Prenatal and infancy origins of biological and social-cognitive processes in disruptive behaviour problems in children aged 7 - 9 years.

Young children who frequently hit other people, who disobey rules and are disruptive in social and school settings, are much more likely than other children to show continued behaviour problems into adult life, including criminality, unstable relationships, poor work record, depression, alcohol and drug problems. They are more likely to expose their own children to maltreatment. The problems arise from a complicated mix of genetic and environmental influences, in which key factors probably include, prenatal stress, early infant emotionality, and harsh or abusive parenting as risk, and warm parenting as protective factors. Prevention needs to start in pregnancy and infancy, and treatment in early childhood.
There are strong indications that there are important differences among children with aggressive and disruptive behaviour problems. There are some whose behaviours are driven mainly by angry, impulsive, reactions to the behaviours of other people, and some where lack of emotional reactivity and of empathic responses to others' feelings are the key. We predict that infants who are highly emotional, especially those who react strongly to frustration, and also those who show higher hormonal and nervous system reactions to stress, and who are exposed to family adversity, are more likely later to see others' behaviours as threatening and to react angrily and aggressively. By contrast we expect the unempathic children, as infants to have engaged less with other people, and to have shown lack of fear to ordinary stressors, and that this will have contributed to a lack of emotional responsiveness to others, and hence indifference to their distress. We propose that persistent levels of threat in the early environment will contribute to a third route to aggressive and disruptive behaviours, in which the young child initially shows high reactivity, but then adapts by developing low reactivity leading to a lack of responsiveness to others' distress. It is essential to identify these differences as a basis for developing specific interventions in pregnancy and infancy, and treatments in early childhood.
This will be the first study following children from pregnancy to age 9 years that will test for the three proposed pathways. Funded by two previous MRC grants we have followed, from pregnancy, first time mothers and their children with assessments at two time points in pregnancy and at 5 and 9 weeks after birth, then 7 months, 14 months, 2.5 years, 3.5 years, and 4.5 years, and now plan to assess at 7 and 9 years. We initially recruited 1286 first time pregnant women who were representative of the general population. Of these 1233 mothers were available for postnatal follow-up together with their infant. We have studies them from birth to age 4.5 years using questionnaires, health visitor reports, and home assessments. During pregnancy we invited a smaller number of women (316), of whom many reported high relationship stress, to form a higher risk group for more intensive assessments over time. We have interviewed the mothers regularly about their own mental health and social support, and assessed their children in interaction with their mothers, and as individuals, up to the age of 4.5 years.
At age 7 years we will assess around 300 children and their parents with a comprehensive battery of measures, many of which, such as of planning and inhibiting inappropriate responses, we have used before. Measures of particular interest will be of children's behavioural and physiological reactions to a social exclusion game, to emotionally arousing pictures, and to scenes depicting children in situations that most people see as frightening, or likely to lead to sadness or anger. We will assess the wider group of around 540 children with briefer, but related measures. At ages 7 and 9 years we will obtain standardized information about the children's behaviours and emotions from parents, teachers, and the children themselves.

The study aims to identify pathways from pregnancy and infancy to mechanisms underpinning aggressive and disruptive behaviours in children. These behaviours commonly start in early childhood, are difficult to treat, and are associated with personality and other psychiatric disorders in adult life. We have hypothesised three pathways characterised by high behavioural and physiological reactivity, low reactivity, and a switch from high to low reactivity, each with distinctive child vulnerabilities and environmental contributions. The aim of the study is to show how biological and social-cognitive and emotional processes in 7 year olds have their origins in these pathways, representing distinct mechanisms in the maintenance of aggressive and disruptive behaviours as evidenced in prediction of those behaviours to age 9 years. We will assess children and parents followed from pregnancy to 4.5 years. Using a two phase design, a general population 'extensive' sample has been followed with brief measures (1286 recruited, 68% retained, 6 assessment points), alongside a stratified 'intensive' subsample (316 recruited, 81% retained, 12 assessment points) studied with a combination of biological, observational and experimental measures rarely found in epidemiological studies. Published findings from this study have provided support for the pathways. At age 7 years we will assess around 300 intensive sample children and their parents with a comprehensive range of measures, many of which we have used before. In addition we will assess children's behavioural and physiological reactions to a social exclusion game, to emotionally arousing pictures, and to scenes depicting children in situations likely to be associated with fear, sadness or anger. We will assess the 'extensive' group of around 840 children with briefer, but related measures. At ages 7 and 9 years we will obtain standardized information about the children's behaviours and emotions from parents, teachers, and children.

This research has been designed to have significant impact beyond the academic environment. Aggressive and disruptive behaviour problems are the most common reason for referral to Child and Adolescent Mental Health Services in the Western world, with significant impact on the individual, family and wider community, and an estimated tenfold increase in economic costs to society compared to those without behaviour problems. Improved intervention to reduce the prevalence of these disorders will reduce the adverse impact of such problems on families directly and the communities living in close proximity affected by antisocial acts. Better targeted interventions will reduce the economic costs incurred through the criminal justice system as these children move into adolescence and adulthood. This research aims to characterize distinct developmental pathways to these disorders in middle childhood so that the findings can directly contribute to (1) the development of new more precisely targeted clinical or social interventions to ameliorate such disorders (2) inform the optimal timing for intervention (3) provide new foci for timed assessments in children's lives so as to detect early indicators of poor prognosis.
(1)New Interventions- The research findings will help to generate new targets for focused clinical or social interventions to improve child and family functioning. More knowledge concerning the key characteristics or processes that are predictive of later adverse outcomes will inform clinicians and policy makers about the required content and ideal timing for interventions. Current national guidance (Conduct disorders and antisocial behaviour in children and young people: recognition, intervention and management, NICE, 2013) recommends broad-based parent training interventions as the gold standard treatment for childhood conduct problems in middle childhood. The results of the current study may seriously challenge this broad first line recommendation and may provide evidence to suggest which children might best benefit from improvements in specific aspects of parenting, which children are likely not to benefit from changes in parenting behaviours, and which children might benefit from entirely different treatment approaches and foci. (2) Timing- We expect the work will also generate important information concerning the best time to intervene in a child's life; this might be prenatally to ameliorate stress in pregnancy, postnatally to promote a particular form of parenting or to facilitate understanding of child temperamental or neurobiological sensitivities, or later in childhood at age 7 when social-cognitive processes can be assessed and altered with individual psychological interventions. Clinicians, clinical services like the NHS and the children seeking help from those services all stand to benefit from such information. Reductions in the prevalence of childhood antisocial behaviour that result from such work will impact on the environment of communities and wider society as a whole. (3)New domains assessment- We will identify key early predictors of severity of aggressive and disruptive behaviour problems in middle childhood. The information derived will be able to directly inform assessment procedures and risk assessments on which decisions about care pathways are based. The findings from our work have enormous potential to inform government policy on universal assessment early in life by Health Visitors as part of the Healthy Child Programme, identification of children in school, and on the use of new domains of assessment in Child and Adolescent Mental Health Services. They also have potential to impact on decisions made regarding focus families for government initiatives such as The Troubled Families agenda. Our national and international links with other longitudinal cohorts provides good opportunities for replication of study findings on which policy and practice change can robustly be based.