Three-year course of behavioral/emotional problems in a national sample of 4- to 16-year-olds: I. Agreement among informants

Predicting Young Adult Tobacco, Drug and Alcohol Use Among Participants in the CAMP Trial

The development of substance abuse in youth with asthma have seldom been examined with longitudinal research. The prospective and well-characterized CAMP cohort provides outcome data on youth with asthma over 13 years. This manuscript seeks to determine the contributions of asthma features and child behavioral/emotional functioning to subsequent tobacco, alcohol, and drug use in early adulthood. Childhood smoking exposures as well as parent report and youth report of substance use were prospectively assessed concurrently with assessments of asthma symptoms, study medication, and lung development. Logistic regression models evaluated predictors of adolescent and young adult tobacco, alcohol, and drug use. Use of tobacco products was reported by 33% of youth with mild/moderate asthma. Tobacco use was significantly associated with self-reported externalizing behaviors. Early life passive smoke exposure, especially in utero exposure, makes a significant contribution to tobacco use (OR1.58). Greater risk for tobacco use is conveyed by self-reported externalizing behaviors, which are consistently robust predictors of any future use of tobacco products, alcohol and drugs. These findings provide evidence for health care providers to use routine behavioral screening in youth with asthma.

Trajectories of aggressive and depressive symptoms in male and female overweight children: Do they share a common path or do they follow different routes?

The prevalence of childhood overweight is a major social and public health issue, and primary assessment should focus on early and middle childhood, because weight gain in these phases constitutes a strong predictor of subsequent negative outcomes. Studies on community samples have shown that growth curves may follow linear or non-linear trajectories from early to middle childhood, and can differ based on sex. Overweight children may exhibit a combination of physiological and psychosocial issues, and several studies have demonstrated an association between overweight and internalizing/externalizing behavior. Nevertheless, there is a dearth of longitudinal studies on depressive and aggressive symptoms in children with high BMI. This study adopted a growth curve modeling over three phases to: (1) describe BMI trajectories in two groups of children aged 2–8 (overweight and normal weight) from a community sample; (2) describe the developmental trajectories of children’s aggressive and depressive symptoms from 2 to 8 years of age. Results indicate higher BMI in 2-year-old girls, with males catching up with them by age 8. While overweight females’ BMIs were consistently high, males’ increased at 5 and 8 years. The mean scores for aggressive symptoms at T1 (2 years of age) were the same in all subjects, but a significant deviation occurred from T1 to T2 in both samples, in divergent directions. With regards to children’s depressive symptoms, the two groups had different starting points, with normal weight children scoring lower than overweight youths. Overweight females showed lower depressive scores than overweight males at T1, but they surpassed boys before T2, and showed more maladaptive symptoms at T3. This study solicits professionals working in pediatric settings to consider overweight children’s psychopathological risk, and to be aware that even when children’s BMI does not increase from 2 to 8 years, their psychopathological symptoms may grow in intensity.

Quality of life changes in children following emergency dental extractions under general anaesthesia

OBJECTIVES

To assess the changes in the oral health-related quality of life (OHRQoL) of 221 preschool children who presented to the emergency department with the consequences of untreated dental caries requiring dental extractions under general anaesthesia (DEGA).

METHODS

Two hundred and twenty-one healthy preschool children, who required emergency DEGA, were recruited over a period of 12 months. The same parent or caregiver completed the Early Childhood Oral Health Impact Scale (ECOHIS) questionnaire; both, prior to the DEGA and at the 2-week post-treatment visit. Data were analysed using repeated anova with adjustments for multiple comparisons using the Bonferroni tests with the significance level set at 5%.

RESULTS

One hundred and twenty-six participants, with a mean age of 4.02 and a mean dmft score of 8.27 (SD = 4.13), completed the 2-week post-treatment questionnaires. The overall ECOHIS, CIS, and FIS scores decreased significantly (P < 0.001) after emergency DEGA, demonstrating large effect sizes. The biggest decrease in prevalence after emergency DEGA was observed for the items of pain in teeth, trouble sleeping, being irritated or frustrated, difficulty drinking food, and parents being upset.

