Screening for Dysregulation Among Toddlers Born Very Low Birth Weight

Erickson, Sarah J. PhD; MacLean, Peggy PhD; Duvall, Susanne Woolsey PhD; Lowe, Jean
R. PhD

Author Information
Departments of Psychology (Dr Erickson) and Pediatrics (Drs MacLean and Lowe),
University of New Mexico, Albuquerque; and Oregon Health and Science University,
Division of Psychology, Institute on Development and Disability, Portland (Dr Duvall).
Correspondence: Jean R. Lowe, PhD, Department of Pediatrics, MSC10 5590, 1, University
of New Mexico, Albuquerque, NM 87131 (jrlowe@unm.edu).
The authors have no financial relationships to disclose. This research was supported by
DHHS/NIH/NCRR/GCRC Grant No. 5M01RR00997 and the UNMH Pediatric Research
Committee.
The authors declare no conflict of interest.
Abstract
Background: Children born very low birth weight (VLBW) are at increased risk for
regulatory difficulties. However, identifying toddlers at risk has been impeded by a lack of
screening measures appropriate for this population.
Methods: We studied the nature of dysregulation in toddlers born VLBW (N = 32) using the
Infant-Toddler Social and Emotional Assessment (ITSEA) Dysregulation Domain, a
multiscale (including negative emotionality, sleep, eating, and sensory sensitivity) screening
assessment of regulatory abilities.
Results: As evidence of construct validity for this population, ITSEA scores for toddlers born
VLBW showed greater overall dysregulation, as well as sensory sensitivity, compared with
an ITSEA manual-based premature/LBW sample. This was seen both by higher overall
Dysregulation Domain scores and higher percentages of toddlers exceeding the clinical cutoff
levels. Furthermore, compared with age- and gender-matched full-term toddlers, the VLBW
toddlers displayed gender-specific dysregulation profiles.
Conclusions: The greater overall dysregulation in VLBW toddlers compared with
premature/LBW toddlers suggests that early screening for such difficulties among VLBW
toddlers is warranted, and this study provides preliminary evidence that the ITSEA
Dysregulation Domain may be an appropriate screening measure.

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THE ABILITY to self-regulate—defined as the ability to modulate emotion, self-soothe,
delay gratification, and tolerate change in the environment (DeGangi, Breinbauer, Roosevelt,
Porge, & Greenspan, 2000)—is considered an important developmental task of early
childhood (Bronson, 2000; Holodynski, Seeger, Kortas-Hartmann, & Wörmann, 2013). Of
particular significance, regulatory difficulties in infancy and toddlerhood have been
associated with a host of socioemotional and cognitive difficulties, including motor,
language, and cognitive delays, as well as behavioral difficulties during the preschool and
early school years (Aarnoudse-Moens, Duivenvoorden, Weisglas-Kuperus, Van Goudoever,
& Oosterlaan, 2012; DeGangi et al., 2000; Forsyth & Canny, 1991; Hack et al., 2009; Scott et
al., 2012). Furthermore, the impact of regulatory difficulties in early childhood has been
shown to be long lasting, with early dysregulation being associated with externalizing and
internalizing socioemotional difficulties (Calkins & Howse, 2004), as well as sensory
processing difficulties (Desantis, Coster, Bigsby, & Lester, 2004), in middle and late
childhood (Gomez, Baird, & Jung, 2004).
REGULATORY DIFFICULTIES AMONG CHILDREN BORN VERY LOW BIRTH
WEIGHT
Because of the documented relationship between regulatory difficulties and later
socioemotional and cognitive difficulties, early identification among populations who have
heightened vulnerability to regulatory difficulties is essential. Studies comparing children
born preterm with those born full-term show that children born preterm, particularly those
born very low birthweight (VLBW; <1250 g), are more likely to display regulatory problems
(Clark, Woodward, Horwood, & Moor, 2008; Hack et al., 2009; Mouradian, Als, & Coster,
2000; Wolf et al., 2002). In fact, examining dysregulation in children born VLBW, compared
with those born low birth weight (LBW; <2500 g) and those born full-term, may be
particularly important because the risk of regulatory difficulties increases as birth weight
decreases among children born preterm (Black et al., 2004; Moehler et al., 2006; Ni, Huang,
& Guo, 2011; Ohgi, Akiyama, & Fukuda, 2005). The greater risk of dysregulation among
VLBW samples is also consistent with the increased vulnerability for cognitive,
neuropsychological, academic, and behavioral difficulties found in children born VLBW
compared with those born LBW (Hack et al., 2009; Taylor, Klein, Minich, & Hack, 2000).
