Psychometric properties of a German parent rating scale for oppositional defiant and conduct disorder (FBB-SSV) in clinical and community samples

Stability of the effects of a social competence training program for children with oppositional defiant disorder/conduct disorder: a 10-month follow-up

The stability and effectiveness of the Treatment Program for Children with Aggressive Behavior (THAV) in terms of reducing behavioral problems in children with oppositional defiant disorder (ODD) and conduct disorder (CD) were examined at a 10-month follow-up (FU). A total of 76 families and their children (boys aged 6-12 years), who previously participated in a randomized controlled trial comparing THAV with an active control group, took part in the 10-month FU assessment. Outcome measures were rated by parents and included the evaluation of child aggressive behavior, prosocial behavior, problem-maintaining and problem-moderating factors, and comorbid symptoms. Linear mixed models for repeated measures (MMRM) were conducted. The results revealed that THAV effects remained stable (problem-maintaining and problem-moderating factors; comorbid symptoms) and even partially improved (aggressive behavior; ADHD symptoms) over the FU period. Additionally, the differences between the THAV intervention group and the control group, which were apparent at the end of the treatment (post), mainly also remained at the FU assessment. It can be concluded that THAV is an effective and stable intervention for boys aged 6-12 years with ODD/CD.

Parent-Child Inpatient Treatment in Child and Adolescent Mental Healthcare: Predictors of Child Outcomes

Family inpatient units in child and adolescent mental health (CAMH) services engage all admitted family members in the treatment of children's symptoms. Studies demonstrated improvements in child and family functioning following family inpatient treatment, but evidence regarding predictors of treatment outcome is lacking. We analyzed data of families (n = 66) who received a four-week inpatient treatment for families with severe parent-child interaction problems. Hierarchical linear regression analyses revealed that parents who recalled harsher parenting practices of their own fathers reported greater improvements in their children's externalizing and internalizing problems. Greater improvements in externalizing problems were further predicted by lower parental educational level, less adverse impacts of stressful life events, and less internalizing child problems prior to admission. We therefore conclude that family inpatient treatment was particularly effective for children in families with lower parental education and a history of harsh parenting.

Negative Parenting Mediates the Longitudinal Association between Parental Internalizing Symptoms and Child Oppositional Symptoms

Research has pointed to both cross-sectional and longitudinal associations between parental internalizing symptoms and child externalizing symptoms. This study analyzed whether the association is mediated by negative parenting behavior in view of previous reports that both parental internalizing symptoms and child externalizing symptoms are related to parenting behaviors. Longitudinal data for the current analyses were derived from a randomized controlled trial on the efficacy of a web-assisted self-help intervention for parents of children with elevated levels of externalizing symptoms. Two different mediation models were analyzed, one using attention-deficit/hyperactivity disorder (ADHD) symptoms as the dependent variable and the other using oppositional defiant disorder (ODD) symptoms. Both models included parental internalizing symptoms as the independent variable, negative parenting behavior as a mediator, and study condition as a confounder. The longitudinal analyses support the mediating role of negative parenting behavior in the association between early parental internalizing symptoms and later child ODD symptoms.

Validation of a new emotion regulation self-report questionnaire for children

OBJECTIVE

To examine and validate the self-report Questionnaire on the Regulation of Unpleasant Moods in Children (FRUST), which is a modified and shortened version of the Questionnaire for the Assessment of Emotion Regulation in Children and Adolescents (FEEL-KJ).

METHODS

The data comprised child and parent ratings of a community-screened sample with differing levels of affective dysregulation (AD) (N = 391, age: M = 10.64, SD = 1.33, 56% male). We conducted latent factor analyses to establish a factor structure. Subsequently, we assessed measurement invariance (MI) regarding age, gender, and AD level and evaluated the internal consistencies of the scales. Finally, we examined the convergent and divergent validity of the instrument by calculating differential correlations between the emotion regulation strategy (ERS) scales and self- and parent-report measures of psychopathology.

RESULTS

A four-factor model, with one factor representing Dysfunctional Strategies and the three factors Distraction, Problem-Solving and Social Support representing functional strategies provided the best fit to our data and was straightforward to interpret. We found strong MI for age and gender and weak MI for AD level. Differential correlations with child and parent ratings of measures of psychopathology supported the construct validity of the factors.

CONCLUSIONS

We established a reliable and valid self-report measure for the assessment of ERS in children. Due to the reduced number of items and the inclusion of highly specific regulatory behaviors, the FRUST might be a valuable contribution to the assessment of ER strategies for diagnostic, therapeutic, and research purposes.

Parenting Behaviors as Mediators of the Association Between Parental Internalizing Symptoms and Child Externalizing Symptoms

This study analyzes whether the association between parental internalizing symptoms (depression, anxiety, stress) and child symptoms of attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) is mediated by positive and negative parenting behaviors. Cross-sectional data of 420 parents of children (age 6-12 years) with elevated levels of externalizing symptoms were collected in a randomized controlled trial. Measures included parent ratings of their internalizing symptoms and parenting behaviors and of their child's externalizing symptoms. Two mediation models were examined, one including ADHD symptoms and one including ODD symptoms as the dependent variable. Parental internalizing symptoms were modeled as the independent variable and positive and negative parenting behaviors were modeled as parallel mediators. Regression analyses support negative parenting behavior as a mediator of the association between parental internalizing symptoms and child ODD symptoms. For the ADHD model, no significant mediator could be found. Future studies should use prospective designs and consider reciprocal associations.

Child-therapist and parent-therapist alliances and outcome in the treatment of children with oppositional defiant/conduct disorder

OBJECTIVE

This study examined the quality of therapeutic alliance from different rater perspectives (child, parent, therapist) in cognitive behavioural therapy for children with oppositional defiant disorder (ODD) and conduct disorder (CD), and its association with symptom severity. Further, a panel model with an autoregressive cross-lagged panel design was used to explore whether therapist-rated and parent-rated therapeutic alliance influences change in symptom severity, or vice versa.

