Considering the realities of salivary research with young children:
What’s spit all about?
Christine O’Farrellya and Eilis Hennessya
aSchool of Psychology, University College Dublin, Dublin, Ireland
Corresponding Author: Eilis Hennessy, School of Psychology F208, University College
Dublin, Newman Building, Belfield, Dublin 4, IRELAND.
E-mail: [email protected]
Phone: 00353 1 716 8362
Christine O’Farrelly is a PhD candidate at the School of Psychology at University
College Dublin. Her PhD research is investigating children’s experiences of transitions
to new rooms in early childhood care and education settings.
Eilis Hennessy is senior lecturer in developmental psychology at the School of
Psychology at University College Dublin. Her research interests include children’s
experiences in day care and out-of-school care.
O’Farrelly, C. & Hennessy, E. Considering the realities of salivary research with young children: What’s spit all about? International Journal of Social Research Methodology
Considering the realities of salivary research with young children:
What’s spit all about?
Over the last two decades interest in salivary research in the social sciences has
grown rapidly. Salivary research is appealing as a quick, inexpensive, and
noninvasive means of determining a range of biological markers, which offer
insight into a variety of human responses, for example, stress. To the social
researcher these advantages provide exciting possibilities for new transactions
between social, behavioural, and biological models of development. Salivary
research is especially attractive to those working with children. Indeed, as well as
being noninvasive, saliva also provides an opportunity to measure variables with
young children where self-report measures may be inappropriate. Yet, for all its
appeal the reality of saliva collection with younger populations appears far from
straightforward. This article draws on two research examples to illustrate some of
the methodological, ethical, and practical issues pertinent to salivary research
with young children. Specifically, it considers barriers to participation and
possible strategies for promoting the methodological and ethical basis of salivary
research. In doing so it provides starting points for discussion in what has become
a critical methodological debate.
Keywords: salivary research; young children; biobehavioural research; assent;
play
Introduction
Saliva, previously the purview of clinical science, has become a common feature of
research in the social and behavioural sciences. The enthusiasm is palpable, with some
suggesting that salivary markers may be key in facilitating the integration of biological,
behavioural, and social models of development (Granger & Kivlighan, 2003). Interest in
saliva is driven in large part by the ever-increasing catalogue of information that can be
determined in small samples. These biomarkers offer insight into a variety of human
responses such as stress levels and immune function. Saliva’s appeal is also built on its
inherent advantages as a means of collecting biological specimens. Indeed, next to
blood or urine sampling saliva collection is cheap, convenient, and noninvasive
(Hofman, 2001). This makes saliva both affordable and amenable to collection in the
field. Consequently, saliva collection has become a feasible option for social scientists
seeking to integrate biological markers into their research.
Saliva’s advantages are especially attractive to social and developmental
researchers working with children. Firstly, unlike blood draw, which can be acutely
painful, saliva collection is relatively noninvasive. Consequently, saliva is likely to
reduce the risk of distress to children, an ethical necessity in research contexts.
Secondly, saliva offers information on variables, such as stress, that young children may
have difficulty describing verbally (Jessop & Turner-Cobb, 2008). Moreover, as
children’s stress levels cannot always be reliably determined by their behaviour,
researchers are increasingly turning to physiological measures, such as salivary cortisol,
as an index of children’s stress response (Vermeer & van IJzendoorn, 2006).
By virtue of this versatility saliva has enabled researchers to tackle questions
that were previously only theoretical. For example, salivary cortisol has been employed
to indicate the pattern of infants’ stress reactivity during enrolment in Early Childhood
Care and Education (ECCE) settings for the first time (Ahnert, Gunnar, Lamb, &
Barthel, 2004). Others have used salivary biomarkers of immune function to investigate
the relationship between children’s mental health and their immunity (Keller, El-Sheikh,
Vaughn, & Granger, 2010). In many ways the possibilities for insight seem limitless.
However, as Granger and colleagues (2007) point out, the reality of saliva collection
with younger populations is often far from straightforward.
This article considers some of the barriers to salivary research with young
children (2-6 years), including children and caregivers’ resistance to saliva collection,
the absence of a superior saliva collection method, and a lack of reporting on assent
3
procedures. It draws on two research examples to further explore these issues and offers
practical suggestions as to how they might be addressed.
Saliva collection with young children: A confounding situation?
Perhaps the most challenging aspect of salivary research with young children is the
tendency for some children to resist saliva collection. This pattern is particularly
problematic for research investigating children’s stress response. Here it is possible that
some children may react stressfully to the collection process itself, which undermines
the validity of the data collected (Gunnar & White, 2001). In this way the method itself
risks operating as a confounding variable. This concern has received some support from
a recent study, which found that young children who resisted, but did not outright refuse
to participate in saliva collection, showed higher levels of the stress hormone cortisol
(Kaitz, Sabato, Shalev, Ebstein, & Mankuta, 2012). To complicate matters it appears
that some children may be more likely to resist saliva collection than others.