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Similar to findings with children born full-term, studies suggest that the regulatory
difficulties displayed by children born VLBW are likely to affect multiple domains of
functioning, including affect/arousal (DeGangi et al., 2000), sleep (Rosen et al., 2003),
feeding/eating (Thoyre, 2007), and sensory processing (Salt & Redshaw, 2006).
Affective/arousal regulatory difficulties typically manifest as difficulty self-calming and
modulating emotions. Sleep dysregulation typically includes problems falling and/or staying
asleep, whereas eating or feeding dysregulation includes extremely picky eating and even
gagging when eating. Sensory difficulties include difficulty processing sensory information,
including tactile, auditory, olfactory, and kinesthetic input.
GENDER DIFFERENCES
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Regarding gender differences or gender-specific dysregulation profiles, many studies with
children born VLBW report that girls demonstrate more favorable outcomes, as measured by
cognition, executive function, and motor skills (Bohm, Smedler, & Forssberg, 2004; Hintz,
Kendrick, Vohr, Poole, & Higgins, 2006). However, there is little consensus on gender-
specific dysregulation findings or gender differences on dysregulation components among
toddlers born VLBW, although the need to explore the influence of gender on outcomes has
been emphasized (Aylward, 2002).
SCREENING FOR DYSREGULATION
Unfortunately, the ability to identify those at risk for regulatory difficulties is impeded by the
lack of measures currently available for screening such difficulties in early childhood (Clark
et al., 2008). Studies that have included dysregulation assessments of infants born full-term
have typically included a rather extensive clinical interview (DeGangi et al., 2000; Porge,
Sickel, & Greenspan, 1993). In contrast, the Infant-Toddler Social and Emotional Assessment
(ITSEA) (Briggs-Gowan & Carter, 1998; Carter & Briggs-Gowan, 2000, 2006) allows for a
brief multidomain screening assessment of regulatory abilities in young children.
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The ITSEA has been validated with full-term and premature/LBW samples (<2500 g) as part
of its heterogeneous clinical sample data (Briggs-Gowan & Carter, 1998; Carter & Briggs-
Gowan, 2000, 2006) but has not been validated with a VLBW sample. Psychometric
properties of the ITSEA with these validated samples support its reliability and validity with
sociodemographically diverse pediatric samples of 12- to 36-month-olds (Briggs-Gowan &
Carter, 1998; Carter & Briggs-Gowan, 2000, 2006). First, the internal structure of the ITSEA
is well supported by factor analyses and structural equation modeling. Most relevant to this
study's focus on dysregulation, the ITSEA Dysregulation Domain demonstrated good internal
consistency ([alpha] = .86); with negative emotionality, sleep, eating, and sensory sensitivity
Dysregulation scales having internal consistency estimates of .84, .78, .78, and .63,
respectively (Carter & Briggs-Gowan, 2000). One- to 2-month test-retest reliability was
excellent (ICC = 0.91), and 1-year stability was adequate (ICC = 0.65) for the Dysregulation
Domain. Regarding criterion and construct validity, the ITSEA Dysregulation Domain was
significantly correlated with parental report of child temperament (r = .15–.42) and child
problem behaviors (r = .49–.52) in expected ways, given convergent and divergent validity
considerations (Briggs-Gowan & Carter, 1998; Carter & Briggs-Gowan, 2000).
