Journal of Pediatric Psychology, Vol. 15, No.

2, 1990

Perceived Temperamental Characteristics and

Regulation of Physiological Stress: A Study of

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Wheezy Babies1
Beatrice Priel,2 Avishai Henik, Amira Dekel, and Asher Tal
Ben Gurion University of the Negev, Israel

Received September 26, 1988; accepted April 5, 1989

Exploredprospectively were the temperamental dimensions involved in the

modulation of wheeziness in infancy. Subjects were 69 infants, 4 to 8 months
old, referred to the emergency room because of wheeziness, and a control
group of 30 infants, 4 to 8 months old, referred to the emergency room be-
cause of an acute illness other than wheeziness. Infant respiratory clinical
score for wheeziness was registered and the Revised Infant Temperament
Questionnaire and a demographic questionnaire were completed. Fourteen
months later the reccurrence of wheeziness attacks—that is, asthma—was
investigated. Maternal reports of infant's rhythmicity signifcantly improved
the prediction of asthma among wheezy babies; wheezy babies were perceived
as significantly less active than nonwheezy babies.
KEY WORDS: asthma; temperament; rhythmicity; infants.

Temperament has been recently defined as consisting "of relatively consis-

tent, basic dispositions inherent in the person that underlie and modulate
the expression of activity, reactivity, emotionality and sociability". (Gold-
smith et al., 1987, pp. 524). While most approaches emphasize the biologi-
cal and personological basis of this construct, the effect of environmental
factors on temperamental characteristics and on maternal perceptions of tem-
•This research has been supported by the Levin Center for the Development of the Child and
Adolescent, Hebrew University, Jerusalem.
2
All correspondence should be sent to Beatrice Priel, Department of Behavioral Sciences, Ben
Gurion University, P.O. Box 653, Beer Sheva 84105, Israel.
197
0146-8693/9O/04O0-0197J06.00/0 © 1990 Plenum Publishing Corporation
198
Priel, Henik, Dekel, and Tal

perament has been widely recognized (Campos, Barrett, Lamb, Goldsmith,

& Stenberg, 1983; Goldsmith et al., 1987; Sameroff, Seifer, & Elias, 1982;
Vaughn, Bradley, Joffe, Seifer, & Barglow, 1987). Various dimensions of
temperament have been related to the individual's self-regulation processes
or to the modulation of stressful stimulation (Garmezy & Rutter, 1983; Kagan,
1983; Lerner, Baker, & Lerner, 1985; Leraer & East, 1984; Lerner & Lerner,
1983; Rothbart & Derryberry, 1981; Rutter, 1981; Werner & Smith, 1982).
The literature on coping with stress shows a relevant distinction between
those reactions to stress that are reflexive or involuntary and those that are
effortful and purposive (Lazarus & Folkman, 1984; Murphy, 1974). In adult

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research the term coping is reserved for the latter (Compas, 1987). But in
the context of coping responses in childhood, coping has been placed mid-
way on a continuum ranging from reflexive, dispositional reactions at birth
to learned responses that may become automatized later on (Murphy, 1974;
Murphy & Moriarty, 1976). Research on coping in infancy supports this
model, as, for instance, does the study on organized behavioral patterns that
serve to reduce stress from birth onward (Cohen, 1980; Escalona, 1962; Korn-
er, 1973; Rothbart & Derryberry, 1981; Wolff, 1965), the research on at-
tachment and separation (Ainsworth, 1979), and that on resiliency to stress
in infancy (Werner & Smith, 1982).
The study on coping with stress in infancy emphasizes a role for tem-
peramental characteristics in infants' sensitivity to the environment as well
as in the way infants will react once aroused or distressed (Garcia Coll, Kagan,
& Reznick, 1984; Kagan, 1982). The dependency on the environment for sur-
vival is a central feature in the study of infants coping with stress. It is there-
fore claimed that the adaptation between infant and environment will
influence the effectiveness of infants coping with stress (Lerner & East, 1984;
Lerner & Lerner, 1983).
The present study explores the temperamental dimensions that are relat-
ed to the modulation of a specific physiological stress —i.e., airways
difficulties — in infancy. Research on coping with stress demonstrates that
psychological factors may be significantly involved in the decrease of phys-
iological arousal; i.e., the physiological response to noxious stimuli is marked-
ly altered by psychological factors (Levine, Weinberg, & Brett, 1979). Mason
(1968), for instance, reported that physical stressors like cold, heat, and food
deprivation failed to stimulate the hypothalamic-pituitary-adrenocortical axis
when cognitive and emotional factors were controlled. Animal research has
amply demonstrated this point (Levine, 1983).
Physiological parameters related to individual differences among in-
fants have been studied mainly from the perspective of the relationship be-
tween autonomic responsivity and behavioral expressions. Already in 1930
Temperament and Regulation of Wheeziness 199

