The Influence of Early Childhood Temperament on Later Social–Emotional Functioning in Youth with Cancer

Abstract

Objective

One of the peak incidences of childhood cancer is during the early childhood years. This is also an important time for psychosocial and personality development, and it is well known that early childhood temperament influences later psychosocial functioning. However, this association has not been examined in young children with cancer.

Methods

Parents of children with cancer (N = 39) and healthy comparisons (N = 35) completed an indicator of temperament (Children’s Behavior Questionnaire) when children were young (M_age=4.99 ± 1.05 years). Five years later, parents and youth completed measures of psychosocial functioning (M_age=10.15 ± 1.10 years; Behavior Assessment Scale for Children, 2nd edition and Social Emotional Assets and Resilience Scale).

Results

Parents of healthy comparisons reported that their children demonstrated greater surgency than youth with cancer; there were no differences in negative affect or effortful control. Children with cancer and healthy comparisons were rated similarly on measures of psychosocial functioning. Health status was not a significant predictor of later functioning, but socioeconomic status and temperament were. The influence of temperament was stronger for strengths-based functioning (e.g., social competence, adaptive functioning) versus distress (internalizing and externalizing problems).

Conclusions

Early childhood temperament is a strong predictor of later psychosocial functioning, regardless of health status. Findings highlight the need to consider temperament in the clinical assessment of psychosocial functioning in children with cancer. Additional research is needed to specifically assess how a diagnosis of cancer in early childhood influences temperament over time.

Introduction

A significant number of pediatric cancers are diagnosed in early childhood (ages 0–6; Ward et al., 2014). Emerging evidence suggests that the experiences of these children—who are spending their formative years in hospital beds and waiting rooms rather than in daycare and on playgrounds—are qualitatively different than their age-typical peers, as well as those children who are diagnosed in later childhood (Harman et al., 2018). Indeed, recent papers have identified both cognitive (Bornstein et al., 2012; Willard et al., 2014, 2017) and social–emotional weaknesses (Cox et al., 2019; Darcy et al., 2014) in these children, even when traditional risk factors for these deficits (e.g., central nervous system diagnoses or treatments) are not present (Bornstein et al., 2012; Willard et al., 2014). Limited research, however, has examined the longer term impact of an early childhood cancer diagnosis, with even less attention paid to domains of functioning that are developed during early childhood, and how the diagnosis of cancer during this period may influence trajectories.

Developmental theorists have frequently examined the impact of early childhood temperament on later functioning. Indeed, temperament is regarded as those enduring traits that govern how a child may react to or regulate within his or her environment (Putnam & Rothbart, 2006; Rothbart, 2007). Longitudinal research has indicated that early childhood temperament characteristics—assessed during the preschool years (ages 3–6) or earlier—are predictive of social–emotional functioning in later childhood (Dollar et al., 2017), adolescence (Honomichl & Donnellan, 2012; Pérez-Edgar et al., 2010), and beyond (Caspi et al., 2003; Newman et al., 1997). However, to date, this trajectory has not been examined in youth with cancer.

There are three main components of temperament that have received the most attention within the literature: surgency, negative affect, and effortful control (Rothbart, 2007). Surgency indicates high levels of energy, coupled with a lack of shyness. It is associated with the experience of positive emotions and higher surgency may be protective against the development of depression (Kotelnikova et al., 2015). Negative affect, in contrast, is associated with the tendency to experience distress in novel situations, and may be associated with emotions such as fear, anger, sadness, and discomfort. It has been linked with the development of internalizing and externalizing problems (Wichstrøm et al., 2018). Finally, effortful control refers to self-regulation, problem solving, and inhibition of responses. It is also associated with externalizing problems (Honomichl & Donnellan, 2012), and has been linked with executive functioning (Liew, 2012). Theorists have proposed that individual differences in temperament form the foundation for the development of later personality constructs (Rothbart et al., 2000).

Temperament characteristics may adapt and change over time, either as a result of the normal aging process or in response to a significant event, such as a trauma or illness, though the magnitude of change is more debatable (Kopala-Sibley et al., 2018). For example, several studies have noted increases in effortful control as children age (Kochanska et al., 2000; Li-Grining, 2007), and adolescents who experienced more stressful life events over a 5-year period evidenced different age-related changes in temperament as compared with adolescents who experienced fewer stressful events (Laceulle et al., 2012). Perhaps most relevant to the cancer experience, Séguin et al. (2020) recently demonstrated that a traumatic brain injury in young childhood was associated with changes in temperament, especially surgency, post-injury. Such findings raise the question of whether a cancer diagnosis in young childhood may be associated with changes in temperament, or if the association between early temperament and later functioning may be different in children with cancer versus those without.