METHODS

Sixty boys aged 6-12 years with a principal diagnosis of ODD/CD, and their parents, received individually delivered social competence training for childhood aggressive behaviour problems. Child, therapist, and parent ratings of therapeutic alliance and symptom severity were measured twice.

RESULTS

Our results indicate good to very good therapeutic alliance that was relatively stable over time. The cross-sectional analyses of the alliance-symptom association revealed moderate correlations. However, effects of early alliance on later treatment outcome or of early symptom severity on later alliance were marginal. The only significant association was found between early parent-rated therapist-parent alliance and later parent-rated symptom severity.

CONCLUSION

Our study shows a moderate correlation between simultaneously assessed therapeutic alliance and symptoms. The findings of the panel model indicate that an early good therapeutic alliance is a component of later therapeutic success (parent perspective).

Irritability and Emotional Impulsivity as Core Feature of ADHD and ODD in Children

The categorical approach of diagnosing mental disorders entails the problem of frequently occurring comorbidities, suggesting a more parsimonious structure of psychopathology. In this study, we therefore aim to assess how affective dysregulation (AD) is associated with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in children. To assess AD in children aged 8–12 years (n = 391), we employed the parent version of a newly constructed parent rating scale. Following item reduction, we conducted exploratory and confirmatory factor analyses to establish a factorial structure of AD. One core dimension was identified, comprising irritability and emotional impulsivity, and two smaller dimensions, comprising positive emotionality and exuberance. Subsequently, we examined five different latent factor models – a unidimensional model, a first-order correlated factor model, a second-order correlated factor model, a traditional bifactor model, and a bifactor S-1 model, in which the first-order factor AD-Irritability/Emotional Impulsivity (II) was modeled as the general reference factor. A bifactor S-1 model with the a priori defined general reference domain AD-II provided the best fit to our data and was straightforward to interpret. This model showed excellent model fit and no anomalous factor loadings. This still held true, when comparing it to bifactor S-1 models with ADHD/ODD-related reference factors. Differential correlations with emotion regulation skills and the established Parent Proxy Anger Scale validate the interpretation of the different dimensions. Our results suggest that irritability/emotional impulsivity might be a common core feature of ADHD and ODD.

Prediction of Educational Attainment and Occupational Functioning in Young Adults With a Childhood Diagnosis of ADHD: Results from the Cologne Adaptive Multimodal Treatment (CAMT) Study

OBJECTIVE

This longitudinal study examined early predictors of educational attainment and occupational functioning in adults with a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD).

METHOD

Participants (n = 70) of the Cologne Adaptive Multimodal Treatment (CAMT) Study were diagnosed with ADHD and received adaptive multimodal ADHD treatment during childhood. They were then followed through adolescence into adulthood.

RESULTS

Hierarchical regression analysis revealed that poor reading skill and externalizing behaviors in childhood were early predictors of educational and occupational difficulties in adulthood. The use of stimulant medication in childhood predicted lower high school achievement, probably because medication use was confounded by indication. The regression models improved when intelligence scores and/or externalizing behaviors, especially delinquency, assessed in adolescence were considered as additional predictors.

CONCLUSION

Children with ADHD, who continue to show reading difficulties and externalizing behavior problems after initial treatment, are at risk for educational and occupational difficulties and may need additional support.

Predicting delinquent behavior in young adults with a childhood diagnosis of ADHD: results from the Cologne Adaptive Multimodal Treatment (CAMT) Study

The aim of this study was to investigate which factors predict lifetime reports of delinquent behavior in young adults who had received adaptive multimodal treatment of attention-deficit/hyperactivity disorder (ADHD) starting at ages 6-10 years. Participants were reassessed 13-24 years (M = 17.6, SD = 1.8) after they had received individualized ADHD treatment in the Cologne Adaptive Multimodal Treatment Study (CAMT). Their behavior was classified as non-delinquent (n = 34) or delinquent (n = 25) based on self-reports regarding the number of police contacts, offenses, and convictions at follow-up. Childhood variables assessed at post-intervention (e.g., externalizing child behavior problems, intelligence, and parenting behavior) that were significantly associated with group membership were entered as possible predictors of delinquency in a Chi-squared automatic interaction detector (CHAID) analysis. Delinquent behavior during adolescence and adulthood was best predicted by (a) meeting the symptom count diagnostic criteria for conduct disorder (CD) according to parent ratings, in combination with a nonverbal intelligence of IQ ≤ 106 at post-intervention, and (b) delinquent behavior problems (teacher rating) at post-intervention. The predictor variables specified in the CHAID analysis classified 81% of the participants correctly. The results support the hypothesis that a childhood diagnosis of ADHD is only predictive of delinquent behavior if it is accompanied by early conduct behavior problems. Low nonverbal intelligence was found to be an additional risk factor. These findings underline the importance of providing behavioral interventions that focus on externalizing behavior problems to children with ADHD and comorbid conduct problems.

