 0.9 .64 .01 40 39 40 51.0 (9.3) 50.1 (9.4) 1.1 (1.1) 44.4 (10.9) 47.3 (10.3) 0.8 (0.8) 7.8 (4.6) 16.6 (3.9) 12.5 (5.4) 13.2 (5.4) 107.0 (11.4) 102.9 (9.6) 101.1 (13.2) 107.9 (11.1) 110.5 (12.0) 111.0 (8.6) 107.0 (11.0) 107.2 (13.0) 0.5 ⬍0.5 ⬍0.5 1.2 0.9 0.9 0.6 ⬍0.5 0.9 0.5 ⬍0.5 ⬍0.5 ⬍.05 .37 .25 .01 ⬍.01 .02 .04 .35 ⬍.01 .13 .85 .24 35 40 40 Note: Normal t score range for CBCL is ⬍60. Average range for WISC-III is 90-109. Cohen’s d was used to calculate univariate effect size and d2 was used for multivariate effect size. *Unequal because outliers were removed. 18 cluding less attention regulation and would have mothers who were more stressed. The colic sample was compared with a matched sample of children who did not have colic as infants and who were retrospectively identified. The hypothesis was partially supported; whereas children were reported to have more difficult behaviors by parents and were observed to have different attention regulation styles, parents of children who had colic did not report greater current stress than parents of children who did not have colic. No differences were found between maternal ratings of children with regard to difficult temperament, the CBCL internalizing subscale, or sleeping difficulties. Although mothers in the colic group rated their children higher than mothers in the matched noncolic group on the CBCL externalizing scale, the difference was not significant (with Bonferroni correction) and the effect size was moderate. Only a small percentage of mothers in both groups rated their children in the borderline or clinical range in the CBCL. However, mothers in the colic sample rated their children approximately twice as high on the ADHD Checklist than mothers in the matched noncolic sample, with a large effect size (Cohen, 1988). A higher percentage of mothers in the colic sample also rated their children in the clinical range on the ADHD Checklist. Half of the children in the colic sample had at least one indicator of difficulty in emotional regulation (score in clinical range), compared with fewer than one fourth of the children in the noncolic sample. Most children in the study had only one such indicator. Cognitive scores of the children in the colic group differed from their noncolic matches. On the MFFT, children who had infant colic made more errors and responded more quickly than their noncolic peers. Children in the colic group also scored lower than children in the noncolic group on the WISC-III, although mean scores were in the average range. No group differences were found in parent distress or parent-child interaction. Group differences in maternal ratings of emotional arousal focused more on active and impulsive behavior than on difficult temperament or withdrawn/depressed behaviors that suggest negativity. Findings in this study of similarity in sleep patterns and temperament ratings between the colic and noncolic groups after infancy are similar to those of other research involving prospectively identified children who had colic (Lehtonen et al., 1994). NEU AND ROBINSON The difference found between groups on the ADHD Checklist is in agreement with prior findings of high activity levels, impersistence, and distractibility of infants and young children who had colic (Keefe et al., 1996; Keefe et al., 1998; Lehtonen et al., 1994; Neu & Keefe, 2002). We also expected to find a difference between groups on the CBCL externalizing subscale. However, with ␣ set at .01, only a trend toward a difference and a moderate effect size was found. Perhaps a larger sample might have shown differences. Not all externalizing behaviors may be characteristic of children with prior colic. The combination of the externalizing behaviors on the CBCL externalizing subscale might be less characteristic of children who had colic than active, impulsive behavior assessed with the ADHD Checklist. The MFFT is a measure of cognitive style, either slow and accurate (reflective) or quick and inaccurate (impulsive), that is used in problem solving when several possible solutions are presented (Kagan, 1965). Young school-aged children who respond impulsively on the MFFT are reported to use less effective methods to deal with frustration (Campbell & Douglas, 1972) and to be more distractible (Goldstein, Rollins, & Miller, 1986) than children who respond reflectively. These behaviors reflect lessened abilities to modulate emotional arousal or behavior by using effortful attentional strategies (Rothbart & Ahadi, 1994). Mothers in a previous study described their children with prior colic as having severe tantrums when frustrated (Neu & Keefe, 2002). The more impulsive performance of the colic group (in comparison to the noncolic group) on the MFFT lends some support to mothers’ perceptions of their children’s impulsive behavior identified on the ADHD Checklist. The perceptual organization factor contributed most strongly to the difference in intelligence scores. Other studies have shown that children with an impulsive