CURRENT STUDY
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Although the ITSEA has been validated with full-term and premature/LBW samples, it has
not been validated with a VLBW sample. To provide initial evidence of construct validity
with a new (VLBW) sample, the performance of a VLBW sample on the ITSEA
Dysregulation Domain would be expected to be poorer than the performance of two samples
(both ITSEA manual-based premature/LBW and ITSEA manual-based full-term) (Messick,
1989). Toward that end, the current study had two aims: (1) to compare the Dysregulation
Domain and its scales (negative emotionality, sleep, eating, and sensory sensitivity) in a
sample born VLBW with those of a premature/LBW ITSEA manual-based (henceforth
referred to as LBW) sample and with those of an age- and gender-matched full-term ITSEA
manual-based (henceforth referred to as FT) sample. We also compared boys and girls in the
VLBW sample to determine whether there were gender main effects on Dysregulation scale
scores and whether gender interacted with Dysregulation scale scores. As preliminary steps,
we compared the scale structure between the Dysregulation scales within the sample born
VLBW with that in the LBW sample; and (2) we compared the proportion of the VLBW
sample that exceeded clinical cutoff levels on the Dysregulation scales with the proportion of
the LBW sample that exceeded these cutoff levels. These aims serve the larger goal of
gaining understanding into the nature of dysregulation in preterm and VLBW toddlers,
including providing preliminary evidence regarding construct validity with this population,
and identifying the proportion of VLBW toddlers who meet a clinical cutoff level. These
aims provide a foundation for determining the appropriateness of utilizing the ITSEA
Dysregulation Domain as a screening measure with a VLBW population.
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METHODS
Participants
The current sample consisted of 32 children born preterm between the ages of
18 and 22 months (sample mean = 20.43, SD = 1.16, age adjusted for
prematurity) and their mothers. To be considered preterm, infants weighed less
than 1250 g at birth and were born less than 32 weeks' gestation. An illness
severity rating of days on ventilation ranged was used as a measure of illness Table 1
severity (Laptook, O'Shea, Shankaran, & Bhaskar, 2005; Walsh et al., 2005)
and ranged from zero to 80 (mean = 23.19, SD = 25.40). Infants were excluded
from the study if they had been prenatally exposed to drugs, were
visually/hearing impaired, had a known genetic abnormality, constituted a
multiple birth, and/or did not reside with their biological families. Child
ethnicity was determined by maternal report and the VLBW preterm sample
included 14 Caucasian (44%), 9 Hispanic (28%), 8 Native American (25%),
and 1 “other ethnicity” (3%) participants. The median level of maternal
education for the preterm sample was high school completion. The median
yearly income level for the sample was $20,000–$30,000 (see Table 1).
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The demographic information for the two ITSEA manual-based samples (LBW and FT) is
based on the ITSEA Examiner's Manual (Carter & Briggs-Gowan, 2006). Available
demographic data for the LBW sample were similar to our preterm VLBW sample in terms
of child age and maternal education. Ethnicity was somewhat different between the two
samples, whereby the LBW sample included 28 of 46 Caucasian (62%), 8 of 46 Hispanic
(17%), 8 of 46 African American (17%), and 2 of 46 Asian (4%) mother–toddler dyads.
Demographic data for the FT sample represents 80% of an age- and gender-stratified sample
of children randomly selected from 1995 to 1997 birth records at the State of Connecticut
Department of Public Health (Carter & Briggs-Gowan, 2000).
Study procedure
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This study was approved by the Human Research Protections Office of the University of New
Mexico Health Sciences Center. Research nurses at the University of New Mexico Hospital
Pediatric clinic initially recruited participants. All mothers were informed that participating in
the study was voluntary and that declining to participate would not affect access to health
care services. Once informed consent was obtained, a developmental evaluation of the child
was conducted by a senior developmental psychologist or an advanced graduate student while
mothers completed self-report questionnaires.