The impact of preschool child and maternal attention-deficit/hyperactivity disorder (ADHD) symptoms on mothers' perceived chronic stress and hair cortisol

Providing care for a child with attention-deficit/hyperactivity disorder (ADHD) is associated with parenting stress. Moreover, adults with elevated ADHD symptoms report increased perceived stress. Despite this, it has rarely been examined whether and how child and maternal ADHD symptoms may affect maternal perceived stress and the stress-sensitive hypothalamic–pituitary–adrenal axis. This study therefore investigated the possible impact of child and maternal ADHD symptoms on mothers' perceived chronic stress and hair cortisol concentration (HCC), while simultaneously considering the effects of child oppositional defiant/conduct disorder (ODD/CD) and maternal depressive symptomatology. In total, 124 mothers (35.96 ± 5.21 years) of preschool children were included. Maternal perceived stress, ADHD and depressive symptoms were assessed using self-report measures. Child ADHD symptoms were assessed using an interview and questionnaires completed by mothers and teachers. Additionally, mothers provided information about their children’s ODD/CD symptoms. Hair samples were taken from mothers to assess HCC. Child and maternal ADHD, child ODD/CD, and maternal depressive symptoms accounted for 50% of the variance in perceived chronic stress (F(4, 119) = 30.24; p < 0.01), with only maternal ADHD (β = 0.52, p < 0.01) and depressive symptoms (β = 0.49, p < 0.01) being uniquely significant. Maternal ADHD symptoms did not moderate the relationship between child ADHD symptoms and maternal perceived chronic stress (b = − 0.01; SE b = 0.17; t(5, 118) = − 0.05; p = 0.96). Mother’s age became the only significant predictor of maternal HCC (β = 0.29; p < 0.01). Based on these findings, practitioners are advised to be aware of and take into account possible maternal ADHD and depressive symptomatology and perceived chronic stress when treating children diagnosed with ADHD.

Impulsivity as Early Emerging Vulnerability Factor-Prediction of ADHD by a Preschool Neuropsychological Measure

Impulsivity, comprising deviations of brain-based bottom-up and top-down control processes, has been regarded as a crucial, early emerging marker of a developmental pathway to attention-deficit/hyperactivity (ADHD) and externalizing disorders. In two independent studies (a cross-sectional study and a longitudinal study), we analyzed the concurrent and predictive validity of a task-based neuropsychological impulsivity measure for preschool children. The sample of Study 1 comprised 102 3-5-year-old children (46% boys). In Study 2, 138 children (59% boys) with elevated ADHD symptoms were recruited and assessed at the ages of 4-5 and 8 years. In both studies, preschool impulsivity was measured by a summary score of neuropsychological tasks on approach motivation and hot inhibitory control. For Study 1, the impulsivity measure was significantly associated with symptoms of ADHD and oppositional defiant disorder (ODD) (χ²(1) = 9.8, p = 0.002; χ²(1) = 8.1, p = 0.004). In Study 2, the impulsivity measure predicted the 8-year-olds' ADHD diagnoses over and above concurrent ADHD symptoms (χ²(1) = 10.0, p = 0.002, OR = 5.0, 95% CI: 1.8-14.0). The impulsivity measure showed good concurrent and predictive validity. The measure can be useful for the early identification of children at risk for developing ADHD and externalizing disorders.

Long-Term Effectiveness of Guided Self-Help for Parents of Children With ADHD in Routine Care-An Observational Study

Objective:To assess long-term effectiveness of guided self-help for parents of children with ADHD under routine care conditions. Method: 6- to 12-year-old children diagnosed with ADHD were enrolled in an observational study on a 1-year telephone-assisted parent-administered behavioral intervention. N = 136 families who completed the intervention participated in a follow-up assessment. Pre-, post-, and follow-up data were analyzed by repeated measures ANOVA with planned contrasts. Clinical significance was analyzed according to the reliable change index. Results: Child ADHD symptoms (primary outcome), oppositional defiant disorder (ODD) symptoms, overall behavioral problems, and quality of life improved during the intervention. There was a further improvement in ADHD symptoms at follow-up, with a medium effect size. Improvements during treatment in ODD symptoms, overall behavioral problems, and quality of life were maintained at follow-up. Conclusion: The findings suggest that telephone-assisted self-help interventions may result in a long-term reduction of child behavior problems.

Negative parenting behaviour as a mediator of the effects of telephone-assisted self-help for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder

A previous randomised controlled trial demonstrated the effects of a telephone-assisted self-help (TASH) intervention for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder (ADHD) on ADHD symptoms, oppositional symptoms, functional impairment, and negative parenting behaviour (per-protocol analyses). In the current study, we examined whether changes in positive and negative parenting behaviour mediated the effects on symptoms and impairment. Parents in an enhancement group (n = 51) participated in a 12-month TASH intervention (eight booklets plus up to 14 telephone consultations) as an adjunct to routine clinical care, whereas parents in a waitlist control group (n = 52) received routine clinical care only. Parents completed measures of child symptoms, child functional impairment, and parenting behaviour at baseline, at 6 months, and at 12 months. The mediating effects of parenting behaviour were examined using regression analyses. Per-protocol analyses (n = 74) revealed a significant indirect intervention effect on functional impairment through negative parenting behaviour at 6 months as well as indirect intervention effects on oppositional symptoms and functional impairment through negative parenting behaviour at 12 months. The indirect effect on ADHD symptoms through negative parenting behaviour at 12 months just failed to reach significance. The analyses yielded no indirect intervention effects through positive parenting behaviour. The study provides some, albeit limited, support for the importance of changes in negative parenting behaviour to achieve changes in symptoms and functional impairment during parent training. In consideration of the inconsistent results of previous studies concerning the mediating role of positive and negative parenting behaviour, further research is required to better understand the mechanisms of change during parent training, also including other possible mediators like parenting stress and parental self-efficacy.

Toward a Dimensional Assessment of Externalizing Disorders in Children: Reliability and Validity of a Semi-Structured Parent Interview

OBJECTIVE

This study assesses the reliability and validity of the DSM-5-based, semi-structured Clinical Parent Interview for Externalizing Disorders in Children and Adolescents (ILF-EXTERNAL).