Jones suggested that there might be a negative relatidnship between children's

overt behavioral expression and their covert autonomic responses. This
assumption was later confirmed by Buck (1975, 1977). Accordingly, Field
(1982) suggested that the measurement of individual differences in behavioral-
autonomic expressivity among infants may allow for the identification of
children at risk of subsequent stress-related disease; Field (1982) as well as
Buck (1975, 1977) and Jones (1950) argue for a heredity—environment in-
teraction on behavioral-autonomic expressivity.
There seem to be specific methodological difficulties that are involved

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in the research on physiological stressors and stress reactions in infancy. It
has been suggested (Gunnar, 1987) that one of the main reasons for the lack
of research on physiological stress reactions among infants is the difficulty
in obtaining reliable physiological measures of stress at this age level. A similar
difficulty applies to any attempt to evaluate physiological stressors (i.e., colic
pains or skin irritations) in infancy. In addition, stress regulation mechan-
isms must generally be studied retrospectively, when the infant has already
experienced the stress. However, note that such a design leads to the necessi-
ty to evaluate temperamental characteristics on the basis of data that have
already been influenced by the infants' recurrent experiences of stress and
by the environmental reactions to it (Campos et al., 1983; Cohen, 1980).
To deal with these methodological problems a prospective study relat-
ing temperamental characteristics relevant to the modulation of a specific
measurable physiological stress—wheeziness (i.e., airways hyperreactivity)—
was conducted. Wheezy baby is a term employed to describe infants with
wheezing episodes before meeting the criteria of infantile asthma. Infants
with recurrent episodes of wheezing (three or more attacks) are considered
as having asthma, regardless of age of onset or apparent precipitating cause
of the wheeze (Levison, Tabachnick, & Newth, 1982). Asthma is a disease
characterized by increased responsiveness of the airways to various stimuli
(e.g., viral infections of the respiratory tract, allergens such as house dust,
grass, pollens, cigarette smoke, seasonal weather changes) and manifested
by a widespread narrowing of the bronchi that changes in severity either spon-
taneously or as a result of therapy (American Thoracic Society, 1962).
Wheeziness is a rather common pediatric problem, and, among the
wheezy babies, 60% become chronically asthmatic, while the other 40% de-
velop free from respiratory symptoms (McConnochie & Roghman, 1984).
Even though wheezy babies constitute a population at risk for chronic asth-
ma, there are no known physiological parameters that will allow the predic-
tion of who, among wheezy babies, will become asthmatic (Schwartz, 1984).
The investigation of the temperamental characteristics of this population al-
lowed the utilization of a prospective research design to explore the temper-
200 Priel, Henik, Dekel, and Tal

amental dimensions that may discriminate between the wheezy babies who
became asthmatic and those who did not.
We attempted to deal with two issues: (a) Which temperamental dimen-
sions are related to coping with this specific stress (i.e., airway difficulties)?
Or, in other words, which temperamental dimensions will predict the develop-
ment of asthma? (b) The second issue refers to the possibility of discriminating
between wheezy and nonwheezy infants on the basis of their temperamental
characteristics. Specifically, one may ask if there is a temperamental differ-
ence between these two populations of infants. A relevant question is whether

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the same or different aspects of temperament would be unfolded in dealing
with these two issues.