Consequently, missing data is unlikely to be random, but rather related to individual
characteristics such as children’s temperament (Granger et al., 2007; Kaitz et al., 2012).
This resistance has various repercussions. Ethically, this pattern suggests that
saliva collection may pose a risk of distress for some children. Practically, resistance
can reduce both the amount of saliva and the number of participants available, a
frequently reported scenario (e.g., de Haan, Gunnar, Tout, Hart, & Stansbury, 1998).
Where stress hormones are of interest resistance may introduce sampling bias because
the children who resist may be the ones who are most stressed by their experiences.
From a methodological perspective this resistance ultimately stands to undermine the
validity of the very data it seeks to collect (at least in the case of stress hormones).
4
Saliva collection as noninvasive - do children agree?
One possible explanation for children’s resistance to saliva collection is that their
perceptions of saliva collection may differ from those of adults. This is illustrated by a
surprising research report suggesting that children’s preferences for saliva collection did
not dramatically outweigh their preferences for blood draw, despite parents choosing
saliva collection in the vast majority of cases (Gorodischer, Burtin, Hwang, Levine, &
Koren, 1994). Unfortunately, these results are difficult to interpret due to
methodological inconsistencies in how saliva and blood were collected. Nonetheless,
others assert that children can respond anxiously to medical procedures irrespective of
their invasiveness (Gold, Kim, Kant, Joseph, & Rizzo, 2006). Thus, it is possible that
children do not see saliva collection as being noninvasive in the same way that adults
appear to.
The search for an acceptable saliva collection method
Difficulties with children’s participation are further exacerbated by the absence of a
gold standard saliva collection method. This is because collection methods that work
well with adults and older children often prove ineffective when used with younger
participants (e.g., Watamura, Donzella, Kertes, & Gunnar, 2004). A variety of methods,
from drooling to absorbent oral devices, have been employed with young children with
varying success. These methods typically involve children drooling into a cup or vial or
mouthing a device for one to two minutes. In particular, cotton-based devices seem to
be especially unpalatable and their use has been linked to poor participation (Clements,
Parker, Dixon, & Salley, 2007). Collection methods can prove so ineffective with some
children that some researchers have been forced to change or revise their collection
methods to encourage greater participation (e.g. Watamura et al., 2004). Yet, in spite of
5
these frustrations, the value of investigating the acceptability of these collection
methods from children’s own point of view has been completely overlooked.
Assent procedures in salivary research with young children
Another feature of salivary research that may well relate to challenges with participation
is the absence of reporting on assent procedures. It is possible that this omission reflects
word limits rather than practices, as manuscript length is believed to constrain reporting
on methodological issues (Brannen, 2005). However, it is similarly conceivable that
assent procedures are one example of the dissonance between qualitative and
quantitative research paradigms (Brannen, 2005). Although accounts of assent
procedures are often omitted from salivary research with young children, reports from
research with infants are far from encouraging. Here authors concede to attempting to
coax infants into participation (Goldberg et al., 2003). Others report only stopping short
of insisting that infants participate because of the confound with stress levels (van Bakel
& Riksen-Walraven, 2004).
Seeking children’s assent regarding their research participation is critical for two
reasons. Firstly, such procedures are an ethical necessity. Secondly, negotiating assent
on children’s terms, using meaningful information, benefits all parties including the
researcher (Lindeke, Hauke, & Tanner, 2000). For example, meaningful assent may
help promote children’s sense of ownership in the research, which in turn may boost
participation rates. Some may take the view that assent procedures are unnecessary or
ineffective with younger children because of misconceptions regarding young children’s
cognitive competencies (Morrow & Richards, 1996). However, Hill (2005) holds that it
is wrong to assume that young children lack the competency to make decisions about
6
their research participation. Indeed, even simple explanations can help young children
make sense of what their research participation will involve (Fine & Sandstrom, 1988).
Parental and caregiver resistance to salivary research
A further issue with saliva collection arises from how the collection of biological
samples is perceived by parents and other caregivers. Aside from being gatekeepers,
parents and other caregivers are increasingly being recruited to collect samples with
young children. For example, parents and practitioners have been asked to collect
samples in research investigating what appears to be evidence of atypical stress patterns
in some children attending full-day ECCE settings (see Vermeer & van IJzendoorn,
2006). However, participation in such research is often low, a trend one study suggested
may be due to parents and ECCE providers’ dislike of saliva samples being collected
from children (Groeneveld, Vermeer, van IJzendoorn, & Linting 2010).
What is it about saliva collection that parents and caregivers might dislike?
Saliva collection may be disagreeable to caregivers because of concerns that
participation will encourage children to drool or spit. In fact there are reports of children
refusing to participate because of their parents’ rules about spitting (Kaminski, Pellino,
& Wish, 2002). But evidence from epidemiological salivary research suggests that
resistance goes beyond this explanation. Here reports have demonstrated that adults
often refuse their participation based on a variety of concerns ranging from the
plausible, such as drug testing, to the unlikely, such as cloning (Adam & Kumari, 2009).