METHOD

Participant data were drawn from the ongoing ESCAschool intervention study. The ILF-EXTERNAL was evaluated in a clinical sample of 474 children and adolescents (aged 6-12 years, 92 females) with symptoms of attention-deficit/hyperactivity disorder (ADHD). To obtain interrater reliability, the one-way random-effects, absolute agreement models of the intraclass correlation (ICC) for single ICC(1,1) and average measurements ICC(1,3) were computed between the interviewers and two independent raters for 45 randomly selected interviews involving ten interviewers. Overall agreement on DSM-5 diagnoses was assessed using Fleiss' kappa. Further analyses evaluated internal consistencies, item-total correlations as well as correlations between symptom severity and the degree of functional impairment. Additionally, parents completed the German version of the Child Behavior Checklist (CBCL) and two DSM-5-based parent questionnaires for the assessment of ADHD symptoms and symptoms of disruptive behavior disorders (FBB-ADHS; FBB-SSV), which were used to evaluate convergent and divergent validity.

RESULTS

ICC coefficients demonstrated very good to excellent interrater reliability on the item and scale level of the ILF-EXTERNAL [scale level: ICC(1,1) = 0.83-0.95; ICC(1,3) = 0.94-0.98]. Overall kappa agreement on DSM-5 diagnoses was substantial to almost perfect for most disorders (0.38 ≤ κ ≤ 0.94). With some exceptions, internal consistencies (0.60 ≤ α ≤ 0.86) and item-total correlations (0.21 ≤ r it ≤ 0.71) were generally satisfactory to good. Furthermore, higher symptom severity was associated with a higher degree of functional impairment. The evaluation of convergent validity revealed positive results regarding clinical judgment and parent ratings (FBB-ADHS; FBB-SSV). Correlations between the ILF-EXTERNAL scales and the CBCL Externalizing Problems were moderate to high. Finally, the ILF-EXTERNAL scales were significantly more strongly associated with the CBCL Externalizing Problems than with the Internalizing Problems, indicating divergent validity.

CONCLUSION

In clinically referred, school-age children, the ILF-EXTERNAL demonstrates sound psychometric properties. The ILF-EXTERNAL is a promising clinical interview and contributes to high-quality diagnostics of externalizing disorders in children and adolescents.

Cross-Cultural Validity of the Child and Adolescent Dispositions Model in a Clinical Sample of Children With Externalizing Behavior Problems

Background: The Child and Adolescent Dispositions Scale—parent rating (CADS-P) explores three emotional dispositions that may enlarge the probability of future externalizing problem behavior. The English version has proven its psychometric quality within a population-based sample of children and adolescents. The presents study investigates the German version of the CADS-P by examining a clinically referred sample of children with externalizing behavior problems.

Methods:The sample included 132 children aged 4–11 years with a diagnosis of attention- deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD). The factor structure of the CADS-P was evaluated using exploratory (EFA) and confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha). Validity was assessed through linear regression analyses, with symptoms of externalizing [conduct disorder (CD), ODD, ADHD] and internalizing behavior problems (anxiety, depression) as criterion variables and the three CADS-P factor scores as predictors.

Results:After eliminating eight items due to insufficient psychometric properties, EFA and CFA supported a three-factor solution for the German CADS-P. Cronbach's alpha coefficient exceeded α = 0.70 for all subscales. Mostly, as predicted, the CADS-P dimensions were associated with symptoms of ODD/CD and ADHD and symptoms of anxiety and depression.

Conclusions:The present study provides evidence for the cross-cultural validity of the CADS- P in a non-English-Speaking country. Results show that the German version of the CADS-P is a reliable and valid parent questionnaire for assessing prosociality, negative emotionality and daring as emotional dispositions that may enlarge the probability to develop externalizing problem behavior.

Trial Registration: The study was approved by the review board of the Medical Faculty of the University of Cologne (ID 09-123) and was pre-registered at ClinicalTrials.gov (ID: NCT01350986).

Long-Term Course After Adaptive Multimodal Treatment for Children With ADHD: An 8-Year Follow-Up

Objective: This study reassessed adolescents and young adults (15-22 years old) who received individually tailored multimodal treatment for ADHD (behavior therapy and/or stimulant medication) during childhood 6 to 12 years after treatment (M = 8.8 years, SD = 1.6). Method: All participants (N = 75) provided information about their social functioning. Most parents (83%) completed behavior rating scales. Results: Participants demonstrated significant improvement in behavior during the follow-up period with effect sizes on ADHD symptoms of d = 1.2 and 68% of the former patients in the normal range at follow-up. Participants reported elevated rates of grade retention (51%), school dropout (13%), special education service use (17%), school change (47%), and conviction (16%), but few were unemployed (4%). Conclusion: This study provides evidence that the effects of individually tailored multimodal treatment for ADHD in childhood are maintained into adolescence and young adulthood. No hints could be found that continued medication results in a more favorable long-term outcome.

Low hair cortisol concentration predicts the development of attention deficit hyperactivity disorder

OBJECTIVE

Low activity of the hypothalamic-pituitary-adrenal axis (HPAA) resulting from genetic and early environmental factors has been thought to indicate risk for the development of attention deficit hyperactivity disorder (ADHD) and externalizing disorders. However, longitudinal research on this issue is scarce. We analyzed whether hair cortisol concentration (HCC), i.e. accumulated long-term HPAA activity, predicts the development of ADHD between preschool and school age.

METHODS

A community-based sample of 126 children was assessed at the ages of 4, 5 and 8 years. ADHD and symptoms of oppositional defiant and conduct disorder (ODD/CD), callous unemotional (CU) traits, and internalizing symptoms were measured by clinical parent interviews and parent and teacher questionnaires. HCC was analyzed in the most proximal 3-cm scalp hair segment using luminescence immunoassay.

RESULTS

Low HCC at preschool age predicted an increase in ADHD symptoms between preschool and school age while adjusting for gender of child, maternal education level, and internalizing symptoms (F_(1,119) = 6.5; p = .012). The prediction held after additionally adjusting for ODD/CD symptoms and CU traits (F_(1,116) = 4.1; p = .045). The same was true for the prediction of the ADHD diagnosis at the age of 8 years (Chi²₍₁₎ = 7.3; p = .007). The prediction of ADHD was mainly based on the presentation of inattention symptoms (F_(1,119) = 7.4, p = .008).