Both temperament and personality/disposition have been assessed in youth with cancer, but typically with those school-aged (e.g., 8 years of age and older) and beyond. For example, Salley et al. (2015) sought to determine whether temperament characteristics may at least partially explain the difficulties with social functioning so often seen in survivors of pediatric brain tumors. Results indicated that survivors of brain tumors demonstrated less surgency and effortful control than healthy comparisons, and effortful control and prosocial behavior were associated. However, effortful control did not explain cancer-control differences in social functioning. As such, while findings support the potential impact of a cancer diagnosis on aspects of temperament, further research was needed to understand the longitudinal impact of temperament in this population. Similarly, several investigators have examined the role of temperament in understanding variability in emotional functioning and quality of life (Harper et al., 2014; Miller et al., 2009; Tillery et al., 2019). Findings have provided support for the influence of negative affect on anxiety, depression and posttraumatic stress symptoms, and effortful control on quality of life. Relatedly, personality/dispositional traits have been explored as a mechanism for understanding variability in coping and adjustment outcomes seen in youth with cancer (Howard Sharp et al., 2015; Phipps et al., 2009). Findings suggest that personality traits—such as neuroticism or optimism—may be a strong indicator of the experience of distress related to cancer. Together, such findings highlight the importance of considering temperament factors in the assessment of social–emotional functioning, but also raise questions regarding the longitudinal influence of these factors, particularly when assessed early in life.

The objective of this article was to examine the influence of early childhood temperament (assessed when children are between the ages of 3–6) on school-age psychosocial functioning (assessed 5 years later, ages 8–12) in children with cancer, as compared with a control group of typically developing children. Consistent with literature on change in temperament postevent or injury, it was hypothesized that both temperament and the magnitude of the influence of temperament on later functioning would be impacted based on health status (cancer vs. comparison). Further, consistent with the literature in typically developing children, it was hypothesized that ratings of surgency and effortful control in early childhood would be predictive of social–emotional functioning (e.g., social competence, adaptive functioning) and that negative affect would impact emotional–behavioral functioning (e.g., internalizing and externalizing behavior) 5 years later.

Methods

Procedures

Young children between the ages of 3 and 6 years and diagnosed with cancer were recruited from outpatient clinics at a children’s cancer center to participate in a longitudinal study of coping and adjustment (Phipps et al., 2015; Tillery et al., 2019). Youth and their parents completed measures at four timepoints over 5 years, with data for the current project pulled from the initial and final timepoints. Eligibility criteria at study entry include: (a) child between 3 and 6 years of age; (b) at least 1 month from diagnosis of a malignancy; (c) no significant cognitive or sensory deficits that would preclude participation; and (d) parent/legal guardian was willing to participate and could speak/read English. A total of 50 participants were enrolled at study entry (of 66 contacted, participation rate 75.7%), with 39 (78%) completing measures at both timepoints and thus eligible for the current analysis. There were no demographic or temperament characteristic differences between those who were included in analyses and those who were not.

A comparison group of typically developing healthy children was recruited in a two-step process. First, permission slips were sent home with children enrolled at local daycares and other early childhood learning centers in a three state area surrounding the hospital. Returned permission slips gathered information regarding age, race, and gender of the child and occupation/education of the caregiver. A pool of potential participants was thus created and families who were a close demographic match to a cancer participant using a frequency matching procedure were contacted for participation. Due to limitations in the comparison pool with regards to socioeconomic status (SES), a full match to each cancer participant was not always possible. Eligibility criteria at baseline included (a) age 3–6 years; (b) no personal or family history of a serious illness; (c) no significant cognitive or sensory deficits that would preclude participation; and (d) parent/legal guardian was willing to participate and could speak/read English. A total of 47 comparison participants completed an initial visit (of 56 contacted, participation rate 83.9%), with 35 (74.4%) completing measures at both time points and thus eligible for the current analysis. There were no differences between those who were included and those who were not on any demographic or temperament characteristic.