METHOD

Subjects

The subjects were 69 infants, 4 to 8 months old, referred to the Soroka

Medical Center Pediatric Emergency Room because of wheeziness. Thirty-
four of these infants (20 boys and 14 girls) were hospitalized, and 35 (23 boys
and 12 girls) were sent back home, after physical examination, with treat-
ment prescriptions; the different proportions of boys and girls relates to the
known greater incidence of wheeziness among boys. Only infants having a
first episode of wheeziness were included in this study.
A control group was composed of 30 infants (18 boys and 12 girls),
4 to 8 months old, that were referred to the emergency room because of an
acute illness other than wheeziness (acute infections mainly); 15 subjects were
hospitalized while 15 were sent back home after physical examination. This
control group permitted the comparison of perceived temperamental charac-
teristics among wheezy and nonwheezy babies while the effects of hospitali-
zation or emergency room experiences on the infants and mothers were kept
constant. Since temperament was measured 3 to 4 weeks after the visit to
the emergency room and when the infant was well and back to routine life,
a group of otherwise normal infants having the experience of emergency room
or hospitalization allowed us to control for possible effects of these ex-
periences on maternal reports of infant temperament.
Infants in both the wheezy and nonwheezy groups were growing ac-
cording to the 25th to 50th percentile (for weight and height). All the chil-
dren in this study were white; 24.6% of the wheezy infants had parents or
grandparents that immigrated to Israel from Asia or Africa, 39.2% from
Europe or America, and 36.2% had mixed parents (i.e., one parent or grand-
parent born in Asia or Africa and the other one born in Europe or Ameri-
Temperament and Regulation of Wheeaness 201

ca). In the nonwheezy group 21.1% of the parents or grandparents

immigrated from Asia or Africa, 39.9% from Europe or America, and 39%
were mixed. Differences in ethnic origin were also tested comparing wheezy
hospitalized with nonwheezy hospitalized and wheezy nonhospitalized with
nonwheezy nonhospitalized subjects; no significant differences were found
for these groups (x2(3, n = 49) = 3.77, n.s., and x2(3, n = 50) = 4.46,
n.s., respectively). All subjects were raised by their own parents with the
mother as principal caregiver. The four groups, wheezy hospitalized, wheezy
nonhospitalized, nonwheezy hospitalized, and nonwheezy nonhospitalized
infants, did not differ significantly regarding maternal educational level; mean

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educational levels were 11.9, 12.2, 12.5, and 12.2, respectively (F(3, 100) =
0.168, n.s.). Cases of pre- or perinatal problems and children suffering from
any chronic condition, congenital abnormality, or developmental disturbance
were excluded from this study. Eight additional subjects were excluded from
the study since they left town before phase 2 of the study, and one other
child was excluded because of a congenital abnormality diagnosed after our
first interview with the mother.

Measures

For temperament assessments we employed the Revised Infant Tem-

perament Questionnaire, ITQ-R (Carey & Me Devitt, 1978). The ITQ mea-
sures nine temperamental dimensions corresponding to the domains identified
by Thomas and Chess: activity, rhythmicity, approach, adaptability, inten-
sity, persistence, distractibility, threshold, and mood (Thomas & Chess, 1977;
Thomas, Chess, & Birch, 1968).
Demographic data regarding each child were collected according to a
demographic questionnaire designed for the present study; this questionnaire
included data regarding maternal education, number of siblings, parental
ages, and countries of origin.
Airway difficulties were evaluated clinically during the pediatric evalu-
ation, by means of a clinical score (Tal, Barilski, & Yohai, 1983). The score
included respiratory rate, wheezing, cyanosis, and the use of accessory mus-
cles. The maximum possible score was 12, which indicated severe illness. In-
fants with a score of 6 or higher were admitted while those with clinical scores
of 5 or less were sent home.
A follow-up questionnaire was designed to evaluate the infant's health
status a year after his or her first visit to the hospital; this questionnaire in-
quires mainly about airway difficulties and was coded by a pediatrician blind
to the child's belonging to the experimental or the control group. Scoring
in the follow-up questionnaire was from 1 (no wheeziness at all) to 4 (chronic
asthma).
202 Priel, Henik, Deke), and Tal