CONCLUSION

Low HCC in preschool children indicates an increased risk of developing ADHD at school age. In future research, it would be of theoretical and clinical importance to further circumscribe this HCC-related developmental pathway and track its further course of development.

Functional Impairment in Children With Externalizing Behavior Disorders: Psychometric Properties of the Weiss Functional Impairment Rating Scale-Parent Report in a German Clinical Sample

OBJECTIVE

To examine the psychometric properties of a German adaptation of the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) in a clinical sample of children (4-12 years) with externalizing behavior disorders.

METHOD

Data were collected within two clinical trials (N = 264). Factorial validity, reliability, and divergent validity from symptoms of ADHD and oppositional defiant disorder (ODD) were assessed.

RESULTS

Confirmatory factor analyses revealed that a bifactor model consistent with the theoretical assumption of a general construct of impairment (total scale) and additional specific factors (subscales) provided satisfactory data fit. Model-based reliability estimates showed that both the general construct and specific factors accounted for item variance. Internal consistencies were >.70, part-whole corrected item-scale correlations mostly >.30. Correlations between the WFIRS-P Scales and ADHD and ODD symptoms were low to moderate.

CONCLUSION

The results support the factorial validity, reliability, and divergent validity of the WFIRS-P.

Assessing Callous-Unemotional Traits in 6- to 18-Year-Olds: Reliability, Validity, Factor Structure, and Norms of the German Version of the Inventory of Callous-Unemotional Traits

Background: This article reports reliability, validity, and norms for the German version of the multi-informant questionnaire Inventory of Callous-Unemotional Traits (ICU). Method: The ICU was filled in by nonreferred children aged 13 to 18 years old (n = 645), parents of children aged 6 to 18 years old (n = 1,005), and their teachers (n = 955). Results: Confirmatory factor analysis resulted in a two-factor solution giving the best fit. Still none of the models showed an adequate model-fit applying the chi-square exact fit test. The internal consistency of the parent's, teacher's, and self-report version were α = .830, α = .877 and α = .769, respectively. Interrater reliability was moderate. Convergent validity with the Youth Psychopathic Traits Inventory, the externalizing scores of the Youth Self-Report/Child Behavior Checklist, and with the German oppositional Defiant Disorder/Conduct Disorder Rating Scale "FBB-SSV" were good. German norms were calculated. Conclusions: The ICU is a reliable and valid dimensional measure to describe callous-unemotional traits.

Efficacy of an Individualized Computer-Assisted Social Competence Training Program for Children With Oppositional Defiant Disorders/Conduct Disorders

Group-based child-centered cognitive behavioral therapy (CBT) for children with aggressive behavior has been found to significantly reduce child behavior problems. Nevertheless, most children suffer from residual symptoms at the end of treatment. Therefore, individualized interventions that treat the specific problem-maintaining factors and that use digital support may enhance treatment effects. However, enhanced computer-facilitated interventions have not been examined in clinical samples. Therefore, we tested the efficacy of an individualized computer-facilitated social skills training for children with clinically referred aggressive behavior problems. Fifty children aged 6-12 years with peer-related aggressive behavior problems were included in a within-subject design with two phases (waiting, treatment). The course of the outcome measures during an 8-week waiting phase was compared with that in the subsequent treatment phase (16 weekly child sessions and 2 parent psychoeducation contacts at the beginning of the treatment) using multilevel modeling. The primary outcome was peer-related aggressive behavior rated by parents. Further outcome measures included parent ratings and patient self-reports of aggressive and prosocial behavior. No significant changes occurred for any of the outcome variables during the waiting phase. During treatment, most parent-rated outcome measures (including the primary outcome measure) showed a significant decrease, which was stronger than changes in the waiting phase. Most self-rated outcome measures also showed significant decreases during treatment, but a stronger decrease than in the waiting phase was only found for peer-related aggressive behavior. The computer-facilitated social skills training appears to be an effective CBT intervention for children with peer-related aggressive behavior.

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4-11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post-assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination.

Hair cortisol concentration in mothers and their children: roles of maternal sensitivity and child symptoms of attention-deficit/hyperactivity disorder

Associations between mothers' and children's cortisol secretion parameters are well established. According to the bio-behavioral synchrony model, these associations reflect influences of the mother-child relationship, the child's social adjustment, and might also reflect shared genetic dispositions. From the bio-behavioral synchrony model, we predicted a stronger mother-child hair cortisol concentration (HCC) link in mothers showing highly adequate (compared to those showing less adequate) parenting behaviors and in children showing low (compared to those showing high) ADHD symptoms. From a genetic perspective, no such moderator effects, or a stronger mother-child HCC link in children with high ADHD symptoms, can be expected. The study sample consisted of 111 4-5-year-old children (64 of whom screened positive for increased ADHD symptoms) and their mothers. ADHD symptoms were assessed by a clinical interview and parent and teacher questionnaires. Maternal sensitive/responsive parenting behavior was assessed by an at-home behavior observation procedure. In mothers and children, HCC in the most proximal 3-cm scalp hair segment was analyzed using luminescence immunoassay. Overall HCCs of mothers and their children correlated significantly. Maternal sensitivity/responsiveness and child ADHD symptoms proved to be significant moderator variables of this association: High maternal sensitivity/responsiveness and low ADHD symptoms of the child were associated with a stronger mother-child link in HCC. The findings are in line with the bio-behavioral synchrony model in the mother-child relationship, and are less compatible with a genetic perspective. The results might hint at environmental events influencing the development of stress axis functioning in subgroups of preschoolers with high ADHD symptoms.

Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety and stress

Previous research has shown that child-oppositional defiant disorder (ODD) and conduct disorders (CD) are associated with parental symptoms of depression, anxiety and/or stress, probably in a bidirectional relationship with mutual influences. It is, therefore, reasonable to assume that in child-centered treatment, a decrease in child-oppositional behavior problems constitutes (at least in part) a mechanism of change for a subsequent reduction in parental psychopathology. The aim of the present study (Clinical trials.gov Identifier: NCT01406067) was to examine whether the reduction in ODD symptoms due to child-based cognitive behavioral treatment (CBT) led to a reduction in parental depression, anxiety and stress. Eighty-one boys (age 6-12 years) with a diagnosis of ODD/CD were randomized either to a cognitive behavioral intervention group or an educational play group (acting as control group). Mediation analyses were conducted using path analysis. The stronger reduction in child ODD symptoms in the CBT group compared to the control group led to a decrease in parental depression and stress, as indicated by significant indirect effects (ab = 0.07 and ab = 0.08, p < 0.05). The proposed model for mechanisms of change was, therefore, confirmed for two of the three outcome parameters. Parental psychopathology and stress can be modified by child-centered CBT. The preceding reduction in ODD symptoms acts as a mediator for at least some of the changes in parental depression and stress. However, due to some limitations of the study, other possible explanations for the results found cannot be completely ruled out and are, therefore, discussed.

Maternal Responsiveness as a Predictor of Self-Regulation Development and Attention-Deficit/Hyperactivity Symptoms Across Preschool Ages

Preschool-age "hot" executive function capacity (i.e. reward-related effortful control) represents an early kind of self-regulation that is involved in social adjustment development as well as the development of subtypes of attention-deficit/hyperactivity disorder (ADHD). Early self-regulation development might be malleable by responsive parenting. We analyzed whether maternal responsiveness/sensitivity predicts reward-related control (RRC) development within the preschool period, and whether RRC mediates a negative link between maternal responsiveness and ADHD symptoms. A sample of 125 preschoolers and their families were seen at the ages of 4 and 5 years. Maternal responsiveness/sensitivity was assessed via home observations, RRC by neuropsychological tasks, and ADHD symptoms by a structured clinical parent interview. Maternal responsiveness/sensitivity predicted RRC development. The negative link between maternal responsiveness/sensitivity at 4 years and ADHD symptoms at 5 years was mediated by RRC performance at 5 years. Preschoolers showing ADHD symptoms combined with low RRC capacity in particular might benefit from responsive/sensitive parenting.

Social skills training and play group intervention for children with oppositional-defiant disorders/conduct disorder: Mediating mechanisms in a head-to-head comparison

Objective: Social-cognitive information processing, social skills, and social interactions are problem-maintaining variables for aggressive behavior in children. We hypothesized that these factors may be possible mediators of the mechanism of change in the child-centered treatment of conduct disorders (CDs). The aim of the present study (Clinical trials.gov Identifier: NCT01406067) was to examine putative mechanisms of change for the decrease in oppositional-defiant behavior resulting from child-centered treatment of patients with oppositional-defiant disorder (ODD) or CD. Method: 91 children (age 6-12 years) with ODD/CD were randomized to receive either social skills training or to a resource activating play group. Mediator analyses were conducted using path analyses. Results: The assumed mediating effects were not significant. However, alternative models with the putative mediators and outcome in reversed positions showed significant indirect effects of the oppositional-defiant symptoms as mediator for the decrease of disturbance of social-information processing, social skills, and social interactions. Conclusions: The proposed model for mechanisms of change could not be confirmed, with the results pointing to a reversed causality. Variables other than those hypothesized must be responsible for mediating the effects of the intervention on child oppositional-defiant behavior. Possible mechanisms of change were discussed.

Hair cortisol concentration in preschoolers with attention-deficit/hyperactivity symptoms-Roles of gender and family adversity

OBJECTIVE

Previous studies on the association between hypothalamic-pituitary-adrenal axis (HPAA) activity and ADHD yielded inconsistent findings, particularly in younger children. This might be due to the heterogeneity of the disorder, making moderator effects of variables probable, which circumscribe more homogenous subgroups. There have been indications of moderator effects on this association by gender of child and exposure to family adversity. Moreover, difficulties in capturing long-term basal HPAA activity in younger children might have contributed to the inconsistencies. We therefore analyzed moderator effects of gender and family adversity while using the hair cortisol concentration (HCC) to assess integrated long-term HPAA.

METHODS

The community-based sample consisted of 122 4-5-year-old preschoolers (71 screened positive for elevated ADHD symptoms). ADHD symptoms were measured by a clinical parent interview and parent and teacher questionnaires. HCC in the most proximal 3-cm scalp hair segment was analyzed using luminescence immunoassay. An extended family adversity index was used.

RESULTS

Hierarchical linear regression analyses yielded an interaction effect (p<.05) between ADHD symptom groups and gender on HCC, indicating a low HCC in boys with elevated ADHD symptoms. Further exploratory analyses revealed that this interaction effect was most pronounced under the condition of family adversity. The results held after controlling for oppositional, anxiety, and depressive symptoms.

CONCLUSION

Low HCC might indicate a specific pathogenic mechanism in boys with elevated ADHD symptoms. This mechanism might further involve an exposure to family adversity. However, the results need to be cross-validated before definitive conclusions can be drawn.

Telephone-assisted self-help for parents of children with attention-deficit/hyperactivity disorder who have residual functional impairment despite methylphenidate treatment: a randomized controlled trial

BACKGROUND

Self-help parenting interventions have been shown to be effective in the management of children with attention-deficit/hyperactivity disorder (ADHD) and may be useful when there are barriers to face-to-face therapist-led parent trainings. Previous studies indicate that behavioral interventions might be a useful adjunct to medication in children with residual ADHD symptoms, and regarding comorbid oppositional symptoms and multiple domains of functional impairment. In the present study, we examined whether a telephone-assisted self-help (TASH) parenting behavioral intervention (written materials plus telephone counseling) enhanced the effects of methylphenidate treatment in children with ADHD.

