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Psychological Science
https://doi.org/10.1177/0956797617721271
© The Author(s) 2017
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DOI: 10.1177/0956797617721271
www.psychologicalscience.org/PS
Attachment and Effortful Control in
Toddlerhood Predict Academic
Achievement Over a Decade Later
Lilian Dindo1,2, Rebecca L. Brock3, Nazan Aksan4,
Wakiza Gamez5, Grazyna Kochanska5, and Lee Anna
Clark6
1Menninger Department of Psychiatry and Behavioral Sciences, Baylor
College of Medicine; 2Center for Innovations in Quality, Effectiveness and
Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; 3Depart-
ment of Psychology, University of Nebraska–Lincoln; 4Department of
Neurology, Carver College of Medicine, University of Iowa; 5Department
of Psychological and Brain Sciences, University of Iowa; and 6Department
of Psychology, University of Notre Dame
Corresponding Author
Lilian Dindo
Menninger Department of Psychiatry and Behavioral Sciences
Baylor College of Medicine
2002 HOLCOMBE (152)
HOUSTON TX 77030
E-mail: lilian.dindo@bcm.edu
Keywords
effortful control, attachment, academic performance, longitudi-
nal, temperament
A child’s attachment to his or her caregiver is central to the
child’s development. However, current understanding of subtle,
indirect, and complex long-term influences of attachment on var-
ious areas of functioning remains incomplete. Research has
shown that (a) parent-child attachment influences the develop-
ment of effortful control and that (b) effortful control influences
academic success. The entire developmental cascade among
these three constructs over many years, however, has rarely been
examined. This article reports a multimethod, decade-long study
that examined the influence of mother-child attachment and ef-
fortful control in toddlerhood on school achievement in early ad-
olescence. Both attachment security and effortful control
uniquely predicted academic achievement a decade later. Effort-
ful control mediated the association between early attachment
and school achievement during adolescence. This work suggests
that attachment security triggers an adaptive cascade by pro-
moting effortful control, a vital set of skills necessary for future
academic success.
Received 2/20/17; Revision accepted 6/27/17
Research Article
Research suggests that school achievement is a function
of both intellectual and nonintellectual strengths (e.g.,
La Paro & Pianta, 2000; Liew, McTigue, Barrois, & Hughes,
2008; Swanson, Valinete, Lemery-Chalfant, Bradley, &
Eggum-Wilkens, 2014). However, far less research has
examined long-term cascades, anchored in early childhood
experiences, that ultimately lead to academic
achievement. Investigations of developmental cascades
linking early deficits or strengths to outcomes much
later in development are critically important given their
potential to (a) isolate key domains in early childhood
that trigger adaptive or maladaptive cascades and (b)
clarify the subsequent mechanisms unfolding over time
that ultimately affect development. Such research has
the potential to elucidate how best to interrupt negative
cascades—and promote positive cascades. It thus has
important implications not only for theory but also for
interventions aimed at promoting healthy child development
(Masten & Cicchetti, 2010).
The quality of children’s relationships with caregivers
is one key consideration in early childhood (Bowlby,
1969). A child’s attachment to his or her caregiver is a
vital process and has widespread implications for a
range of socioemotional outcomes (e.g., Kim, Boldt, &
Kochanska, 2015; Laible, Carlo, Davis, & Karahuta,
2016). Thus, it is not surprising that attachment security has im-
plications for such achievement-relevant variables
as preacademic reading skills in preschool years
(e.g., Bus, Belsky, van IJzendoorn, & Crnic, 1997) and
mastery motivation and cognitive engagement in early
school years (e.g., Moss & St-Laurent, 2001). Nonetheless,
most research spans only a few years, typically
from preschool to the first years of school. Thus, the
long-term impact (e.g., into adolescence) of attachment
on academic achievement is unclear.
Further, the mechanisms through which attachment
ultimately influences academic achievement have
received limited attention and warrant closer examination.