CONCLUSIONS

The OHRQoL of preschool children, who presented to the emergency department with the consequences of untreated dental caries, was significantly improved following emergency DEGA.

Impact of Prominent Themes in Clinician-Patient Conversations on Caregiver's Perceived Quality of Communication with Paediatric Dental Visits

Patients’ perceived satisfaction is a key performance index of the quality health care service. Good communication has been found to increase patient’s perceived satisfaction. The purpose of this study was to examine the impact of the prominent themes arising from clinician-patient conversations on the caregiver’s perceived quality of communication during paediatric dental visits. 162 video recordings of clinical dental consultations for 62 cases attending the Paediatric Dentistry Clinic of The Prince Philip Dental Hospital in Hong Kong were captured and transcribed. The patients’ demographic information and the caregiver’s perceived quality of communication with the clinicians were recorded using the 16-item Dental Patient Feedback on Consultation skills questionnaires. Visual text analytics (Leximancer^™) indicated five prominent themes ‘disease / treatment’, ‘treatment procedure related instructions’, ‘preparation for examination’, ‘positive reinforcement / reassurance’, and ‘family / social history’ from the clinician-patient conversation of the recorded videos, with 60.2% of the total variance in concept words in this study explained through principal components analysis. Significant variation in perceived quality of communication was noted in five variables regarding the prominent theme ‘Positive reinforcement / reassurance’: ‘number of related words’ (p = 0.002), ‘number of related utterances’ (p = 0.001), ‘percentage of the related words in total number of words’ (p = 0.005), ‘percentage of the related utterances in total number of utterances’ (p = 0.035) and ‘percentage of time spent in total time duration’ (p = 0.023). Clinicians were perceived to be more patient-centered and empathetic if a larger proportion of their conversation showed positive reinforcement and reassurance via using related key words. Care-giver’s involvement, such as clinicians’ mention of the parent, was also seen as critical to perceptions of quality clinical experience. The study reveals the potential of the application of visual text analytics software in clinical consultations with implications for professional development regarding clinicians’ communication skills for improving patients’ clinical experiences and treatment satisfaction.

The dynamics of internalizing and externalizing comorbidity across the early school years

High rates of comorbidity are observed between internalizing and externalizing problems, yet the developmental dynamics of comorbid symptom presentations are not yet well understood. This study explored the developmental course of latent profiles of internalizing and externalizing symptoms across kindergarten, first grade, and second grade. The sample consisted of 336 children from an urban, low-income community, selected based on relatively high (61%) or low (39%) aggressive/oppositional behavior problems at school entry (64% male; 70% African American, 20% Hispanic). Teachers reported on children's symptoms in each year. An exploratory latent profile analysis of children's scores on aggression/oppositionality, hyperactivity/inattention, anxiety, and social withdrawal symptom factors revealed four latent symptom profiles: comorbid (48% of the sample in each year), internalizing (19%-23%), externalizing (21%-22%), and well-adjusted (7%-11%). The developmental course of these symptom profiles was examined using a latent transition analysis, which revealed remarkably high continuity in the comorbid symptom profile (89% from one year to the next) and moderately high continuity in both the internalizing and externalizing profiles (80% and 71%, respectively). Internalizing children had a 20% probability of remitting to the well-adjusted profile by the following year, whereas externalizing children had a 25% probability of transitioning to the comorbid profile. These results are consistent with the hypothesis that a common vulnerability factor contributes to developmentally stable internalizing-externalizing comorbidity, while also suggesting that some children with externalizing symptoms are at risk for subsequently accumulating internalizing symptoms.

Marijuana use and service utilization among adolescents 7 years post substance use treatment

BACKGROUND

In an environment of increasingly liberal attitudes towards marijuana use and legalization, little is known about long-term trajectories of marijuana use among clinical samples of adolescents, and how these trajectories relate to health services utilization over time.

METHODS

Latent growth curve analysis was used to identify distinct trajectories of marijuana use in a clinical sample of adolescents (N=391) over 7 years post substance use treatment in an integrated health system. We examined psychiatric problems and polysubstance use associated with the identified trajectory groups using general linear models. Nonlinear mixed-effects logistic regressions were used to examine associations between health services use and the trajectory groups.