METHODS

In this randomized controlled trial, parents of 103 school-aged children with ADHD and residual functional impairment despite methylphenidate treatment were randomly assigned to either the enhancement group, which received the TASH intervention as adjunct to routine clinical care (including continued medication), or to the active control group, which received routine clinical care only (including continued medication). Parent-completed outcome measures at baseline and at 12 months (postassessment) included functional impairment, ADHD symptoms, oppositional defiant disorder (ODD) symptoms, parenting behavior, and parental satisfaction with the intervention (ClinicalTrials.gov: NCT01660425; URL: https://clinicaltrials.gov/ct2/show/NCT01660425).

RESULTS

Intention-to-treat analyses of covariance (ANCOVAs), which controlled for baseline data, revealed significant and moderate intervention effects for ODD symptoms and negative parenting behavior at the postassessment, whereas per-protocol analyses additionally showed significant and moderate effects on functional impairment (primary outcome). Parents expressed high satisfaction with the program.

CONCLUSIONS

The TASH program enhances effects of methylphenidate treatment in families who complete the intervention. The discontinuation rate of about 30% and comparison between completing and discontinuing families suggest that the program may be more suitable for families with a higher educational level and fewer additional stresses.

[Expressed emotion, mother-child relationship, and ADHD symptoms in preschool- a study on the validity of the German Preschool Five Minute Speech Sample]

An inadequate parent-child relationship with hostility, low warmth, and a lack of responsiveness/sensitivity on the part of the primary caregiver often accompanies a child's externalizing disorders and predicts a negative developmental course. The Preschool Five Minute Speech Sample (PFMSS) was developed to enable an economic assessment of components of an inadequate parent-child relationship. In this article we investigate aspects of the validity of the German version of the PFMSS. We analyze whether the PFMSS scales are associated with observed maternal sensitivity, symptoms of attention deficit-/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and maternal depressive symptoms. The sample consists of n = 114 families with 4- to 5-year-old children, whereof n = 65 (57 %) show heightened ADHD-symptoms. The families were recruited from local kindergardens. Maternal sensitivity was assessed by observing the mother-child interaction at home. ADHD, ODD, and maternal depressive ~symptoms were measured by clinical interviews and questionnaires. Most of the PFMSS scales showed the expected associations with maternal sensitivity, ADHD, and ODD symptoms of the child. The German PFMSS thus validly captures significant components of an inadequate mother-child relationship within the context of preschool externalizing behavior problems.

Parent-child inpatient treatment for children with behavioural and emotional disorders: a multilevel analysis of within-subjects effects

BACKGROUND

The importance of parental involvement in child treatment is well-established. Several child psychiatric clinics have, therefore, set up inpatient family units where children and parents are both actively involved in the treatment. Unfortunately, evidence supporting the benefits of these units is sparse.

METHODS

We evaluated the effectiveness of inpatient treatment for families with severe parent-child interaction problems in a child psychiatric setting. Consecutive admissions to the parent-child ward (N = 66) were studied. A within-subjects design was used with four assessment points (baseline, admission, discharge, four-week follow-up). Outcome measures were 1) parent and teacher ratings of child behaviour, and 2) parent self-ratings of parenting practices, parental strains and parental mental health. Data were analyzed using multilevel modelling for longitudinal data (piecewise growth curve models).

RESULTS

All parent-rated measures improved significantly during the four-week treatment period (d = 0.4 - 1.3). These improvements were significantly greater than those observed during the four-week pre-admission period. In addition, benefits were maintained during the four-week follow-up period. Only parents' self-efficacy in managing their child's behaviour showed continued improvement during follow-up. Teacher ratings of children's disruptive behaviour at school were stable during the pre-admission period and showed significant improvements at follow-up (d = 0.3 - 0.4).

CONCLUSIONS

We conclude that parent-child inpatient treatment has positive effects on child and parent behaviour and mental health, and can therefore be recommended for children with behavioural and emotional disorders and severe parent-child interaction problems.

Efficacy of an individualized social competence training for children with Oppositional Defiant Disorders/Conduct Disorders

OBJECTIVES

Group-based Cognitive-Behavioral Therapy of children with aggressive behavior has resulted in significant reductions of behavior problems with small to medium effect sizes. We report the efficacy of an individualized Treatment Program for Children with Aggressive Behavior.

METHOD

A within-subject design with two phases (waiting, treatment) was chosen. Sixty boys aged 6-12 years with peer-related aggressive behavior were included. The course of the outcome measures (growth rates) during a 6-week waiting phase was compared with those in the subsequent treatment phase (24 weekly child sessions together with an average of 8 parent contacts) by multilevel modeling. Primary outcome was peer-related aggressive behavior rated by parents. Further outcome measures included parent ratings and patient self-reports of aggressive and prosocial behavior.

RESULTS

During the treatment, growth rates for all parent-rated outcome measures were significant (p < .001) and comparison with the waiting phase indicated a stronger decrease in aggressive behavior and a stronger increase in prosocial behavior. For all self-rated outcome measures, growth rates during the treatment were significant (p < .01), but comparison with the waiting phase indicated a stronger decrease only for disturbance of social interaction.

CONCLUSIONS

The treatment program is an effective intervention for children with peer-related aggressive behavior.

Incontinence and parent-reported oppositional defiant disorder symptoms in young children--a population-based study

BACKGROUND

Oppositional defiant disorder (ODD) and incontinence are common disorders of childhood. We have examined associations between ODD symptoms and incontinence in a representative sample of young children.

METHODS

A questionnaire with seven questions referring to incontinence, eight DSM-IV items of ODD, 15 items of the Home Situations Questionnaire and six items regarding eating, drinking or toileting refusal was administered to the parents of 718 children at school-entry from a defined geographical area at school-entry.