In cases where parents are being asked to consent to sample collection on behalf of their
child, these uncertainties may be heightened and concerns and misconceptions may
operate more intensely. It is also possible that parents may feel that the use of a clinical
7
method for research that promotes an understanding of social rather than medical
phenomena is unjustified.
Playful alternatives to saliva collection
One possible means of promoting the methodological, ethical, and practical basis of
salivary research with young populations could be to employ collection approaches that
are enjoyable for and attractive to children. Adopting techniques that respond to how
young children naturally engage with their worlds has a strong tradition in participatory
research. Yet such attempts are rare in salivary research with young children.
Exceptions include reports of ‘tasting games’ that involve children guessing the flavour
of various powdered drink mixes (Watamura, Sebanc, & Gunnar, 2002), and presenting
saliva collection as a ‘tea-party game’ (Legendre & Trudel, 1996). Perhaps, the most
detailed and notable example is Zimmermann’s (2008) ‘feed the frog’ collection
method. This technique involved asking children to drool saliva into a model of a
‘hungry’ frog. Utilising a playful rationale for saliva collection appeals to children’s
natural competencies and in doing so may reduce the likelihood that children will react
stressfully to the collection method itself.
Salivary research in action
In order to further unravel the issues outlined above two research examples are
considered. The authors arrived at these research examples unexpectedly, based on the
findings of a mixed-method exploratory study suggesting that some children may find
transitions to new rooms in ECCE settings stressful. To further explore this stress we
decided to investigate children’s salivary cortisol patterns during transitions. However,
saliva collection seemed almost the antithesis of participatory research. And so we
8
found ourselves at the intersection of two seemingly incompatible research paradigms:
the social and natural sciences. A clash of research cultures was evident, most notably in
how children’s participation was positioned in the respective approaches. In salivary
research accounts of children’s active participation were often invisible. And yet in the
social sciences there is a long-established reflective discourse on children’s research
participation. Overall, we found that there were few signposts to indicate how best to
provide meaningful opportunities for assent, what collection methods would be
acceptable to children and parents, and how children were likely to respond to salivary
research activities.
To help address these gaps the objective of the first research example was to
explore the acceptability of different saliva collection methods to young children, their
parents, and ECCE practitioners using a play-based approach. Social scientists have
long been aware of the need to communicate effectively with young children in order to
avoid misunderstanding and potentially uninterpretable findings (e.g., Donaldson,
1978). This is repeated here with a new data collection method, because if the
collection method for saliva causes stress this will render the findings uninterpretable.
The findings of the first research example informed the methodology of the second
study, which investigated the cortisol patterns of preschool children as they moved to
new rooms in ECCE settings. These research examples are included in this paper to
springboard discussion on issues related to saliva collection with young populations.
Research example 1: An investigation of saliva collection methods
The saliva collection study was designed to compare the acceptability of three saliva
collection methods to 17 preschool-aged children (2-5 years) children, their parents, and
ECCE practitioners. This convenience sample of preschool children and their families
9
was recruited from two centre-based ECCE settings. The parental response rate in each
centre was 43.33% and 35.29%. In addition to background literature, parents and
practitioners were given a short illustrated booklet as a tool to discuss the research
activities with the children. As well as comparing collection methods the study served
as a pilot for a larger study investigating children’s cortisol patterns. Because of this
consent was sought to run cortisol analysis on the samples collected.
Saliva samples were collected using three methods:
Sorbettes (BD Visispear™ Eye Sponge distributed by Salimetrics): Children
mouthed two Sorbettes for 90 seconds. Once wet Sorbettes were placed in
storage tubes.
Salimetrics Children’s Swab: Children mouthed the swab for 90 seconds. Once
wet swabs were cut at the wet/dry section using a scissors and the saturated end
was placed in storage tubes.
Passive Drool: Children tilted their head forward and drooled either through
straws or funnels into vials.
A timer was used to record the 90 seconds required for the Sorbette and swab methods.
The pilot also included the use of a play-based collection technique that was
purposefully designed to make the saliva collection fun and meaningful for the children.
This involved a story about ‘Rocco the Astronaut’ who needed saliva, the secret
ingredient in rocket fuel, to fix his spaceship, along with a commercially available hand-
sized astronaut puppet. Children were also given the opportunity to choose a sticker as a
thank you for their participation. Stickers were provided to children irrespective of
whether they chose to participate and children were not told about the stickers before
being invited to take part. Two practitioners and parents collected saliva samples with
children in each ECCE setting and at home respectively. The first author assisted the
10
saliva collection in the ECCE settings. It was emphasised to both parents and
practitioners that saliva collection should only be carried out where children were
willing to participate.
