Cumulative Risk Factors for Socioemotional Problems in Toddlers with Developmental Delays
Authors:   , Day Chelsea M. , Daly Brian P. 
Published: July 2021

Offspring who encounter biological and psychosocial adversities early in development are vulnerable to lasting physical, mental, emotional, and social deficits across the lifespan, especially autism spectrum disorders (ASD) and socioemotional problems. Numerous individual risk factors have been linked with these problems separately in children of various ages. However, few studies have analyzed the effects of prenatal, perinatal, and early life exposure to cumulative risk factors in predicting socioemotional problems co-occurring with ASD in toddlers. The current study aimed to determine if ASD was associated with internalizing, externalizing, and dysregulation problems in toddlers, and if a novel measure of cumulative risk explained observed deficits above and beyond an ASD diagnosis. 344 participants from an ongoing multisite longitudinal study evaluating optimal timing for repeat ASD screening were divided into 3 groups based on a diagnosis given at a clinical evaluation by trained research staff: ASD (n = 107), developmental delays (DD; n = 145), and typical development (TD; n = 92). The Cumulative Risk Scale was developed from a developmental history questionnaire. The presence of a risk factor (e.g., prenatal SSRI exposure, prematurity, low birth weight, maternal psychiatric diagnosis) was coded as 1 and the absence as 0, and the sum total created each participant's Cumulative Risk Score. After handling significant amounts of missing data with five iterations of multiple imputation, three multiple hierarchical regressions were conducted to determine if an ASD diagnosis was significantly associated with the Externalizing, Internalizing, and Dysregulation domain standard scores of the Infant-Toddler Social-Emotional Assessment (ITSEA). A second block of the hierarchical regression containing the novel Cumulative Risk Scale was added to determine if cumulative risk predicted these outcomes and increased the predictive ability of the model. The "segmented" package of R was then utilized to identify a linear or threshold relationship between cumulative risk and ITSEA outcomes. Results show that an ASD diagnosis was significantly associated with Internalizing problems ([beta] = .143, p = .035, 95% CI [.305, 8.430]), partially supporting the first hypothesis that an ASD diagnosis would be associated with internalizing, externalizing, and dysregulation problems. Further analyses show that both an ASD ([beta] = .278, p < .001, 95% CI [.088, .231]) and DD diagnosis ([beta] = .157, p = .010, 95% CI [.020, .149]) predict Depression/Withdrawal symptoms when controlling for child age. The addition of the Cumulative Risk Scale to the regression model improved prediction of Dysregulation problems only ([beta] = .103, p = .039, 95% CI [.027, 1.010], R2 change = .009, p = .039), partially supporting the second hypothesis that Cumulative Risk would significantly predict socioemotional problems. Further hierarchical multiple linear regressions showed cumulative risk significantly predicted Sleep Problems ([beta] = .101, p = .048) and Eating Problems ([beta] = .102, p = .045). Both hierarchical regressions showed a significant R2 change as well, but should also be interpreted with caution, as both increases were small (0.9% increases). An ASD diagnosis was significantly predictive of only the Negative Emotionality Subscale of the Dysregulation domain ([beta] = .151, p = .047). Results from the "segmented" package of R estimate a break point of 10.27 (p = .04171) for predicting Externalizing problems, but not Internalizing or Dysregulation problems. Toddlers ages 12-60 months with ASD are more likely to experience comorbid internalizing problems, which can have numerous clinical implications in the detection and prevention of internalizing problems early in life. Cumulative risk in early developmental periods overall does not explain socioemotional deficits in toddlers with ASD, DD, or with typical development. However, cumulative risk does predict dysregulation problems across children, regardless of diagnosis. A model depicting the relationship between cumulative risk in early developmental periods, dysregulation or non-disorder-specific socioemotional problems, and later psychopathology was proposed and should be investigated further in future research. A significant threshold of 10 risk factors was identified in predicting externalizing problems but may be possible in predicting internalizing and dysregulation problems as well. A more sensitive measure of cumulative biomedical risk early in life may also improve assessment of cumulative risk.