At both timepoints, caregivers and the participating child met with a clinical research assistant in the hospital’s psychology clinic to complete consent procedures and measures. At the final timepoint, a portion of the sample (<10%) completed measures by mail. The study was approved by the hospital Institutional Review Board at all time points, and consent, and assent if appropriate, was obtained. Participants and their caregiver received a small incentive upon completion of measures at all time points.

Participants

The final sample included 39 children with cancer and 35 healthy comparison children. Children were an average of 4.99 (SD = 1.05) years of age at the first time point, and 10.15 (SD = 1.10) years of age at the final time point. The sample was predominantly male (55.4%) and white (79.7%). SES varied significantly by group, with comparison children reporting higher SES (t[72] = 2.92, p = .005); there were no other demographic differences between groups (see Table I for demographic information by group).

Children in the cancer group were about 2.62 (SD = 1.54) years of age at diagnosis, with diagnoses representing each of the diagnostic categories: leukemia/lymphoma (38.5%), solid tumors (46.2%), and brain tumors (15.4%). The most common diagnoses were acute lymphoblastic leukemia (28.2%) and retinoblastoma (30.8%), consistent with the most common diagnoses of this age range (Ward et al., 2014). About half the sample (51.3%) was off therapy at the first time point, and all but one child was off therapy at the final time point.

Measures

Demographic and Clinical Information

At all timepoints, parents provided information regarding demographic variables, including age, gender, race, and caregiver occupation/education. This information was subsequently converted to an indicator of SES using the Barratt Simplified Measure of SES (Barratt, 2006). For the cancer group, diagnosis and treatment information was abstracted from medical records and updated at each timepoint. Clinical variables included diagnosis, age at diagnosis, and current treatment status.

Children’s Behavior Questionnaire, Very Short Form

Child temperament was assessed at baseline only using the parent-completed Children’s Behavior Questionnaire (CBQ), a 36-item measure designed to assess temperament of 3- to 7-year old children. The CBQ yields three subscales—Surgency, Negative Affect, and Effortful Control—reflective of common aspects of children’s temperament. Our analyses utilized raw scores (no standard scores are available) with each score representing a simple sum of the items (range 12–84). Reliability for each subscale—Surgency (α = .664), Negative Affect (α = .725), and Effortful Control (α = .785)—was adequate for the current sample (Putnam & Rothbart, 2006).

Social Emotional Assets and Resilience Scale

The Social Emotional Assets and Resilience Scale (SEARS) is a self- and parent-report strengths-based questionnaire of social–emotional functioning that was completed at the final time point only (Merrell, 2011). The parent-report version is 39 items and yields a total score as well as three subscales: Self-Regulation/Responsibility (self-awareness/insight, self-management, accepts responsibility for actions), Empathy (ability to understand others’ feelings or situation), and Social Competence (maintain friendships, communicate effectively, comfortable within social groups). The self-report version is 35 items and designed for youth ages 8–12 years of age and yields a total score only. All scores are presented as T-scores (M = 50, SD = 10). The SEARS correlates highly with other ratings of social adjustment, including the Social Skills Rating System (Gresham & Elliott, 1990) and has been used with survivors of pediatric cancer (Willard et al., 2019).

Behavior Assessment Scale for Children, 2nd Edition

The Behavior Assessment Scale for Children, 2nd edition (BASC-2) is a commonly used parent- and self-report measure of emotional–behavioral functioning. Raw scores are converted to gender- and age-standardized T-scores (M = 50, SD = 10). While parents completed the entire BASC-2, child participants completed the internalizing scales only, given time constraints within the larger study. As such, composite scores of Internalizing Problems are available for both raters, with Externalizing Problems and Adaptive Skills available just by parent-report. The BASC-2 was completed at the final time point only. Reliability and validity of the BASC-2 has been well-established (Reynolds & Kamphaus, 2004), and it is frequently used to assess emotional–behavioral functioning in youth with cancer (Wolfe-Christensen et al., 2009).

Analytical Plan

Potential differences between the cancer and healthy comparison groups on the three measures (CBQ, SEARS, and BASC-2) were assessed via analysis of covariance (ANCOVA). Given significant differences between groups, SES was controlled for in all analyses. Hierarchical regression analyses were used to assess the influence of initial time point temperament on final time point social–emotional functioning. For each model, the same steps were used: Step 1 was SES; Step 2 was health status (cancer or control); and Step 3 was the three CBQ temperament subscales: Surgency, Negative Affect, and Effortful Control. Outcome variables included the parent- and self-report version of the SEARS and the BASC-2.