Procedure

The present study had a prospective design consisting of the following

two phases: During phase 1 the respiratory clinical score was evaluated at
the emergency room as part of the regular pediatric evaluation. At the time
of discharge, maternal consent to be included in this study was obtained.
Three to 4 weeks later a structured interview took place at home; during this
interview the ITQ-R and the demographic questionnaire were completed by
a trained interviewer, blind to the clinical score values registered in the child's
hospital file. The interview procedure assured that subjects' inclusion in the

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study was not biased by the selective responsiveness characteristic of data
collected through mailed questionnaires. At the end of this interview mater-
nal permission was obtained to contact her again in a year's time.
Phase 2 of the research took place 14 months after the first interview,
when each child's history of wheeziness since the first visit to the hosptial
was registered. Infants who had had three or more episodes of wheeziness
were considered asthmatic according to accepted pediatric criteria (Levin-
son et al., 1982). This classification was made by a physician blind to both
the clinical score and the ITQ-R results. We had to wait this long since
seasonal changes are a significant variable in the study of asthma and wheez-
iness. A four-season period was necessary in each case to determine if the
child became asthmatic or not, according to the accepted medical definition.

RESULTS

We conducted two basic analyses of the data. One analysis concerns

predicting the development of asthma within the population of infants with
airway difficulties (i.e., wheezy infants). The other analysis deals with the
possibility of differentiating between the experimental (wheezy) and the con-
trol (nonwheezy) subjects.
The first analysis was aimed at finding the dimensions of temperament
that are related to the regulation of airway difficulties and that would predict
the development of asthma a year after the first episode at the emergency
room. We performed a stepwise multiple regression analysis on the data col-
lected from the experimental group. In this analysis temperamental dimen-
sions, demographic data, and clinical score were entered as independent
variables in an attempt to predict the follow-up score. The results of this
analysis are presented in Table I.
Rhythmicity was the only temperamental dimension that significantly
predicted the development of asthma (R = 39, .FCl, 67) = 12.31, p < .001).
Note that the clinical score that is employed in clinical evaluations of airway
Temperament and Regulation of Wtaeeziness 203

Table I. Results of Stepwise Regression Analysis with Follow-Up Clinical Score of Air-
way Difficulties as the Dependent Variable
Step Variable entered F to enter Multiple R Overall F
1 Rhythmicity 12.31' .394 12.31'
2 Clinical score of airway difficulties
at phase 1 2.22 .427 7.38'
3 Mood 1.17 .444 5.32*
4 Approach 1.51 .464 4.40*
5 Intensity .65 .473 3.63*
6 Persistence .90 .485 3.17'
7 Education .95 .497 2.85°

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"P < .05.
.01.
C
P< .001.