Researchers have postulated that attachment security
promotes (a) receptivity to influence and (b) good
coping and emotion-regulation skills, which in turn
support cognitive and learning activities (Bergin &
Bergin, 2009); however, these postulates have not been
tested empirically. Attachment may also influence academic
achievement through its effect on the development
of a child’s ability to inhibit a dominant response
voluntarily and to activate a subdominant response (i.e.,
effortful control; Kochanska, Murray, & Harlan, 2000;
Rothbart & Bates, 2006). It is important to examine this
possibility, because effortful control appears to be a
key variable in a range of developmental outcomes,
including academic success in early school years (Liew
et al., 2008; Swanson et al., 2014). Further, research has
demonstrated that attachment security plays a pivotal
role in the development of self-regulatory skills (e.g.,
Kochanska, 2001), which suggests that parent-child
attachment may trigger a cascade that influences academic
achievement much later in development via
effortful control. We now examine each element of this
proposed cascade more closely.
Effortful Control Predicts Academic Achievement
Effortful control shares features with constructs that are
arguably better established and have longer histories in
the scientific narrative. For example, the ability to delay
gratification (Mischel & Ebbesen, 1970) is a central component
of behavioral batteries of effortful control
(Carlson, 2005; Kochanska et al., 2000). Compared with
other personality dimensions, conscientiousness (i.e., a
tendency to be organized and self-disciplined on the
one hand as opposed to disorganized or careless on the
other) has the highest correlation with effortful control
(Rothbart & Bates, 2006). Further, some consider emotion
regulation to be closely related to effortful control
in childhood (Eisenberg, Smith, & Spinrad, 2011).
Evaluated from this broader perspective, effortful control
(and related constructs) predict academic achievement
over and above the effects of more traditional
aptitude-based predictors such as intelligence
(Duckworth & Seligman, 2005; Noftle & Robins, 2007).
Yet effortful control has been linked only to academic
achievement 1 or 2 years later, with one exception: In a
classic study by Mischel, Shoda, and Peake (1988), delay
of gratification at age 4 predicted better academic functioning
a decade later. There are two prevailing hypotheses
regarding why effortful control affects achievement.
First, children with low effortful control tend to procrastinate
on tasks, spend less time attending to tasks, and
receive less instruction and feedback from teachers,
whereas children high in effortful control have qualities
that promote school learning (e.g., ability to focus on
work, better attention for longer periods of time, voluntary
control of behavior; Tice & Baumeister, 1997). Second,
effortful control promotes better social competency
and fewer behavior problems, which “frees up” resources
to meet academic challenges, which in turn promotes
academic success (Valiente et al., 2011).
A Cascade From Attachment to Academic Achievement via
Effortful Control
As noted, attachment security promotes (a) receptivity
to influence and (b) good coping and emotion-regulation
skills, which in turn support learning activities (Bergin
& Bergin, 2009). Further, evidence increasingly indicates
that effortful control can be modulated by the quality
of the attachment relationship (Kochanska, 2001; Viddal,
Berg-Nielsen, Wan, Green, Hygen, & Wichstrøm, 2015)
and should not be viewed as static (Kochanska & Kim,
2013).
As discussed previously, effortful control appears to
be an important predictor of future achievement (Bergin
& Bergin, 2009; Valiente et al., 2011). For example,
Swanson et al. (2014) demonstrated that effortful control
mediated the effects of positive parenting on achievement
between kindergarten and the second grade,
which provides support for this pathway in early childhood.
Collectively, the evidence suggests that one key
pathway leading to adolescent academic achievement
may lead from the quality of formative relationships with
parents to children’s effortful control to achievement.
However, this pathway has yet to be tested across multiple
stages of development.
In summary, attachment security has far-reaching
implications for emotion and self-regulation (Cassidy,
1994; Eisenberg et al., 2011; Sroufe, 2005); however, the
current understanding of how attachment exerts its influence
on various areas of functioning—and how it initiates
long-term cascades, leading to important outcomes
of interest (e.g., academic achievement)—remains
incomplete. The aim of the current study was to examine the ex-
tent to which early attachment security may trigger
a cascade leading to academic success in adolescence
by influencing effortful control. To achieve this goal, we
used a multimethod design—including standardized
behavioral laboratory tasks; nationally standardized,
norm-referenced achievement test scores; and maternal
reports—spanning over a decade of development from
toddlerhood to adolescence.
Method
Overview of the longitudinal design
Attachment was assessed when the children were
between 2 and 3 years old, and effortful control was
assessed at age 3. When the children were between 11
and 15 years old, a separate research team (the current
authors) obtained information about the socioemotional
and academic functioning of the children from various
sources. Effortful control and mother-child attachment
security during toddlerhood were examined as predictors
of academic achievement in early adolescence,
which was measured with standardized national test
results in math and reading as well as maternal ratings
of scholastic competencies. Further, the potential mediating
role of effortful control in the link between
mother-child attachment security and adolescent academic
achievement was examined.