The ITSEA
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The ITSEA (Briggs-Gowan & Carter, 1998; Carter & Briggs-Gowan, 2000) is a parent report
questionnaire addressing social–emotional problems and competencies of 12- to 36-month-
olds. The ITSEA contains 4 domains, including the Dysregulation Domain (Negative
Emotionality, Sleep, Eating, Sensory Sensitivity) utilized in the current study. The
Dysregulation Domain captures children's level of regulation in regard to emotions, sensory
experiences, and daily living. The Negative Emotionality scale taps into toddler's emotion
regulation (e.g., tantrums, anger, and difficulty with change). The Sleep scale assesses
difficulties children have falling asleep and staying asleep. The Eating scale captures
challenges that children have with feeding (e.g., picky eating, food refusal, and spitting out
food). The Sensory Sensitivity scale measures difficulties that children have with sensory
input or the processing of sensory experiences (e.g., sensitivity to touch, texture, sound, and
motion). Internal consistency estimates for the current sample were good, with the exception
of the Sensory Sensitivity scale (Cronbach [alpha] for the Dysregulation Domain, Negative
Emotionality, Sleep, Eating, and Sensory Sensitivity scales were .81, .79, .65, .84, and .22,
respectively). Because the internal item consistency estimate for the Sensory Sensitivity scale
was poor, we identified and removed two problematic items (related to being bothered by
loud noises and lights; and being bothered by the feel of some things), with an improved
internal consistency estimate (Cronbach [alpha] = .50). Primary analyses were based on the
Sensory Sensitivity scale from the manual (7 items), although secondary analyses were
conducted to assess how the reduced (5 item) scale performed.
Data analyses
This study included a cross-sectional single cohort of toddlers (18–22 months) born VLBW
and their mothers (N = 32). Data analyses correspond to the two study aims. To address Aim
1, comparing the Dysregulation Domain and scale means (Negative Emotionality, Sleep,
Eating, and Sensory Sensitivity) in the sample born VLBW with those of the LBW sample (n
= 46; collapsed across age and gender) and the age- and gender-matched FT sample (Carter
& Briggs-Gowan, 2006), we used one-sample t tests. For all comparisons with the ITSEA
manual-based samples, the ITSEA manual-based sample means, standard deviations, and
sample sizes were used in single-sample t tests as estimates of the population parameters.
Next, we compared boys and girls in the VLBW sample on the Dysregulation Domain score
and its scales through a profile analysis (Harris, 1985). Profile analysis investigates whether
mothers of boys and girls report different Dysregulation scale scores across the 4 scales
(levels test), and whether the magnitudes of gender differences are consistent across the 4
scales (parallelism test). In other words, it explores whether the between-subjects factor
(gender) interacts with the within-subjects factor (Dysregulation scale scores).
As a preliminary step to Aim 1, to ensure that the measurement structure was
similar for the VLBW sample compared with the LBW sample, we compared
associations between the Dysregulation scales within the two samples using
Pearson correlations within each sample and Fisher's z tests to compare the Table 2
Pearson correlations between samples (Table 2).
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To address Aim 2, tests of proportion were used in exploring the threshold cutoff levels
between the sample of toddlers born VLBW and those of the LBW sample (Carter & Briggs-
Gowan, 2006). For this aim, we compared the percentage of the VLBW sample exceeding the
clinical cutoff level on the Dysregulation Domain with those percentages among the LBW
and FT samples (Carter & Briggs-Gowan, 2000).
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RESULTS
Preliminary analysis: Scale structure
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As a preliminary analysis, to determine whether the scale structure between
the Dysregulation scales was similar for the VLBW sample compared with
that of the validated LBW sample, we investigated the magnitude of
associations between the Dysregulation scales for the VLBW sample (N = 32),
as reported in Table 3. We then compared these correlation coefficients with
LBW sample reported in the ITSEA manual and found that the covariance
among scales between the sample-born VLBW and the LBW sample (Carter &
Briggs-Gowan, 2000) was within sampling error. (Although four
intercorrelations among scales for the LBW sample were significant, while Table 3
only two intercorrelations among the VLBW sample were significant,
correlations were in the same direction and of (statistically) equivalent
magnitude [all p > .23].) In short, the associations between Dysregulation
scales were similar in the VLBW sample compared with the LBW sample,
providing preliminary evidence that the validated scales are applicable (i.e.,
work similarly) in a VLBW sample (Table 2).