difficulties enters only at the second step of the analysis and does not con-
tribute significantly to prediction. This regression analysis assumes that asth-
ma is a continuous variable and that the difficulties presented by the subjects
were graded according to the follow-up score. Today's accepted definition
of asthma seems to be discrete; that is, three or more attacks constitute chronic
asthma and less than three attacks are not considered to be chronic asthma
(Levinson et al., 1982). We therefore also performed a discriminant analysis
in which all dependent variables were evaluted as to their ability to distin-
guish between asthmatic and nonasthmatic infants. Analyses were carried
out on the same group of children as the above regression analysis. The ob-
tained results are similar: The only variable that distinguishes between the
two groups (asthmatic vs. nonasthmatic) is rhythmicity (Wilks's Lambda =
.893,F(1,67) = 9.736, p < .005, with 62.32% of correctly classified cases).
The correlations among temperament, maternal education, clinical
score, and follow-up scores are presented in Table II. Table II shows rela-
tively high and significant correlations between rhythmicity and activity lev-
el (r = .413), between rhythmicity and mood (r = .306), and between
rhythmicity and distractibility (r = .312). Rhythmicity correlates significantly
with maternal education (/• = - .383). Note that the correlation between rhyth-
micity and maternal education is negative; that is, mothers with low educa-
tional levels tend to rate their infants as arhythmic.
The second analysis was aimed at unfolding the variables that would
differentiate between the experimental and the control groups (i.e., wheezy
and nonwheezy infants). We conducted a discriminant analysis in which all
the independent variables of the former analysis were evaluated as to their
ability to distinguish between the experimental and the control subjects. In
this analysis only the activity dimension emerged as distinguishing between
the two groups (Wilks's Lambda = .919, F(l, 102) = 8.96, p < .005).
 Table II. Correlations Among Temperament Dimensions, Maternal Education, Clinical Score, and Follow-Up Clinical Score"
Adapt- Distract- Follow-up
Activity Rhythmicity Approach ability Intensity Mood Persistence ability Threshold Education clinical score
1 Clinical score - .034 .186 -.018 -.016 -.134 .151 .108 .165 -.010 -.217 .236
2 Activity .413" -.006 .162 .292* .113 .036 .127 .034 -.051 .101
3 Rhythmicity .148 .220 .169 .306* .110 .312* .060 -.383* .394"
4 Approach .415" .001 .298* .048 .134 .274* -.098 -.046
5 Adaptability .296* .248 -.066 .213 .283* -.130 .096
6 Intensity .030 -.188 .068 .228 -.169 -.045
7 Mood .235 .431C .067 -.161 .250*
8 Persistence .016 -.133 -.162 .003
9 Distractibility -.108 .105 .140
10 Threshold -.447" -.036
11 Education -.245

"For the various dimensions high scores are indicative, respectively, of high wheeziness, high activity levels, arhythmicity, withdrawal, slow adaptability,
high intensity, negative mood, low persistence, low distractibility, low threshold, high maternal education, high follow-up (i.e., asthma).
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"p < .05.

°p < .01.
Temperament and Regulation of Wheeziness 205

Wheezy babies' mean activity score was 3.81 (SD = 0.61) and nonwheezy
babies mean activity score was 4.17 (SD = 0.53). The difference between
these means was significant: ((102) = 2.99, p < .005). Other variables did
not add significantly to the discrimination between the two groups above
the contribution of the activity dimension.

DISCUSSION

The obtained results suggest that maternal perceptions of the infant

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as arhythmic constitute a valuable predictor of asthma among wheezy ba-
bies. This finding is of special interest since, as mentioned above, there are
not any known physiological parameters that can predict asthma in the wheezy
baby population; the respiratory clinical score did not predict asthma in the
present study either. A second main finding refers to the activity level dimen-
sion as discriminative between the wheezy and the nonwheezy babies during
phase 1 of this study.
The dimension of rhythmicity refers mainly to maternal ratings of the
child's consistency in terms of feeding schedules, sleep-wake cycles, and fuss-
iness periods; rhythmicity, in this sense, is the degree to which the mother
perceives the infant as predictable and regular in basic biological functions.
Rhythmicity refers to the regularity of the main biological functions and states
that constitute the main area of mother-infant interaction at the age level
studied. An infant perceived as rhythmic is basically very predictable, en-
hancing maternal feelings of competence. This issue has already been point-
ed out in a study on the relations between maternal temperament ratings and
operant conditioning learning among 2- to 3-month-old infants (Dunst &
Lingerfelt, 1985). According to this study, rhythmicity—measured with the
ITQ —was the best predictor of learning rates. Dunst and Lingerfelt (1985)
considered that regularities of bodily functions provide a basis for the in-
fant to learn about predictability of events. Accordingly, rhythmicity is con-
sidered by these authors to be a factor that increases the response-contingent
associations in infancy.
The evidence that rhythmicity relates to such heterogeneous functions
as regulation of a defined physiological stress like wheeziness, on the one
hand, and to the facilitation of operant learning, on the other hand, sug-
gests that this temperamental dimension may constitute an important indi-
cation of self-regulation and adaptation between infant and environment.
Significant correlations were also found between rhythmicity and mood (r
= .25, p < .05) and between mood and asthma (r = .30, p < .05). However,
the regression analysis shows that mood does not add significantly to rhyth-
micity in predicting asthma. Hence, it seems that rhythmicity and mood con-
tribute in a similar fashion to the modulation of a physiological stress.
206 Priel, Henik, Dekel, and Tal