Short semi-structured interviews were carried out with 2 practitioners and 9
parents and participatory interviews were carried out with 15 children to investigate
saliva collection experiences. Participatory interviews involved a variety of methods
including large puppet, drawing, smiley-face rating-scale, and recommendations for
hypothetical peers activities. Interviews focused on the relative acceptability of the
collection methods to participants, but also explored participants’ research experiences
more generally. Interviews were transcribed verbatim and analysed using the principles
of thematic analysis (Braun & Clarke, 2006). The findings most relevant to the present
paper’s purpose are presented here.
First impressions: Lost for words
Of the parents who chose to take part in the study the majority reported having no
concerns about saliva collection, following consideration of the background literature.
At the same time one parent did highlight that she could ‘see why some people might
find it a little invasive or something’. Similarly, a practitioner reported that ‘the idea of
it seem[ed] maybe a little bit invasive’. This practitioner went on to comment that
measuring biological markers such as cortisol would cause ‘question marks in your
head’. Interestingly, she added ‘I don’t even know why. I can’t actually justify it’.
Another parent referred to similar reticence: ‘I didn’t really want to do it at first...it was
just ‘cause it was saliva or whatever’.
This difficulty in articulating specific concerns could indicate the unfamiliar
place of biobehavioural research in the day-to-day lives of the general public.
11
Nonetheless, these reactions, be they nonverbal or even unconscious, appear to be
negative in nature. In other words, participants may not be quick to identify their
concerns about biobehavioural research, but it appears that they exist. It is important to
note that we did not have the opportunity to consult with parents who decided not to
take part in the study. It is likely that such data would have further illuminated parents’
perceptions of salivary research.
Making saliva collection child’s play
Feedback on the play-based approach was very positive with many parents and both
practitioners reporting that its inclusion made a ‘huge difference’. According to one
parent the story was ‘really helpful, I mean I don’t know how it would have been
without it’. Both the parents and the practitioners highlighted that it would have been
difficult to explain the saliva collection to the children otherwise: ‘that could be very
difficult if you are trying to explain to a child that they need it for a test, a medical test,
they would be looking at you, you know, “what are you talking about mum?”’.
According to some parents the play approach helped better prepare children so that they
‘knew what was coming’. Encouragingly, reports suggested that the medium of play
appealed to the children: ‘she started talking about it as soon as she got in the car on
Friday… She was just talking about it all night, she took [the storybook] to bed with
her’. Children also described the process as ‘fun’ and frequently asked to take part in
saliva collection during their interview. Nearly all of the children recounted the play-
based narrative in their interviews and drawings: ‘It run out of petrol…we got the petrol
out of here…then we put it in the rocket…it goes on the moon again’. However, some
parents did add that the book became less important and sometimes was not necessary:
‘once she knew the story then it was less important’.
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The positive appraisals of the play-based method suggest that play may help to
offer children an enjoyable and attractive saliva collection experience. Together with the
children’s information booklet these attempts at promoting ethical partnerships may
have afforded children greater control in the research process. This in turn may have
optimised participation as reflected by children’s full participation rates. Indeed, failing
to acknowledge the active way in which children try to make sense of their research
participation (Westcott & Littleton, 2005) not only discredits children’s competency,
but also is likely to incur practical consequences for participation. At the same time it
could be argued that a fictitious rationale bypassed the provision of a more
comprehensive account of the study’s purpose. Although this criticism is valid, the
objective was not to convince the children to participate for false ends, but rather to play
to their natural ability to simultaneously engage in, and makes sense of, their
imaginative encounters (Harris, 2000). In hindsight, however, greater efforts should
have been made to explain to the children how their saliva would be used, in line with
recommendations that children should be informed about the full implications of
research (Kellett, 2010).
The medium of play seemed more important than its actual content. In fact one
parent suggested that a second story, more specifically targeted towards girls, would be
a useful revision to the procedure. Either way saliva collection is most likely to be a
credible play activity for children when endorsed by an engaging and responsive sample
collector. Indeed, in the second study a practitioner reported incorporating the story into
other activities whereby the children designed and built a large spaceship themselves.
This coincides with the notion that participatory techniques derive their success not
from the use of specific methods, but rather from the spirit and process in which they
are employed (Gallacher & Gallagher, 2008).
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Children as saliva collection experts
The interview data also indicated children’s expertise in saliva collection. Several
parents noted that their children often showed them what to do: ‘he tells me “I know,
don’t read, let me tell you this, we do that, we do this”’. The children themselves also
referred to their competency, informing the researcher: ‘I’m very good’ and ‘I just did it
all myself’. For several of the children this meant that they were confident in taking the
lead in the collection process, telling the researcher ‘I’ll show you’ and ‘you don’t know
it, we know it’. Interestingly, the children frequently made perceptive observations about
the saliva collection process. For example, some of the children commented on
materials, such as the timer and the scissors, that were employed in the saliva collection
but had not been included as interview props: ‘where’s the beeper though?’, and ‘the
cap can’t cut it’. These findings support arguments that children actively construe their
research participation. Moreover, they demonstrate children’s capacity as competent
research participants.