Comparison of dysregulation domain and subscales in VLBW versus LBW and full-term
samples
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To address Aim 1, a comparison of the Dysregulation Domain and
its scales (Negative Emotionality, Sleep, Eating, and Sensory
Sensitivity) in the sample-born VLBW with those of a LBW
sample, and with those of an age and gender-matched FT sample
(Carter & Briggs-Gowan, 2006), we conducted a series of single
sample t tests. We found that when collapsing across age and
gender, the VLBW sample showed greater overall Dysregulation
Domain scores, t(31) = 2.79, p < .01, and greater Sensory
Sensitivity in particular, t(31) = 4.23, p < .0001, than the LBW
sample (see Table 3 and Figure 1). For gender-specific
comparisons, we compared the means of the VLBW boys with Figure 1 Figure 2
those of the age- and gender-matched FT sample and found that the
VLBW boys obtained higher scores only on the Sensory
Sensitivity scale, t(13) = 3.28; p < .01. Girls differed from the age-
and gender-matched FT sample on the Dysregulation Domain
score as well as on the Eating scale (t(17) = 3.14, p < .01, t(17) =
2.26, p < .05, respectively (Carter & Briggs-Gowan, 2006) (see
Table 3 and Figure 2).
Exploring gender differences
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To address the second part of Aim 1, we compared boys and girls in the VLBW sample to
determine whether there were gender main effects on Dysregulation scale scores and whether
gender interacted with Dysregulation scale scores. We used a profile analysis to investigate
whether boys and girls in the VLBW sample had mean differences on the Dysregulation scale
scores (levels test), and whether the magnitude of gender differences on scale scores differed
by scale (parallelism test) (Harris, 1985). The tests of gender differences (levels and
parallelism tests) were nonsignificant, suggesting that boys and girls obtained similar scores
across Dysregulation scales, and the magnitude of differences across the four scales was not
different (see Figure 1). Thus, the between subjects factor (gender) did not interact with the
within-subjects factor (Dysregulation scale scores).
Clinical cutoff comparisons
Aim 2 compared the proportion of the VLBW sample that exceeded clinical cutoff levels on
the Dysregulation scales with the proportion of LBW sample that exceeded these cutoff
levels. We found that whereas the percentages of LBW sample (collapsed across age and
gender) meeting at least 1, 2, 3, or 4 Dysregulation scale clinical cutoff levels were 37.0%,
6.5%, 2.2%, and 2.2%, respectively, the percentage of boys and girls (combined) in the
VLBW sample meeting those cutoff levels were 53.1%, 21.9%, 7.9%, and 0%, respectively
(Carter & Briggs-Gowan, 2006). Although these proportional differences were not
statistically significant, on average, the proportional difference in exceeding at least one
Dysregulation scale clinical threshold was between -0.02 and -0.34 (90% confidence interval)
greater for the VLBW sample compared with the LBW sample. Next, we compared the
VLBW sample's distribution on the Dysregulation Domain with that of an age- and gender-
matched FT sample. Scores above the 10% cut-point are considered “of concern for problems
(Carter & Briggs-Gowan, 2000).” We found that 3 of 14 boys (21.4%) and 5 of 18 girls
(27.8%) reached the clinical cutoff levels representing the top 10 percentile in the FT sample
(0.81 and 0.83, respectively) (Carter & Briggs-Gowan, 2000).
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Because the internal item consistency estimate for the Sensory Sensitivity scale was poor, we
identified and removed two problematic items (related to being bothered by loud noises and
lights; and being bothered by the feel of some things), with an improved internal consistency
estimate (Cronbach [alpha] = 0.50). Results remained substantively unchanged with this
abbreviated scale, and mean differences were of a larger magnitude.