cognitive style on the MFFT scored lower on the perceptual organization factor on the WISC-III (Brannigan, Ash, & Margolis, 1980; Finch, Spirito, & Brophy, 1982). Tests that load on this factor involve problem solving when a variety of choices are possible (Sattler, 1992). Children with a more impulsive cognitive style may be more likely to choose an answer without reflecting on the other possible responses that might be better. In this study, children in the colic sample scored in the average range but lower than their noncolic INFANTS WITH COLIC matches. No children scored less than 1 SD below the mean on the WISC-III. The results of this study showed no differences between groups with regard to parent stress. The parent distress subscale of the PSI addressed parent-perceived competence, stresses associated with the restrictions placed on other life roles, marital conflict, lack of social support, and depression. This finding suggests that the feelings of maternal incompetence and depression found during and shortly after the colic period (Keefe et al., 1996; St James-Roberts et al., 1998) are transient. In this sample the children in both colic and noncolic groups seemed to be exposed to similar maternal emotional environments. However, only one measure of parent stress was used, and additional questionnaires or observation of parent-child interactions might have shown differences. Limitations Sample homogeneity in this study is both a strength and a limitation. The sample was predominantly middle class, educated, and Caucasian. Most families were headed by two parents and appeared stable. This is a strength of the sample in that potentially fewer extraneous factors would have influenced parent stress and child characteristics than in a less stable sociodemographic sample. Sample homogeneity, however, limits generalizability. It is unknown whether a study of families with a lower or higher socioeconomic status, other ethnic groups, or families in unstable environments would yield similar results. This was an exploratory study. Although child assessment measures were objective, mothers provided most of the information about the child. Without extensive child observation and corroborating reports from other sources, it is difficult to ascertain the validity of the maternal responses, and response bias is a possibility. There are also limitations in the use of a retrospectively identified noncolic sample. It is possible that mothers in the comparison group may have minimized the crying of their infants. Replication of these results is necessary with larger prospectively ascertained samples of children with and without colic. The colic sample in this study was small, which may have inadvertently introduced unique sample characteristics that would not be found in a larger sample. However, given the large effect sizes that were observed in the colic versus noncolic samples, the small sample size generally did not reduce the 19 ability to find significant effects, as is often the case. The sample size was too small to use all of the BSQ and CBCL subscales in the analysis. Similarities and differences in the groups might be better identified if all subscales could be examined in a larger sample. Longitudinal studies incorporating a detailed description of the infant’s colic, multiple methods of data collection (from child, both parents, and teachers), and research assessing other measures of cognitive ability and school performance would yield more comprehensive data on the relationship between a history of colic and subsequent child, maternal, and family characteristics. Summary No differences were found between the colic and noncolic groups in maternal ratings of difficult temperament, the CBCL internalizing or externalizing subscales, sleeping difficulties, or parent distress. However, children who had colic in infancy had significantly higher maternal ratings on the ADHD Checklist, made more errors and responded more quickly on the MFFT, and scored lower on the WISC-III than children in the noncolic group. Half of the children in the colic sample had at least one indicator of difficulty in emotional regulation (score in clinical range) compared with fewer than one fourth of the children in the noncolic sample. Results indicated that children who had colic in infancy generally were in the normal range with regard to child behaviors and cognitive abilities that were associated with difficulty in emotional regulation, although they scored higher than their matched noncolic peers. Implications for Nursing Because infantile colic affects up to 30% of the infant population, nurses who work in pediatrics are likely to encounter colic in their practice. Results of available research on colic sequelae indicate that most children who have had colic are normal. Because a concern of parents of infants with colic is what to expect when the child is older, these results might be reassuring. 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