Sensitive collection strategies
Parents and practitioners also shared insight on other factors that they suggested might
influence participation. In line with caveats in the literature, practitioners and parents
spoke about how personality and age might play a part in participation. ‘I guess it
depends on [the child’s] personality, but I thought that [my daughter] would protest to
something being put on her tongue’. Similarly, one of the practitioners commented that
‘[younger children] would just be a little bit more reluctant’. In these cases respondents
emphasised the importance of familiarity: ‘the most important thing is knowing the
children’. Ensuring that a familiar adult carried out the sample collection was seen as
14
being particularly important in helping younger children feel at ease: ‘[Younger
children] would just be a little bit more reluctant so just making sure that they have a
carer that they are confident in doing it with them’. Where children were more reticent,
practitioners commented that having another child go first might help children feel more
comfortable: ‘[watching another child] just gives them a boost of confidence so it’s not
so bad like’. Alternatively, practitioners could demonstrate themselves when a child
hesitated: ‘just a bit of encouragement and care, just showing him and trying to help
him’. Similarly, one parent noted that participating in both the play and the sample
collection with her daughter worked quite well.
Research Example 2: An investigation of children’s cortisol patterns during
transitions to new rooms in ECCE
The Transitions Study was designed to investigate children’s cortisol patterns as they
moved to new rooms in their ECCE setting. Twenty-six preschool-aged children were
recruited from thirteen ECCE settings. A short-term longitudinal design was employed
whereby salivary cortisol was collected before and following transitions. In addition to
background literature, parents and ECCE centres were given a short illustrated booklet
as a tool for discussing the research process with the children. Parents and practitioners
collected samples with Sorbettes, along with the ‘Rocco the Astronaut’ play-based
technique, using the procedures outlined in the previous research example.
Biobehavioral research: A hard sell
Like many social and behavioural studies, recruitment for the Transitions study was
difficult. Recruitment efforts included written invitations to 74 centres, the distribution
15
of invitation letters by a local ECCE quality-coordinator, and an advertisement in the
Ezine of a leading professional organisation. The low participation rate of 29.69% (of
the 64 suitable settings who received written invitations) was discouraging but
somewhat higher than rates reported in similar studies (Groeneveld et al., 2010). In a
considerable number of cases centres cited concerns over how parents would receive the
study as an explanation for their refusal. Others pitched the study to parents first and
refused on the basis that parents had expressly sounded their objections to research
involving saliva collection. Of the 19 centres who agreed to take part, five were unable
to recruit any of the 28 families invited to take part in the study. Overall parental
interest in the study was somewhat low with 37.83% of eligible parents deciding to take
part in the study.
Promoting children’s participation
More positively, and counter to the greater number of similar studies, all of the children
in the Transitions Study chose to participate in the majority of the saliva collection
occasions. However, as the authors were not present during saliva collection it was
difficult to determine with certainty that missing samples were not due to children’s
refusal. The study’s successful participation rates may be related to a number of factors.
Firstly, we chose to include practice occasions, whereby practitioners were given extra
collection equipment and encouraged to introduce children to the materials and
collection process. This may have helped normalise the collection process and perhaps
went some way in empowering children’s decision making about their participation.
Certainly, practitioners reported that several children were initially hesitant before
practice sessions or until the practitioner had demonstrated the process.
16
A further factor may have been the play-based approach, a possibility endorsed
by many of the centres’ reports. Yet, as can be expected, in some cases practitioners
commented that certain children seemed less interested in the technique. Interestingly,
in a small number of instances practitioners reported that children were most fascinated
by the timer or the selection of stickers they could choose from as a thank you.
Another possible explanation for the participation rates may be the skill of the
data collectors themselves. Entrusting the saliva collection to the practitioners was a
complex decision. On the one hand, research assistants offer maximum protocol fidelity.
This compliance is imperative because, depending on the analyte, even small deviations
from procedures can affect sample validity. Nonetheless, building trust with young
children takes time. Without this investment, young children, especially those with an
inhibited temperament style, may find the presence of a novel researcher stressful.
Again this is likely to reduce children’s participation and confound biomarkers of stress.
Certainly, the first author quickly learnt that her mere presence was enough to elicit
reticence from some children. Consequently, the decision for saliva collection to be
carried out by practitioners who were familiar with the children’s personalities and well
versed in reading their nonverbal cues of interest/disinterest, may have offered
advantages for this study. However, it is important to note that this partnership
sometimes incurred a trade off as practitioners either forgot, or were unable, to observe
certain aspects of the collection protocols.