DISCUSSION
The primary purpose of the study was to better understand the nature of dysregulation in
toddlers born VLBW relative to those born premature/LBW and full-term, and to investigate
preliminary evidence of construct validity and utility of the ITSEA Dysregulation Domain
and its scales for this vulnerable VLBW population. As expected, findings demonstrate that
the sample of toddlers born VLBW showed greater overall dysregulation than the sample
born LBW. Greater dysregulation among the VLBW sample was seen both by the higher
overall Dysregulation Domain scores and by a higher percentage of toddlers born VLBW
exceeding the clinical cutoff levels on Dysregulation scales compared with LBW and FT
samples.
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Although previous studies have not compared dysregulation in toddlers born VLBW with
those born LBW utilizing the ITSEA, the current finding of increased dysregulation among
VLBW toddlers is expected, given previous studies examining components of dysregulation
in both samples. For instance, studies investigating dysregulation components, such as
emotion regulation and physiological regulation, suggest that as birth weight decreases, the
likelihood of dysregulation in these domains increases (Black et al., 2004; Moehler et al.,
2006; Ohgi et al., 2005; Scott et al., 2012; Spittle et al., 2009). In addition to the greater
overall Dysregulation Domain scores found in the VLBW sample, our findings suggest that
VLBW toddlers are significantly more likely to display sensory sensitivity difficulties than
the LBW sample. Previous studies support this finding by showing that among children born
preterm, the likelihood of sensory difficulties increases as birth weight decreases (Vohr et al.,
2000).
Gender-specific findings
We found that the VLBW boys had greater difficulties with sensory sensitivity than the FT
toddlers, suggesting that the VLBW boys' scores may largely explain the sensory sensitivity
finding among the entire VLBW sample. Although no study to our knowledge has examined
gender differences in sensory sensitivity among children born preterm, studies with full-term
children have reported that boys display increased sensory sensitivity compared with girls
(Tirosh, Bendrian, Golan, Tamir, & Cohen, 2003).
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Another gender-specific finding from the current study was that VLBW girls had greater
overall Dysregulation Domain and Eating scale difficulties compared with the FT sample.
This finding is consistent with research documenting increased feeding difficulties among
children born preterm (Thoyre, 2007). Although we found no gender differences on the
Dysregulation Domain or its scales within the VLBW sample (and there were no gender
differences for the FT sample on the Dysregulation Domain or its scales; and no gender-
specific data available for the LBW sample (Carter & Briggs-Gowan, 2000), our within-
gender findings compared with normative samples suggest that gender-specific dysregulation
profiles warrant further investigation in future VLBW studies. To date, there is little
consensus on gender-specific dysregulation findings or gender differences on dysregulation
components among toddlers born VLBW (Aylward, 2002).
Associations among dysregulation scales
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Finally, we found that the associations among the Dysregulation scales (Negative
Emotionality, Sleep, Eating, and Sensory Sensitivity) were similar for the VLBW and LBW
samples. In other words, the measurement structure, and therefore the dysregulation
construct, was similar for both samples. From a psychometric perspective, because the
Dysregulation scale structure was similar for the VLBW sample compared with the LBW
sample, our findings provide preliminary evidence that the ITSEA screening tool may be
appropriate to use with a VLBW sample at 18–22 months. However, this lack of difference
between correlations in the two groups may be due to small sample sizes and therefore must
be interpreted cautiously. Further within-group inspection of the Dysregulation Domain in the
VLBW sample demonstrated that, similar to the LBW sample, the Dysregulation scales were
all highly correlated with the Dysregulation Domain. These findings broaden our
understanding of the nature of dysregulation in toddlers born VLBW and suggest that it may
be quite similar to the structure of dysregulation and its components in LBW samples.
Limitations
The low internal item consistency estimate for the sensory sensitivity scale, however,
suggests that caution is warranted regarding the unitary nature of this scale. In such a young
population, perhaps parents do not report sensory sensitivity across sensory domains, but
rather report on a specific sensitivity (such as sensitivity to motion but not to touch, texture,
or noise) or a combination of some but not all possible sensory sensitivities. In fact, the lower
internal consistency estimate for sensory sensitivity problems may reflect the varying levels
of salience of these behaviors at this stage of development (Carter & Briggs-Gowan, 2000).