RESULTS

We identified three marijuana use trajectory groups: (1) Abstinent (n=117); (2) Low/Stable use (n=174); and (3) Increasing use (n=100). Average externalizing and anxiety/depression scores were significantly lower over time for the Abstinent group compared to the Increasing and Low/Stable groups. The Low Stable and the Increasing group had fewer psychiatric visits over time (p<0.05) and the Low/Stable group used more substance use treatment services over time compared with the Abstinent group (p<0.001).

CONCLUSIONS

Treated adolescents showed distinct marijuana use patterns, one of which indicated a group of adolescents at risk of increased use over time. These individuals have greater psychiatric and polysubstance use over time, but may not be accessing needed services.

A cohort-sequential multivariate latent growth curve analysis of normative CBCL aggressive and delinquent problem behavior: Associations with harsh discipline and gender

The aim of this study was to examine the normative developmental trajectories of aggressive and delinquent behavior in young children. Cohort-sequential univariate latent growth modeling (LGM) analyses were employed to conceptualize and analyze intraindividual changes in children's aggressive and delinquent behavior and interindividual differences in these changes. A multivariate model was tested that related the two developmental trajectories to each other and to harsh discipline. The longitudinal data included mother and father ratings on the Child Behavior Checklist (CBCL) (Achenbach, 1991), the “Leuvens Instrument voor Coërcief Opvoedingsgedrag” (Leuvens Instrument of Coercive Parenting Behavior, LICO) (Hellinckx et al., 2000) and the Parenting Scale (Arnold, O'Leary, Wolff, & Acker, 1993) of 674 school-aged boys and girls of a proportional stratified general population sample, assessed annually for three years. A significant nonlinear decline in aggressive and a significant linear decline in delinquent problem behavior were found both in the mother and in the father ratings. A multivariate latent growth analysis indicated that trajectories in aggressive and delinquent problem behavior were positively associated. The association was stronger for boys than for girls. Parenting behaviors were differentially related to children's aggressive and delinquent problem behavior. Coercion was significantly related to aggressive behavior but not to delinquent behavior. Higher scores on coercion were related to higher initial levels and a slower decrease of aggressive behavior. High scores on overreactivity were associated with higher initial levels of aggressive and delinquent problem behavior but not with the growth rates. Boys were higher than girls in initial status. Conversely, the rate of change was not related to gender. The results were replicated in the father reports.

Only complementary voices tell the truth: a reevaluation of validity in multi-informant approaches of child and adolescent clinical assessments

Multi-informant approaches are thought to be key to clinical assessment. Classical theories of psychological measurements assume that only convergence among different informants' reports allows for an estimate of the true nature and causes of clinical presentations. However, the integration of multiple accounts is fraught with problems because findings in child and adolescent psychiatry do not conform to the fundamental expectation of convergence. Indeed, reports provided by different sources (self, parents, teachers, peers) share little variance. Moreover, in some cases informant divergence may be meaningful and not error variance. In this review, we give an overview of conceptual and theoretical foundations of valid multi-informant assessment and discuss why our common concepts of validity need revaluation.

Parental Reports of Stigma Associated with Child's Disorder of Sex Development

Disorders of sex development (DSD) are congenital conditions in which chromosomal, gonadal, or anatomic sex development is atypical. DSD-associated stigma is purported to threaten positive psychosocial adaptation. Parental perceptions of DSD-related stigma were assessed in 154 parents of 107 children (newborn-17 years) questionnaire comprising two scales, child-focused and parent-focused, and three subscales, perceived stigmatization, future worries, and feelings about the child's condition. Medical chart excerpts identified diagnoses and clinical management details. Stigma scale scores were generally low. Parents of children with DSD reported less stigma than parents of children with epilepsy; however, a notable proportion rated individual items in the moderate to high range. Stigma was unrelated to child's age or the number of DSD-related surgeries. Child-focused stigma scores exceeded parent-focused stigma and mothers reported more stigma than fathers, with a moderate level of agreement. Within 46,XY DSD, reported stigma was higher for children reared as girls. In conclusion, in this first quantitative study of ongoing experiences, DSD-related stigma in childhood and adolescence, while limited in the aggregate, is reported at moderate to high levels in specific areas. Because stigma threatens positive psychosocial adaptation, systematic screening for these concerns should be considered and, when reported, targeted for psychoeducational counseling.