Discussion
The reality of saliva collection with younger populations is clearly more complicated
than it appears at first blush. Yes, saliva may be inexpensive and easy to collect, but
only when considered next to blood and urine sampling techniques. To the social
17
researcher saliva collection may well prove cumbersome, expensive, and time
consuming. As O’Connor (2011) warns biobehavioural research of this kind is not for
‘the faint-hearted or under-resourced’ (p.109). Perhaps more critically, under certain
circumstances the validity of the data collected may be compromised. Unfortunately,
technical research aimed at increasing saliva’s applications seems to be outpacing
efforts to address some of the methodological issues associated with younger
participants. Consequently, although a sophisticated technique is now at our disposal, its
efficacy remains limited without careful consideration of the social context of data
collection. That said, the issues with saliva collection with young children are difficult,
but not intractable. As these examples illustrate, reflective treatments of the pitfalls of
this research may be helpful in contributing to more effective research efforts. However,
these examples draw on limited samples and are not intended to be indicative of salivary
research in general. Nonetheless, they offer a useful starting point to stimulate much
needed discussion and debate. To this end, the most salient discussion points are
summarised below.
Difficulties with participation may well take root where there is public
uncertainty concerning biobehavioural research. Certainly, the examples in this paper
demonstrate that biobehavioural research with young children is a gated process.
Successful research is likely to hinge on trust and well-informed parents and caregivers.
Understanding how best to galvanize such trust requires research on where caregivers’
uncertainty and concerns regarding biobehavioural research lies, irrespective of its
basis. Additionally, at a broader level, greater efforts from the scientific community are
needed to engage with the media and public education on the uses of
psychophysiological measures (Wardlaw et al., 2011).
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Barriers to participation may also stem from children’s perceptions of saliva
collection procedures. Firstly, in deciding which methods (e.g., Sorbettes) are
appropriate for collection attention should be given not only to technical performance,
but also to their acceptability to the given population. Secondly, to counter
misconceptions, and as an ethical priority, greater attention is needed in considering
effective assent procedures. For this purpose those practices that have emerged from
qualitative research may offer a valuable resource. Although the booklets we employed
were useful, they may have been limited in their impact. After all they require the
cooperation of an enthusiastic caregiver who is well acquainted with the saliva
collection procedures. An alternative approach could be to provide a video clip of a
model engaging in saliva collection as a more comprehensive tool for parents,
practitioners, and children to utilise together. This approach offers more scope to
explain the full implications of the research project and may help in minimising
children’s anticipatory stress responses to saliva collection. Indeed, modelling
techniques are commonly used in paediatric practice to reduce procedural anxiety
(O’Byrne, Peterson, & Saldana, 1997). Finally, efforts should also be made to provide
children with ongoing opportunities for consent. In the case that the participants are
very young children (< 3 years) it may be appropriate to employ ‘circles of consent’
(Kellett & Nind, 2001). Here individuals who know the child well are enlisted to help
interpret the ongoing consenting status of the child and prevent potentially distressing
activities.
The value of play-based techniques also deserves greater attention, given their
potential in normalising saliva collection. Play may prove particularly valuable for those
working with younger children with whom resistance has seemed to be more likely
(e.g., de Bruijn, van Bakel, Wijnen, Pop, & van Baar, 2009). Both our own and
19
Zimmermann’s (2008) approach offer viable templates for use with preschool-aged
populations. In designing play approaches for use with biomarkers of stress care should
be taken to choose techniques that are not over-stimulating, so as to avoid eliciting a
potentially confounding excitation response. In large-scale studies the availability of the
required materials should be considered. Also, where practitioners and parents are being
recruited, consideration should be given to how easily the technique can be incorporated
into daily routines. Researchers should avoid insisting that play is implemented where
interest has waned. It may also be appropriate to suggest that play protocols can be used
flexibly, where changes are likely to increase children’s ease. Finally, care should be
taken to balance the provision of play with accurate information on the research process.
Deciding who is best to collect saliva with young children requires careful
consideration. Researchers should avoid attempts to fast track relationships with young
children. Where research assistants are necessary, taking time to teach children how to
provide saliva samples, ahead of data collection (e.g., Lisonbee, Mize, Payne, &
Granger, 2008), may maximise the amount of data available whilst simultaneously
increasing children’s familiarity with the research team. Where ECCE practitioners are
recruited to collect samples it is important that the activities are not overburdening.
Decisions on what level of involvement is appropriate should be taken in line with the
study’s design and the profile of its participants. Overall, it is important that the drive
for data does not take precedence over adequate supports for participants. Of course
such a balance carries implications for a research method that requires strong protocol
fidelity to ensure its reliability. These ethical and practical decisions need to be weighed
carefully as too little attention to either will destabilise the research effort as a whole.
Conclusion
20
The potential of biobehavioural salivary research continues to hold exciting promise for
developmental and social researchers. Realising this potential hinges on improving
public knowledge of biobehavioural research. Moreover, further work is needed towards
the development of sensitive saliva collection methods that are ethically sound,
practically effective, and methodologically reliable. Ultimately a reflective discourse is
needed if a method that is clinical in its appearance, perception, and administration is to
be successful in field settings. To this end the value of a more concerted
methodological debate, one that acknowledges and draws on the expertise of the
participants themselves, should not be overlooked.
