Factor Structure of Dysregulation Syndrome in Toddlers with Prenatal Cocaine/Polydrug Exposure

Background and Purpose: Toddlers with co-occurring problems in regulating affect and behavior, i.e., dysregulation syndrome (DS), can be identified with the Anxious/Depressed, Withdrawn, Aggressive, and Destructive Behavior scales of the Child Behavior Checklist for ages 2 and 3(CBCL/2-3). Growing evidence suggests that DS is a developmental marker for risk behaviors. However, there is no consensus conceptualization and operationalization of DS in high-risk toddlers. Thus, we identified the factor structure of DS in toddlers with prenatal cocaine/polydrug exposure and validate the factor structure by associating it with school-age behavioral outcomes.   

Methods: Participants were 336 toddlers(50% girls), primarily African-American, of low socioeconomic status, participating in a prospective longitudinal study of prenatal cocaine/polydrug exposure since birth. Children’s affective and behavioral regulation at age 2 were assessed by caregivers using the CBCL/2-3. We used items from 4 syndrome scales that compose the Internalizing(Anxious/Depressed; Withdrawn) and Externalizing(Aggressive; Destructive Behaviors) broadband scales. Items, assessing symptoms in the last 2 month, were rated on a 3-point scale. Higher scores indicate greater symptoms. Raw scores were used for analyses. 

To identify a factor structure of DS, confirmatory factor analyses(CFA) were conducted in Mplus 8 using weighted least squares estimator with mean and variance adjustments(WLSMV) estimator due to the polytomous nature of the data. Three competing models were examined, with chi-square difference tests to compare the nested models: bifactor model where items loaded on a general DS and specific syndrome factors; four-syndrome-factor oblique model; and unidimensional model. To examine the construct validity of the factor structure, the following external criteria were entered into the model and regression paths were computed: 7 DSM-IV diagnostic categories from the Dominic Interactive(DI) self-reported at age 6; early substance use(≤12yrs) from the Assessment of Liability and Exposure to Substance Use and Antisocial Behavior Scale(ALEXSA); and sexual intercourse(<15yrs) from Youth Self Report.

Results: The bifactor model best fits the data, Chi-square=4040.335(406), p<.001; CFI=0.90; RMSEA=0.056(90%CI=0.005-0.062); WRMR=1.243. All standardized factor loadings for DS were statistically significant and substantial(≥.30). Factor loadings on DS were generally stronger than scale-specific loadings. Scale-specific factor loadings on Anxious/Depressed(6-items), Withdrawn(7-items), and Destructive Behavior(7-items) were all significant. Scale-specific factor loadings were relatively low for Aggressive Behavior, and 4 of 9 were not significant. Anxious/Depressed increased the odds of sexual intercourse before 15yrs(OR=1.44, p<.001). Withdrawn decreased the odds of attention deficit hyperactivity(OR=0.74, p<.04) and separation anxiety(OR=0.78, p<.02) disorders. Aggressive Behavior increased the odds of alcohol use by 12yrs(OR=1.36, p<.04). Destructive Behavior marginally increased the odds of oppositional defiant disorder(OR=1.27, p<.06). The DS factor increased the odds of tobacco use by 12yrs(OR=1.33, p<.04).

Conclusions and Implications: In toddlers with prenatal cocaine/polydrug exposure, optimal model fit was found for a bifactor model with a broad DS and specific syndrome factors, which evidenced distinctive patterns of external correlates. These findings support the conceptualization of DS in high-risk toddlers as a broad syndrome of dysregulation that exists in addition to specific anxious/depressed, withdrawn, aggressive, and destructive behavior syndromes. Future research should further establish whether DP in toddlerhood can be deemed as a reliable developmental risk marker by incorporating various proximal and distal outcomes.