RESULTS

Of the 718 6-year-old children included in the analysis, 8.2% had nocturnal enuresis (NE), 1.5% had daytime urinary incontinence (DUI) and 1.1% had faecal incontinence (FI). Significantly more boys than girls had NE (12 vs. 4.3%). Overall, 6.7% of children had ODD symptoms. Rates of ODD symptoms were significantly higher in incontinent children (19.5%) than in continent children (5.2%), with the highest rate of ODD symptoms in children with DUI (36.4%). Children with incontinence (mean 6.1 episodes) or ODD symptoms (mean 8.4 episodes) showed non-compliant behaviours in more problem situations than continent children (mean 4.5 episodes) or children without ODD symptoms (mean 4.5 episodes).

CONCLUSIONS

Incontinence and ODD are common comorbid disorders at school-entry age. Boys are more affected by both disorders. Children with DUI have the highest rate of ODD symptoms. As ODD symptoms affect many daily family situations, ODD needs to be diagnosed and treated in children with incontinence, as it can negatively affect compliance.

Prevalence of incontinence, attention deficit/hyperactivity disorder and oppositional defiant disorder in preschool children

Externalizing disorders as attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are common in children with nocturnal enuresis (NE), daytime urinary incontinence (DUI) and faecal incontinence (FI). We examined the prevalence rates of ADHD, ODD and incontinence in a defined geographical area and analysed the association between externalizing disorders and subtypes of incontinence. 1,676 parents of children who were presented at the mandatory school-entry medical examination completed a questionnaire with all DSM-IV items of ADHD, ODD and six questions regarding incontinence. 50.2% were male and mean age was 5.7 years. 9.1% had at least one subtype of incontinence (8.5% had NE, 1.9% DUI and 0.8% FI). Boys were significantly more affected by incontinence overall, NE, FI and ADHD than girls. 6.4% had ADHD, 6.2% had ODD and 2.6% were affected by ADHD and ODD. 10.3% of the children with incontinence had ADHD and 10.3% ODD. Children with FI were significantly more affected by externalizing disorders (50%) than children with isolated NE (14.5%), children with DUI (9.5%) and continent children (9.5%). Children with incontinence, especially those with FI, are at much higher risk of externalizing disorders. An additional effect of children with both ADHD and ODD having higher rates of incontinence than children with only one disorder could not be found. However, these children represent a high-risk group with lower compliance to treatment and worse outcome. Therefore, screening not only for ADHD but also for ODD should be implemented for all children with incontinence.

Adaptive multimodal treatment for children with attention-deficit-/hyperactivity disorder: an 18 month follow-up

The Cologne Adaptive Multimodal Treatment (CAMT) study demonstrated that adaptive and individually tailored multimodal treatment for attention-deficit/hyperactivity disorder (ADHD) [consisting of behavior therapy (BT) and/or stimulant medication] is highly effective. This study reports findings of the 18 month follow-up assessment. Parents and teachers completed broad range behavior scales (Child Behavior Checklist/Teacher Report Form) and standardized ADHD and oppositional defiant disorder/conduct disorder symptom rating scales. Children that used medication to treat ADHD at follow-up (N = 32) and those that did not (N = 34) were analyzed separately. Parents did not report significant changes in child behavior from posttest to follow-up. Teacher ratings revealed some aggravation of ADHD symptoms in children that received medication, but this was not significant after Bonferroni correction. The initial advantage of combined treatment over BT was no longer evident. It can be concluded that treatment for ADHD that is tailored to the assessed needs of children results in large treatment effects that are maintained for at least 18 months.

Reliability and validity of teacher-rated symptoms of oppositional defiant disorder and conduct disorder in a clinical sample

BACKGROUND/AIMS

It is recommended to use information from multiple informants when making diagnostic decisions concerning oppositional defiant disorder (ODD) and conduct disorder (CD). The purpose of this study was to investigate the reliability and validity of teacher-rated symptoms of ODD and CD in a clinical sample.

METHODS

The sample comprised 421 children (84% boys; 6-17 years) diagnosed with ODD, CD, and/or attention deficit hyperactivity disorder (ADHD). Teachers completed a standardized ODD/CD symptom rating scale and the Teacher Report Form (TRF).

RESULTS

The reliability (internal consistency) of the symptom rating scale was high (α = 0.90). Convergent and divergent validity were demonstrated by substantial correlations with similar TRF syndrome scales and low-to-moderate correlations with dissimilar TRF scales. Discriminant validity was shown by the ability of the symptom rating scale to differentiate between children with ODD/CD and those with ADHD. Factorial validity was demonstrated by principal component analysis, which produced a two-factor solution that is largely consistent with the two-dimensional model of ODD and CD proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR, although some CD symptoms representing aggressive behavior loaded on the ODD dimension.

CONCLUSION

These findings suggest that DSM-IV-TR-based teacher rating scales are useful instruments for assessing disruptive behavior problems in children and adolescents.

Effectiveness of telephone-assisted parent-administered behavioural family intervention for preschool children with externalizing problem behaviour: a randomized controlled trial

Externalizing problem behaviour is one of the most common childhood disorders. Parent training is an effective treatment for these children and there is growing interest in the effects of parent-administered interventions with minimal therapist contact. This randomized controlled study examined the efficacy of a telephone-assisted parent-administered behavioural intervention (bibliotherapy) in families with preschool children with externalizing problem behaviour. Families were randomly assigned to a treatment group (n = 26) and an untreated waitlist control group (n = 22). The intervention comprised the reading of an 11 chapter self-help book and 11 weekly telephone consultations. Compared to the control group, the treatment group demonstrated significant decreases in parent-reported externalizing and internalizing child problem behaviour and dysfunctional parenting practices. Moreover, treated parents reported less parenting-related strains and decreases in parental depression, anxiety, and stress. The results suggest that telephone-assisted self-administered parent training is an effective alternative to more intensive forms of behavioural family intervention for preschool children with externalizing problem behaviour.