21
Acknowledgements
We would like to thank all of the participants who shared their perspectives. We
gratefully acknowledge funding from the Department of Children and Youth Affairs
and the University College Dublin Seed Funding Scheme. We are also grateful to
Carmel Smith for her thoughtful suggestions.
22
References
Adam, E. K., & Kumari, M. (2009). Assessing salivary cortisol in large-scale,
epidemiological research. Psychoneuroendocrinology, 34(10), 1423-1436.
doi:10.1016/j.psyneuen.2009.06.011
Ahnert, L., Gunnar, M. R., Lamb, M. E., & Barthel., M. (2004). Transition to child care:
Associations with infant-mother attachment, infant negative emotion, and cortisol
elevations. Child Development, 75(3), 639-650. doi: 10.1111/j.1467-8624.2004.00698.x
Brannen, J. (2005). Mixing methods: The entry of qualitative and quantitative
approaches into the research process. International Journal of Social Research
Methodology, 8(3), 173-184. doi: 10.1080/13645570500154642
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative
Research in Psychology, 3(2), 77-101. doi: 10.1191/1478088706qp063oa
Clements, A. D., Parker, R. C., Dixon, W. E., & Salley, B. (2007). Marshmallows used
as saliva stimulant do not affect cortisol concentrations: finally a palatable alternative
for toddler saliva collection. Developmental Psychobiology, 49(7), 702-707. doi:
10.1002/dev.20238
de Bruijn, A. T., van Bakel, H. J., Wijnen, H., Pop, V. J., & van Baar, A., L. (2009).
Prenatal maternal emotional complaints are associated with cortisol responses in toddler
23
and preschool aged girls. Developmental Psychobiology, 51(7), 553-563. doi:
10.1002/dev.20393
de Haan, M., Gunnar, M. R., Tout, K., Hart, J., & Stansbury, K. (1998). Familiar and
novel contexts yield different associations between cortisol and behaviour among 2-
year-old children. Developmental Psychobiology, 33(1), 93-101. doi.
10.1002/(SICI)1098-2302(199807)33:1<93::AID-DEV8>3.0.CO;2-N
Donaldson, M. (1978). Children’s minds. London: Fontana.
Fine, G. A., & Sandstrom, K. L. (1988). Knowing children. Participant observation
with minors. Qualitative research methods series no. 15, Newbury Park: Sage.
Gallacher, L. A., & Gallagher, M. (2008). Methodological immaturity in childhood
research?: Thinking through ‘participatory methods’. Childhood, 15(4), 499-516. doi:
10.1177/0907568208091672
Gold, J. J., Kim, S. H., Kant, A. J., Joseph, M. H., & Rizzo, A. A. (2006). Effectiveness
of virtual reality for pediatric pain distraction during IV placement. CyberPsychology
and Behavior, 9(2), 207-213. doi: 10.1089/cpb.2006.9.207
Goldberg, S., Levitan, R., Leung, E., Masellis, M., Basile, V., S., Nemeroff, C. B., &
Atkinson, L. (2003). Cortisol concentrations in 12- to 18-month-old infants: Stability
over time, location, and stressor. Biological Psychiatry, 54(7), 719-726. doi:
10.1016/S0006-3223(03)00010-6
24
Gorodischer, R., Burtin, P., Hwang, P., Levine, M., & Koren, G. (1994). Saliva versus
blood sampling for therapeutic drug monitoring in children: patient and parental
preferences and an economic analysis. Therapeutic Drug Monitoring, 16(5), 437-443.
Granger, D. A., & Kivlighan, K. (2003). Integrating biological, behavioral, and social
levels of analysis in early child development: Progress, problems, and prospects. Child
Development, 74(4), 1058-1063. doi: 10.1111/1467-8624.00590
Granger, D. A., Kivlighan, K. T., Fortunato, C., Harmon, A. G., Hibel, L. C., Schwartz,
E. B., & Whembolua, G-L. (2007). Integration of salivary biomarkers into
developmental and behavioral-oriented research: Problems and solutions for collecting
specimens. Physiology and Behavior, 92(4), 583-390. doi:
10.1016/j.physbeh.2007.05.004
Groeneveld, M. G., Vermeer, H. J., van IJzendoorn, M. H., & Linting, M. (2010).
Children’s wellbeing and cortisol levels in home-based and center-based childcare.
Early Childhood Research Quarterly, 25(4), 502-514. doi:
10.1016/j.ecresq.2009.12.004
Gunnar, M. R., & White, B. P. (2001). Salivary cortisol measures in infant and child
assessment. In L. T. Singer & P. S. Zeskind (Eds.), Biobehavioral assessment of the
infant. (pp. 167-189). New York: Guilford Press.