Results

Cancer-Control Comparisons

Means and SDs for all measures—CBQ, SEARS, and BASC-2—by group (cancer, control) are presented in Table II. Examination of the means for the SEARS and BASC-2 suggested that they were well within normal limits. After controlling for SES, there was a significant difference between groups in parent-report of surgency, with healthy comparison parents indicating that their children demonstrated more behaviors associated with this temperament characteristic (F[1, 71] = 4.27, p = .04). There were no group differences in negative affect or effortful control. After controlling for SES, there were also no differences between groups on either the parent- or child-report subscales of the SEARS or BASC-2. Effect sizes (partial η²) were small for all comparisons (Table II).

Impact of Temperament on Later Functioning

Three separate hierarchical regression analyses were conducted to examine the impact of early temperament (CBQ) on school-age parent-reported social–emotional functioning (SEARS-P; Table III). A similar pattern emerged for each of the three subscales, with one exception. Specifically, SES was a significant predictor, while health status was not (though the model remained significant). The impact of temperament varied by measure, though the overall model was significant for each, with temperament contributing between 18% and 29% of the variance in social–emotional functioning. Overall, effortful control was a strong predictor of all three subscales, while negative affect did not contribute. Parent-report of surgency was only significant for Social Competence. In each instance, greater levels of effortful control and/or surgency were associated with stronger social–emotional functioning.

An additional three hierarchical regression analyses were conducted to examine the impact of early temperament (CBQ) on school-age parent-report of emotional–behavioral functioning (BASC-2; Table IV). In these models, SES did not play as significant a role, only significantly contributing to the variance for adaptive skills. Similar to the SEARS-P, health status was not significant. Temperament did contribute to the variance, but on a smaller scale, ranging from 10% to 22%. Additionally, the model that included temperament was only significant for adaptive skills. Effortful control was a significant predictor of externalizing problems and adaptive skills, while negative affect predicted internalizing problems. Surgency did not contribute. Specifically, higher ratings of negative affect were associated with more internalizing problems, less effortful control was associated with more externalizing problems, while better effortful control was associated with stronger adaptive skills.

Two final hierarchical regression analyses were conducted to examine the impact of early parent-reported temperament (CBQ) on school-age self-reported functioning (SEARS and BASC-2; Table V). For the SEARS, neither SES nor health status contributed significantly to the variance; however, 16% of the variance was accounted for by temperament, with all three temperament factors contributing. Specifically, greater parent-reported surgency and effortful control, and less negative affect were associated with stronger self-reported social–emotional functioning. For the BASC-2, SES did contribute to the variance in self-reported internalizing problems, but health status and temperament factors did not.

Discussion

It is well understood that early childhood temperament influences later social–emotional functioning; however, this pattern has not previously been explored in children with cancer, whose early childhood period is disrupted by treatment and subsequent social isolation. As such, the current longitudinal report describes the influence of early childhood parent-reported temperament factors, measured when children were between 3 and 6 years of age, on parent- and self-reported social–emotional functioning 5 years later. Hypotheses regarding differences in temperament were partially supported, with cancer comparison differences for surgency, but not negative affect or effortful control. There were no significant differences between groups on any measure of psychosocial functioning. In support of hypotheses and consistent with prior literature, there was a significant link between early childhood temperament and later functioning. Interestingly, this was primarily observed in social–emotional functioning as compared with emotional–behavioral functioning, and stronger links were also observed with parent-report over self-report.

That there were no differences in functioning—either temperament or adjustment, with the exception of surgency—between youth with cancer and healthy comparisons was in contrast to hypotheses, but in some respects, consistent with the extant literature. Indeed, several papers have demonstrated similar outcomes between youth with cancer and healthy comparisons on aspects of social–emotional functioning, as well as psychological adjustment (Howard Sharp et al., 2015; Noll et al., 1999; Stam et al., 2001). Prior research has indicated variability in psychosocial functioning by cancer diagnosis (Schulte et al., 2018; Willard et al., 2019); however, our sample size was not large enough to examine trajectories by cancer diagnostic category.