Cortical thickness and inattention/hyperactivity symptoms in young children: a population-based study

BACKGROUND

While many neuroimaging studies have investigated the neurobiological basis of attention deficit hyperactivity disorder (ADHD), few have studied the neurobiology of attention problems in the general population. The ability to pay attention falls along a continuum within the population, with children with ADHD at one extreme of the spectrum and, therefore, a dimensional perspective of evaluating attention problems has an added value to the existing literature. Our goal was to investigate the relationship between cortical thickness and inattention and hyperactivity symptoms in a large population of young children.

METHOD

This study is embedded within the Generation R Study and includes 6- to 8-year-old children (n = 444) with parent-reported attention and hyperactivity measures and high-resolution structural imaging data. We investigated the relationship between cortical thickness across the entire brain and the Child Behavior Checklist Attention Deficit Hyperactivity Problems score.

RESULTS

We found that greater attention problems and hyperactivity were associated with a thinner right and left postcentral gyrus. When correcting for potential confounding factors and multiple testing, these associations remained significant.

CONCLUSIONS

In a large, population-based sample we showed that young (6- to 8-year-old) children who show more attention problems and hyperactivity have a thinner cortex in the region of the right and left postcentral gyrus. The postcentral gyrus, being the primary somatosensory cortex, reaches its peak growth early in development. Therefore, the thinner cortex in this region may reflect either a deviation in cortical maturation or a failure to reach the same peak cortical thickness compared with children without attention or hyperactivity problems.

Days La Familia community drug and alcohol prevention program: Family-centered model for working with inner-city Hispanic families

Substance abuse among Hispanics is on the increase despite national efforts toward reducing it. Researchers and service providers have recognized the specific need for better prevention models that address the issues of poor Hispanics. La Familia is a community-based ATOD prevention program that targets Hispanic families with high-risk youth from 6 to 11 years old, and attempts to reduce identified risk factors while building on culturally relevant protective factors. During the 2 years, the program has enrolled 219 youth and their families utilizing existing community networks and aggressive outreach. The program resulted in a 92% retention rate and over 80% attendance per session. As a result of the program, families became more willing to discuss ATOD issues openly and made positive steps toward empowerment.

Language and internalizing and externalizing behavioral adjustment: developmental pathways from childhood to adolescence

Two independent prospective longitudinal studies that cumulatively spanned the age interval from 4 years to 14 years used multiwave designs to investigate developmental associations between language and behavioral adjustment (internalizing and externalizing behavior problems). Altogether 224 children, their mothers, and teachers provided data. Series of nested path analysis models were used to determine the most parsimonious and plausible paths among the three constructs over and above stability in each across age and their covariation at each age. In both studies, children with poorer language skills in early childhood had more internalizing behavior problems in later childhood and in early adolescence. These developmental paths between language and behavioral adjustment held after taking into consideration children's nonverbal intellectual functioning, maternal verbal intelligence, education, parenting knowledge, and social desirability bias, as well as family socioeconomic status, and they applied equally to girls and boys.

Socioeconomic Factors in Relation to Discrepancy in Parent versus Teacher Ratings of Child Behavior

Discrepancies between observers are common in studies of child behavior problems that rely on behavior ratings. Although modest concordance between informants is well-documented, little is known about characteristics that predict discrepancies. In 477 children aged 5 to 12 years, maternal age and indicators of socioeconomic status (SES; maternal education, family income) were evaluated in relation to score discrepancies between the Child Behavior Checklist and Teacher Report Form for Total, Externalizing and Internalizing Problems. Family income <$35,000 was independently associated with discrepancies in which mothers rated more clinically significant child behavior problems than teachers for Total, Externalizing and Internalizing Problems [odds ratio (OR) = 3.26, 95% confidence interval (CI ), 1.19-8.96, OR = 2.76, 95% CI 1.03-7.34 and OR = 3.07, 95% CI 1.30-7.26, respectively]. Maternal education was not associated with discrepancies, but younger mothers were less likely to rate child's behavior in the clinical range for Externalizing Problems than teachers (OR per year of age = 0.88, 95% CI 0.81-0.96). These results suggest that studies that utilize only maternal or teacher report of child behavior may have misclassification of outcomes that is dependent on SES and could produce biased results.