Participants
Participating families were recruited from two separate
longitudinal studies of infancy and toddlerhood initiated
by Kochanska (1997, 2001). The first sample consisted
of 103 children first recruited at the ages of 2 or
3 years (mean age = 32.9 months, SD = 4.09; 51 girls);
the second sample consisted of 112 children first
recruited at the age of 9 months (mean age = 8.94
months, SD = 0.63; 56 girls). Both samples were mostly
White (> 80%), most came from intact families (≥ 85%
intact at recruitment), and all children were born full
term. Maternal age was comparable in the two samples
(first sample: mean age = 32 years; second sample:
mean age = 31 years). Educational attainment and family
income were diverse. Maternal educational attainment
was distributed as follows in the first and second
samples, respectively: 12% and 26% had high school
education, 20% and 15% had some college, and 68%
and 59% had college or postgraduate education. Family
income for the first sample was distributed as follows:
13% earned less than $15,000, 13% earned $15,000 to
$24,999, 14% earned $25,000 to $34,999, 22% earned
$35,000 to $44,999, and more than 38% earned $45,000
or more. Family income for the second sample was
distributed as follows: 7% earned less than $20,000, 13%
earned $20,000 to $29,999, 20% earned $30,000 to
$39,000, 17% earned $40,000 to $49,999, 17% earned
$50,000 to $59,999, and 26% earned $60,000 or more.
Procedure
Toddlerhood. Attachment measures were obtained when
the children were 3 years old for the first sample and when
the children were 2 years old for the second sample. For
both samples, measures of effortful control were obtained
when the children were 3 years old (first sample: mean
age = 32.9 months, SD = 4.09; second sample: mean age =
32.8 months, SD = 0.53). During these assessments, the
children and their mothers were observed in structured
behavioral assessments for 2- to 3-hr periods.
Adolescence. For the follow-up assessments at adolescence,
children from the first and second samples were,
14 or 15 years old and 11 or 12 years old, respectively.
Sixty-nine mother-child dyads from the first sample participated
in the follow-up assessments (67.0%; 54 dyads
came to the laboratory), 27 dyads could not be located,
and 8 dyads declined participation. Seventy-seven motherchild
dyads from the second sample participated in the
follow-up assessments (68.8%; 56 dyads came to the laboratory),
26 dyads could not be located, and 9 dyads
declined participation. Fifty-two percent of the children
were girls, and 92% were White.
Measures
Behavioral effortful control. The behavioral battery
used to assess effortful control was similar in the two
samples and included multitrial tasks that assessed the
functions and capacities that are the most prototypical for
effortful control (Kochanska et al., 2000; Rothbart &
Bates, 2006). These included voluntary slowing down of
motor activity (Slow Turtle & Fast Rabbit task), suppression
and initiation of activity to signal (Tower task), and
delaying gratification (Snack Delay task, Tongue task,
and two Gift Waiting tasks). The task-specific scores
were aggregated across trials for each task and then standard-
ized and aggregated into a single robust and internally
coherent score of effortful control (Cronbach’s α
values ranged from .75 to .84).
Parental reports of effortful control. Mothers completed
the Child Behavior Questionnaire (CBQ; Rothbart
& Bates, 2006), a well-established parent-report measure
of temperament for 3- to 7-year-old children. Items were
rated on scale from 1 (extremely untrue) to 7 (extremely
true). We used the Inhibitory Control scale of the CBQ
(13 items; Cronbach’s α = .82 and .89 in the first and second sam-
ples, respectively) in the current report because this scale maps
most closely to the content of the laboratory effortful-control
measures (Kochanska et al., 2000).
Security of attachment. Mothers completed the Attachment
Q-Set (AQS; Waters & Deane, 1985), a widely used
measure of children’s security of attachment (Van
IJzendoorn, Vereijken, Bakermans-Kranenburg, & Riksen-
Walraven, 2004). For each child, a correlation was computed
between the mother’s sorting of cards (each listing
a specific behavioral characteristic of children between
the ages of 24 and 48 months) and the prototypical secure-
attachment criterion scores provided by Waters and Deane
(1985). These correlations were then standardized using
Fisher’s r-to-z transformation (Van IJzendoorn et al., 2004).