Furthermore, once the problematic sensory sensitivity items were omitted, the internal
consistency estimate for the VLBW sample was similar to that reported by the authors (Carter
& Briggs-Gowan, 2000).
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Because a parent report of dysregulation was the only source of dysregulation data in this
study, additional data from multiple sources would clarify the usefulness of the ITSEA as a
screening tool for children born VBLW. In particular, it would be important to conduct full
developmental batteries with children born VLBW and demonstrate that the children with
observed dysregulation difficulties were identified by the ITSEA screening tool (i.e.,
acceptable sensitivity and specificity). In addition, our sample's ethnic distribution was
somewhat different from both full-term and LBW normative samples, and our age range (18–
22 months) was smaller than the full-term normative sample (12–36 months), suggesting
caution in comparing our findings with those from normative samples. Our sample size
precluded additional validity analyses investigating the internal structure of the four scales
and the larger Dysregulation Domain (e.g., confirmatory factor analysis). Our study suggests
preliminary evidence for its utility, but additional construct validity data are needed.
Clinical Implications
Because our findings are consistent with what one would predict from the extant research
addressing dysregulation among preterm samples, thereby providing initial construct validity
for this population (Messick, 1989), our findings suggest that the ITSEA may be a valid
screening measure for investigating components of dysregulation in toddlers born VLBW.
The greater overall dysregulation across affect, sleep, feeding, and sensory sensitivity scales
in toddlers born VLBW compared with those born premature/LBW suggests that early
screening for such difficulties within this population is warranted. Early screening within this
population may be particularly important because dysregulation has been found to be an
important predictor of poor cognitive and behavioral outcomes (Calkins & Howse, 2004;
DeGangi et al., 2000; Hack et al., 2009; Scott et al., 2012).
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Early identification is also indicated given that brief parent–child interventions in early
infancy have been shown to be effective in both enhancing self-regulation capabilities in
children and helping caregivers cope with regulatory difficulties (Poehlmann et al., 2011).
The benefit of early intervention lies in identifying and treating problems during the most
sensitive and responsive early developmental periods, particularly among high-risk
populations such as toddlers born VLBW. For example, interventions focused on enhancing
parenting by supporting consistency and responsiveness may target self-regulation
weaknesses (Koldewijn et al., 2010; Poehlmann et al., 2011); occupational therapy or
desensitization-based behavioral protocols may address sensory concerns and feeding
difficulties. In addition, the identification of sleep concerns may suggest family-based
behavioral intervention targeting modifiable parental behaviors and sleep hygiene (Hofacker
& Papousek, 1998; Koldewijn et al., 2010; Poehlmann et al., 2011; Touchette et al., 2005).
The ITSEA Dysregulation Domain may thereby serve as a valuable screening tool for
identifying early dysregulation and may be used as a first-stage screen for identifying
toddlers who may benefit from additional follow-up assessment and intervention.
CONCLUSION
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Children born VLBW are at increased risk for regulatory difficulties. However, identifying
toddlers at risk has been impeded by a lack of screening measures appropriate for this
population. As evidence of construct validity for this population, ITSEA scores for toddlers
born VLBW showed greater overall dysregulation compared with an ITSEA manual-based
premature/LBW sample. The greater overall dysregulation in VLBW toddlers compared with
premature/LBW toddlers suggests that early screening for such difficulties among VLBW
toddlers is warranted, and this study provides preliminary evidence that the ITSEA
Dysregulation Domain may be an appropriate screening measure. Early screening within this
population is important because dysregulation has been found to predict poorer cognitive and
behavioral outcomes.
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child; eating; emotion; gender; outcome measures; preterm birth; regulation; screening; sleep;
very low birth weight

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Table 2
Table 1
Table 3

Figure 1 Figure 2