Harris, P. L. (2000). The work of the imagination. Malden: Blackwell.
25
Hill, M. (2005). Ethical considerations in researching children’s experiences. In S.
Greene & D. Hogan (Eds.), Researching children’s experiences: Approaches and
methods. (pp. 61-86) London: Sage.
Hofman, L. F. (2001). Human saliva as a diagnostic specimen. The Journal of Nutrition,
131(5), 1621-1625.
Jessop, D. S., & Turner-Cobb, J. M. (2008). Measurement and meaning of salivary
cortisol: A focus on health and disease in children. Stress, 11(1), 1-14.
doi:10.1080/10253890701365527
Kaitz, M., Sabato, R., Shalev, I., Ebstein., R., & Mankuta., D. (2012). Children’s
noncompliance during saliva collection predicts measures of salivary cortisol.
Developmental Psychobiology, 54(2), 113-123. doi: 10.1002/dev.20580
Kaminski, M., Pellino, T., & Wish, J. (2002). Play and pets: The physical and
emotional impact of child-life and pet therapy on hospitalized children. Children’s
Health Care, 31(4), 321-325. doi: 10.1207/S15326888CHC3104_5
Keller, P. S., El-Sheikh, M., Vaughn, B., & Granger, D. A. (2010). Relations between
mucosal immunity and children’s mental health: the role of child sex. Physiology and
Behaviour, 52, 64-71. doi:10.1016/j.physbeh.2010.08.012
Kellett, M. (2010). Rethinking children and research: Attitudes in contemporary
society. London: Continuum
26
Kellett, M., & Nind, M. (2001). Ethics in quasi-experimental research on people with
severe learning disabilities: dilemmas and compromises, British Journal of Learning
Disabilities, 29(2), 51-55. doi: 10.1046/j.1468-3156.2001.00096.x
Legendre, A., & Trudel, M. (1996). Cortisol and behavioral responses of young children
in a group of unfamiliar peers. Merill-Palmer Quarterly, 42(4), 554-557.
Lindeke, L. L., Hauck, M. R., & Tanner, M. (2000). Practical issues in obtaining child
assent for research. Journal of Pediatric Nursing, 15(2), 99-104. doi:
10.1053/jn.2000.5447
Lisonbee, J. A., Mize, J., Payne, A. L., & Granger, D. (2008). Children’s cortisol and
the quality of teacher-child relationships in child care. Child Development, 79(6), 1818-
1832. doi: 10.1111/j.1467-8624.2008.01228.x
Morrow, V., & Richards, M. (1996). The ethics of social research with children: An
overview. Children and Society, 10(2), 90-105. doi: 10.1111/j.1099-
0860.1996.tb00461.x
O’Byrne, K., Peterson, L., & Saldana, L. (1997). Survey of pediatric hospitals’
preparation programs: Evidence of the impact of health psychology research. Health
Psychology, 16(2), 147-54. doi: 10.1037/0278-6133.16.2.147
O’Connor, T. G. (2011). Factor analyzing an issue. Journal of child psychology and
psychiatry, 52(2), 109-110. doi: 10.1111/j.1469-7610.2010.02363.x
27
van Bakel, H. J. A., & Riksen-Walraven, J. M. (2004). Stress reactivity in 15-Month-
Old Infants: Links with infant temperament, cognitive competence, and attachment
security. Developmental Psychobiology, 44(3), 157-167. doi: 10.1002/dev.20001
Vermeer, H. J., & van IJzendoorn (2006). Children’s elevated cortisol levels at daycare:
A review and meta-analysis. Early Childhood Research Quarterly, 21(3), 390-401. doi:
10.1016/j.ecresq.2006.07.004
Wardlaw, J. M., O’Connell, G., Shuler, K., DeWilde, J., Hayley, J., Escobar, O. (2011).
“Can it read my mind?” – What do the public and experts think of the current (mis)uses
of neuroimaging? PLoS ONE, 6(10): e25829. doi:10.1371/journal.pone.0025829
Watamura, S. E., Donzella, B., Kertes, D. A., & Gunnar, M. R. (2004). Developmental
changes in baseline cortisol activity in early childhood: Relations with napping and
effortful control. Developmental Psychobiology, 45(3), 125-133. doi: 0.1002/dev.20026
Watamura, S. E., Sebanc, A. M., & Gunnar, M. R. (2002). Rising cortisol at childcare:
relations with nap, rest, and temperament. Developmental Psychobiology, 40(1), 33-42.
doi: 10.1002/dev.10011
Westcott, H. L. & Littleton, K. S. (2005). Exploring meaning in interviews with
children. In S. Greene & D. Hogan (Eds.), Researching children’s experiences:
Approaches and methods. (pp. 141-157) London: Sage.
28
Zimmermann, L. K. (2008). A salivary collection method for young children.
Psychophysiology, 45(3), 353-355. doi: 10.1111/j.1469-8986.2008.00647.x
29