Higher scores indicate greater attachment security.
Academic achievement. At follow-up, academic achievement
scores were obtained, and competence was assessed.
Academic achievement was measured by nationally standard-
ized, norm-referenced achievement tests from the
Iowa Testing Program: the Iowa Test of Basic Skills (ITBS;
Hoover, Dunbar, & Frisbie, 2001) and the Iowa Test of
Educational Development (ITED; Feldt, Forsyth, Ansley, &
Alnot, 1993). Mothers provided copies of their children’s
ITBS or ITED scores in math and reading. In addition to
these objective measures, mothers provided ratings on the
Scholastic Competence Scale from the Child Behavior
Checklist (Achenbach & Rescorla, 2001), which includes
ratings of child performance in school, reports of remedial
educational services, grade repetition, and other difficulties.
Raw scores were converted to normalized T
scores (M = 50, SD = 10) using norms for age and sex
from Achenbach and Rescorla (2001). This measure has
been used extensively with normal, clinical, and pediatric
populations and has established validity and reliability for
childhood competency and difficulty.
Statistical analysis
Longitudinal data were analyzed using Mplus (Muthén
& Muthén, 2012). Because of attrition across the
repeated assessments, spanning more than a decade,
some adolescent achievement scores were missing (e.g.,
covariance coverage for the primary mediation model
ranged from .50 to .99; for n at each assessment, see
Table 1). However, there were no significant differences
in toddlerhood attachment, t(207) = −1.30, p = .194, or
toddlerhood effortful control, t(203) = 0.07, p = .931,
as a function of attrition status from toddlerhood to
adolescence. Consistent with contemporary theories of
missing data (Enders, 2010), we adopted the “gold standard”
approach of using full-information maximum
likelihood estimation, which is preferred over more
traditional approaches to addressing missing data (e.g.,
pairwise deletion) when missing data rates are elevated.
Indeed, simulation studies demonstrate its utility even
when rates of missingness are relatively substantial
(e.g., > 50%; Enders, 2010).
Multiple indices were used to assess global model
fit. The comparative fit index (CFI), Tucker-Lewis Index
(TLI), root-mean-square error of approximation
(RMSEA), and standardized root-mean residual (SRMR)
are reported. Once a model was deemed to fit the data
adequately, parameter estimates were interpreted.
Mediation was tested using bootstrapping (Shrout & Bolger,
2002), which provides an empirical approximation
of sampling distributions of indirect effects. We
performed a nonparametric resampling method (bias-corrected
bootstrap) with 5,000 resamples drawn to
derive the 95% confidence intervals (CIs) for the indirect
effects (Preacher, Rucker, & Hayes, 2007). Note that
a bootstrap approach performs well in relatively small
samples, maximizing the power and maintaining Type
I error rate (Shrout & Bolger, 2002).
Mother reports and observed measures of effortful
control were modeled as indicators of a latent effortful control
variable. Scholastic competence and reading
and math test scores were modeled as indicators of the
latent academic-achievement variable. The metric of
the latent variables was set by fixing the variance of
the latent variables to 1.00; thus, latent scores were
standardized.
Results
Analysis of the full data set showed that differences
between the two cohorts with regard to mean scores
of study variables were small and nonsignificant (Table
1). Consequently, the remaining analyses were based
on the combined 210 mother-child dyads across cohorts.
This provided a sample large enough to incorporate
latent variables of constructs into the models (Barrett,
2007), which reduced measurement error.
Associations among measures
Correlations among concurrent measures are shown in
Table 2, and all were in the expected direction. The
strongest association among toddlerhood variables was
between the behavioral and mother-reported measures
of effortful control (r = .44). Security of mother-child
attachment was positively and significantly associated
with effortful control (average r = .24). As expected,
intercorrelations among objective measures of early adolescent
achievement and maternal ratings of scholastic
competence were robust (average r = .51).
Table 2 also presents the correlations of effortful
control and attachment security in toddlerhood with
school achievement in adolescence. Effortful control at
age 3 was significantly associated with better achievement
and scholastic competence in early adolescence
(average r = .20). Finally, security of attachment in toddlerhood
showed modest associations with scholastic
competencies in adolescence.