Perceived positive mood very likely contributes to the elicitation of positive

affective expressions from the environment.
The significant negative correlation between rhythmicity and maternal
education (i.e., mothers with lower educational levels tend to report more
arhythmicity) confirms previous findings about the relationships between
maternal perceptions of easy temperamental characteristics and variables
related to socioeconomic status (Vaughn et al., 1987). Even though mater-
nal education did not contribute significantly to the prediction of asthma
(see Table I), the obtained correlation between rhythmicity and maternal edu-
cation suggests that a low level of maternal education may be a contributing

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factor of risk among wheezy babies. Such a conclusion converges with Esca-
lona's (1982) concept of the "double hazard" to which are exposed physical-
ly more vulnerable babies from less privileged populations.
Interestingly, important self-regulation dimensions of temperament, like
the approach-avoidance, persistence, or distractibility dimensions (Rothbart
& Derryberry, 1981), were not found to predict the modulation of wheezi-
ness in the studied population. A possible explanation for these findings is
that distractibility, approach-avoidance, and persistence are dimensions relat-
ed mainly to the regulation of external, environmental stimulation and less
related to the modulation of internal physiological stress; the items assess-
ing these temperamental dimensions deal with the child's attention and ap-
proach to or avoidance of external stimulation. To the degree that this
explanation is supported by further research, it suggests the idea of modula-
tion of stimuli as a complex process, including different mechanisms for the
modulation of internal and of external stimulation.
The present study's results indicate that activity levels among 4- to
8-month-old subjects discriminate between wheezy and nonwheezy infants.
Our findings point to a greater incidence of children with significantly lower
levels of activity among the wheezy subjects. Comparing these results with
Carey and Me Devitt's reported values regarding the Revised Infant Tem-
perament Questionnaire (Carey & Me Devitt, 1978), it is evident that the non-
wheezy babies presented normal activity levels while the wheezy babies' mean
activity levels were lower by more than 1 standard deviation (according to
both our findings and the Revised Infant Temperament Questionnaire values
reported by Carey and Me Devitt). The observed relationship between low
activity level and wheeziness may be understood as a special case of the nega-
tive correlation between over behavior and autonomic hyperreactivity (Buck,
1977; Jones, 1950; Field 1982). This explanation does not exclude the effect
of environmental factors but suggests an interaction between environment
and autonomic behavior.
Several studies point to the relevance for coping of infants' activity lev-
els. For example, Werner and Smith (1982) found that the most resilient chil-
Temperament and Regulation of Wheeziness 207

dren in a population confronted with adverse biological and social conditions

tend to be the active ones. Also, Korner et al. (1985) reported a positive rela-
tionship between activity levels and approach (as opposed to avoidance) to
new experiences among infants. A possible explanation of the relationship
between adequate activity levels and better coping among young infants is
suggested in a study on the effects of infants' perceived temperament on
maternal behavior (Klein, 1984). According to this study, infants perceived
as more active tend to receive more expressions of positive affect from their
mothers. Thus, passive infants seem both to hyperreact autonomically and
to structure a less positively responding environment.

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To sum up, the main findings of the present study suggest that mater-
nal report of infant temperamental characteristics provides relevant predic-
tive indicators regarding asthma among wheezy babies. Maternal perception
of low levels of infant activity is associated with airway hyperreactivity (wheez-
iness). Perceived arhythmicity improves the ability to predict the develop-
ment of asthma among wheezy babies. The evaluation of infants' rhythmicity
provides a relatively easy way of obtaining information that enables us to
identify a subgroup of wheezy infants at higher risk of developing asthma.

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