That the only difference in temperament between groups was surgency is consistent with recent literature. Specifically, there is recent evidence to suggest that a traumatic brain injury in early childhood is associated with changes in temperament, and specifically in surgency (Séguin et al., 2020). Young patients with more severe traumatic brain injuries demonstrated a slower rate of increase in surgency over the 18 months post-injury as compared with those with less severe injuries and comparison children. Although we did not examine changes in temperament over time, our findings, coupled with those of Séguin et al (2020), may suggest that of the three temperament characteristics measured, surgency is uniquely sensitive to disruptions in typical development caused by illness or injury. Further research will certainly be needed to examine this hypothesis. It is interesting, however, that surgency played a very limited role in predicting later social–emotional functioning, only significantly contributing to parent-reported social competence and self-report SEARS. These two predictions are consistent with the broader literature that indicates the association of surgency with positive functioning (Kotelnikova et al., 2015).

Effortful control was the primary aspect of temperament contributing to later functioning. This is consistent with the broader developmental literature (Eisenberg et al., 2003; Laible et al., 2016), as well as the study by Salley et al. (2015) with older survivors of brain tumors. If effortful control is seen as a precursor to executive functioning (Liew, 2012), it is also consistent with the broader literature that has indicated links with social functioning in survivors (Puhr et al., 2019; Wolfe et al., 2013). Executive dysfunction is a primary neurocognitive late effect observed in survivors of pediatric brain tumors (Robinson et al., 2014; Ventura et al., 2018; Winter et al., 2014; Wolfe et al., 2012), and the early development of this construct is highlighted here. Unfortunately, we were not able to repeat our measure of effortful control later to determine whether there were longitudinal changes with age in the development of this aspect of temperament, and so questions remain regarding this specifically. Additionally, questions remain regarding the potentially differential links that may exist depending on cancer diagnosis or treatment history (e.g., brain tumor, cranial radiation), which our sample was too small to investigate.

This study is not without limitations. First, we did not repeat our measure of temperament, or gather an additional measure of temperament, or disposition/personality, later. As such, we cannot discuss possible changes in temperament that result following a cancer diagnosis in early childhood. Although our measure of temperament is most appropriate for those under 7 years, there are measures available for older youth, and there are also measures that assess personality and disposition which are closely related, though not identical, constructs (Rothbart et al., 2000). Notably, this is a common limitation in longitudinal studies of social–emotional functioning that seek to follow the development of young children over time (Denham et al., 2009). Relatedly, about half of our cancer group was already off therapy at the first time point, and our sample was an average of 2 years postdiagnosis. Therefore, we cannot comment on the true impact of cancer on temperament as we do not have a prediagnosis rating. Future work in temperament may benefit from longitudinal investigations that seek to obtain a baseline measurement close to the time of diagnosis so as to truly examine the impact of a cancer diagnosis in early childhood on the developmental trajectory of temperament. As mentioned throughout the Discussion, our sample size was also a limitation and may have played a role in the lack of significant findings, while also limiting our ability to conduct other analyses (e.g., potential temperament differences within the cancer group). Finally, shared source variance should also be considered a limitation, especially given that our most significant findings were observed for the prediction of parent-reported functioning by parent-reported temperament. Future work would benefit from the inclusion of a larger sample, as well as the use of a self-report indicator of temperament and/or alternative caregiver (e.g., teacher) reports of psychosocial functioning.

From a clinical standpoint, findings highlight the importance of the consideration of temperament in understanding variability in social–emotional functioning. Indeed, it may be worth asking families questions about their child’s early temperament when assessing current functioning, with the understanding that early development influences later functioning. More specifically, the knowledge that a child may be higher in negative affect or lower in effortful control would provide important information regarding the potential need for enhanced support or intervention to promote positive outcomes.

Overall, findings from this study replicate a well-known pattern in the developmental literature in young children with cancer. Specifically, early childhood temperament, as measured by parent-report, is a significant and notable predictor of social–emotional functioning 5 years later. The impact of temperament is much stronger for strengths-based functioning, including indicators of self-regulation, empathy, social competence, and adaptive skills, as compared with psychological concerns such as internalizing or externalizing problems. Further work is needed to establish the developmental trajectory of temperament in young patients with cancer, including longitudinal assessments that begin shortly after diagnosis.

Funding

This research was supported by NIH grant R01CA136782 (to S.P.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. It was also supported by American Lebanese Syrian Associated Charities (ALSAC).

Conflicts of interest: None declared.

References