Results of structural equation modeling
A measurement model comprising both latent variables
demonstrated excellent global fit (CFI = .987, TLI = .968,
RMSEA = 0.044, SRMR = .034). The model explained a
significant percentage of the variance in each indicator
of achievement: 51% for reading (ITBS and ITED; factor
loading = .71), 63% for math (ITBS and ITED; factor
loading = .80), and 45% for scholastic competencies
(Child Behavior Checklist; factor loading = .67). The
model also explained a significant percentage of the
variance in each indicator of effortful control: 51% for
effortful control (CBQ; factor loading = .72) and 38%
for behavioral effortful control (factor loading = .62).
There was a significant association of moderate magnitude
between the two latent variables, r = .40 (SE =
.125), p = .001.
Figure 1 presents results from preliminary models
establishing that (a) attachment in toddlerhood significantly
predicts achievement in adolescence (Model 1)
and (b) effortful control in toddlerhood significantly predicts
achievement in adolescence (Model 2). Each
model demonstrated excellent fit—Model 1: χ2(2) =
1.60, p = .449, CFI = 1.00, TLI = 1.00, RMSEA = 0.000,
SRMR = .021; Model 2: χ2(4) = 5.66, p = .226, CFI = .987,
TLI = .968, RMSEA = 0.044, SRMR = .034.
As shown in Figure 2, the mediational model (Model
3) demonstrated excellent fit, χ2(7) = 7.28, p = .400,
CFI = .998, TLI = .996, RMSEA = 0.014, SRMR = .034,
and an indirect effect of attachment on achievement
via effortful control was present, 95% CI = [0.02, 1.41].
Further, this mediation effect was replicated when we
controlled for the age of the child when achievement
was assessed, 95% CI = [0.02, 1.41]. Note that attachment
was no longer associated with achievement when
we controlled for effortful control.
A multiple-group analysis was conducted to determine
whether there was invariance in the model across
the two aggregated samples (i.e., Sample 1 vs. Sample
2). A model with the paths free to vary between the two
groups did not fit the data better than a model with the
paths fixed to be equal between the groups, χ2(3) =
3.16, p = .368. Thus, the findings were not shown to
vary across samples. Further, a multiple-group analysis
revealed that the model did not vary as a function of
gender, χ2(3) = 4.59, p = .204.
Discussion
In the present study, effortful control in toddlerhood
predicted general academic achievement over a decade later.
These findings complement extant data regarding
positive effects of effortful control on a variety of future
outcomes, including socioemotional competencies,
adjustment, and achievement shown over shorter time
periods (e.g., Kochanska & Kim, 2013; Swanson et al.,
2014; Valiente et al., 2011). Our results also build on
emerging evidence that the quality of formative relationships
in early life predicts positive functional outcomes
(e.g., Kochanska, 2001; Spinrad et al., 2007).
However, the majority of that work concerns outcomes
in the socioemotional domain over shorter periods of
time. More recent research suggests that these effects
may also extend to achievement (e.g., Bergin & Bergin,
2009; Swanson et al., 2014). Our work is the first to
show that early mother-child attachment security triggers
a meaningful cascade that significantly explains
academic achievement over a decade later through its
influence on effortful control.
Implications
This work points to the importance of early parent-child
attachment and its role in enhancing skills and capacities
that might prove foundational for later success in
school and work. Furthermore, our results raise an
important question: Can enhancing mother-child
attachment security or effortful control in toddlerhood
(or both) meaningfully affect academic success in adolescence?
There is some evidence that effortful control
skills can be taught (e.g., Diamond, Barnett, Thomas,
& Munro, 2007); however, future research needs to
ascertain the efficacy of such interventions more fully.
There is broad empirical support for the long-term
implications of parental or home-based interventions
targeting maternal responsiveness, particularly early in
life (Bernier, Carlson, & Whipple, 2010). Research consistent
with our results has demonstrated that a secure,
supportive, responsive caregiving environment early in
life can provide the inner resources that foster such
positive characteristics as effortful control (Kochanska
& Knaack, 2003). In turn, these early differences may
promote better functioning in both the socioemotional
(e.g., Swanson et al., 2014; Valiente et al., 2011) and
achievement domains as much as a decade later.
Attachment theorists have long suggested that attachment
security has implications for emotion and self-regulation
(Cassidy, 1994; Sroufe, 2005). Moreover,
consistent with the notion of phenotypic plasticity
(Hane & Fox, 2006), a growing body of evidence indicates
that effortful control can be modulated by factors
that pertain to the quality of the attachment relationship
(Kochanska, 2001) and should not be viewed as a fixed
trait (Rothbart & Sheese, 2007). Infancy and toddlerhood
also appear to be a period of development during
which exposure to adverse family conditions may have
the greatest effect on neurobiological and physiological
systems (Davies & Sturge-Apple, 2007). Our results indicate
that a social factor (parent-child relationship) in
toddlerhood affects a child temperamental factor, that,
in turn, has an influence on achievement much later in
development. Indeed, it seems critical to investigate
directly whether interventions that enhance security of
mother-child attachment during this heightened time
of susceptibility have direct and indirect positive effects
on academic outcomes. For example, given that insensitive
parents increase the risk of insecure attachment in
offspring, such parents may benefit from efforts to prevent
maladaptive developmental cascades characterized
in part by poor effortful control that may ultimately
lead to deleterious outcomes later in life. Several recent
studies have found that toddlers and preschool-age
children of parents involved in attachment-based interventions
exhibit improved effortful control (e.g., Cassidy
et al., 2017; Lind, Raby, Caron, Roben, & Dozier, 2017).
An important next step would involve examining the
impact of improved effortful control on later achievement-based
outcomes.
Limitations
The children in this study came from a relatively well-functioning
population lacking racial diversity. Although
it is difficult to predict how well these findings would
generalize to samples of children at higher risk, the
magnitude of these associations could be larger for
children growing up in contexts characterized by
greater adversity (Evans, 2004). An important future
step will be to conduct similar studies in children from
high-risk backgrounds, who are more likely to experience
detrimental living conditions and lack of access
to high-quality education. A strength of our work is its
longitudinal design, although we cannot establish causation.
Further, for some participants (Sample 1),
mother-child attachment security and effortful control
were assessed concurrently. In contrast, for participants
in the second sample, attachment security was assessed
approximately 10 months before effortful control. The
model’s paths (including the path from attachment to
effortful control) were invariant across studies. Thus,
the directional path was significant when attachment
temporally preceded effortful control, a finding that is
consistent with emerging evidence showing that parental
behavior fosters children’s effortful control during
preschool years (Lind et al., 2017). Nonetheless, the
results do not rule out alternative pathways of reciprocal
causation. Finally, future studies should assess
whether the current results replicate using the Strange
Situation procedure, a preferred measure of infant
attachment security.
Conclusion
It is striking that noncognitive factors, such as social-affective
and family factors early in development, predict
a societally valued achievement outcome more than
a decade later. Important future directions include
examining additional mechanisms and possible moderators
of this developmental cascade from a mother-child
relationship to a within-child self-regulatory
variable to an achievement outcome. For example, what
effects do fathers and other caregivers (e.g., teachers)
have on this developmental cascade? Could a secure
attachment with other important figures help compensate
for insecure mother-child attachment in the development
of effortful control? Do other within-child
variables, including other temperamental traits, serve
as protective or risk factors for this cascade? These and
other questions can help us further understand the
complex and varied paths ultimately leading to academic
success.
Action Editor
Ralph Adolphs served as action editor for this article.
Author Contributions
L. Dindo developed the study concept and collected the data at follow-up
during adolescence. G. Kochanska collected and analyzed the early child-
hood data. All the authors contributed to the study design. Data anal-
yses were performed by R. L. Brock and N. Aksan. L. Dindo drafted the
manuscript, and L. A. Clark, R. L. Brock, W. Gamez, and N. Aksan pro-
vided critical revisions. All the authors approved the final version of the
manuscript for submission. L. Dindo and R. L. Brock contributed equally
to this work.
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interest with respect
to their authorship or the publication of this article.
Funding
This research was supported in part by the National Science Foundation
(Grants DBS 9209559 and SBR 9510863 to G. Kochanska); the National
Institute of Mental Health (Grants R01-MH63096 and K02-MH01446 to
G. Kochanska); the University of Iowa Obermann Center for Advanced
Studies Spelman Rockefeller Grant for Research on Children and Their
Families (to L. A. Clark and L. Dindo). This material is also the result of
work partly supported by the Houston VA Health Services Research and
Development Center for Innovations in Quality, Efficiency and Safety
(Grant CIN13-413). The opinions expressed are not necessarily those of
the Department of Veterans Affairs or the U.S. government.
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