The persistence and stability of psychiatric problems in adolescents with autism spectrum disorders

BACKGROUND

Psychiatric problems are common in autism spectrum disorders (ASDs), but the reasons are poorly understood. We use a longitudinal population-representative cohort to examine for the first time the persistence of psychiatric problems and to identify risk factors for their occurrence and stability.

METHODS

Eighty-one 16-year olds (75 male, six female), initially seen at 12 years, were re-assessed using the parent-report Strengths and Difficulties Questionnaire (SDQ). Child, family and contextual characteristics from age 12 were tested as risk factors for psychopathology.

RESULTS

Prevalence rates varied depending on whether general population or ASD-specific SDQ cut-offs were used. While the former suggested a decrease in psychiatric problems over time, the ASD-specific cut-offs showed no significant differences. With the exception of ADHD, the ASD-specific cut-offs identified a smaller proportion of individuals as 'affected' than did the general population cut-offs. There was longitudinal domain specificity, with parent correlations ranging from 0.50 to 0.58 and teacher SDQ reports at age 12 correlating 0.33-0.53 with parent reports at 16 years. In examining the role of risk factors, lower IQ and adaptive functioning predicted higher hyperactivity and total difficulties scores. Greater emotional problems at 16 were predicted by poorer maternal mental health, family-based deprivation and lower social class. Improvement from 12 to 16 years in conduct problems was predicted by greater neighbourhood deprivation and special school attendance.

CONCLUSIONS

This is the first longitudinal study of other psychiatric symptoms in ASD. Additional psychiatric problems in ASD are persistent and domain-specific from childhood to adolescence. The finding that age-related reduction in SDQ symptoms does not apply when ASD-specific cut-offs are used requires further evaluation using diagnostic measures. Only a few of the expected risk factor-psychopathology predictions expected from general population studies were found, raising the possibility that the causes of psychopathology in ASD differ from those in the general population.

12-step participation and outcomes over 7 years among adolescent substance use patients with and without psychiatric comorbidity

This study examines the associations between 12-step participation and outcomes over 7 years among 419 adolescent substance use patients with and without psychiatric comorbidities. Although level of participation decreased over time for both groups, comorbid adolescents participated in 12-step groups at comparable or higher levels across time points. Results from mixed-effects logistic regression models indicated that for both groups, 12-step participation was associated with both alcohol and drug abstinence at follow-ups, increasing the likelihood of either by at least 3 times. Findings highlight the potential benefits of 12-step participation in maintaining long-term recovery for adolescents with and without psychiatric disorders.

Child and Parent Psychological Problems Influence Child Weight Control

This study used path analytic methods to assess the influence of child psychopathology measured using the Child Behavior Checklist and parent psychiatric symptoms measured using the Cornell Medical Index on changes in child percent overweight in obese 8- to 11-year-old children over 2 years (6 months of treatment, 18 months of follow-up) provided family-based behavioral intervention. Path analysis for the 0-6 month change showed the influence of mother and father psychiatric symptoms and child age on child anxiety/depression scores that in turn influenced child percent overweight change during treatment, accounting for 41% of the shared variance. The path analysis for follow-up change showed mother and father psychiatric symptoms influenced child social problems at the first stage, and child social problems influenced child percent overweight change, accounting for 68.5% of the shared variance. These results provide the first demonstration that both parent and child problems may influence the short- and long-term success of obese children who participate in family-based behavioral treatment programs.

Preschoolers' psychosocial problems: in the eyes of the beholder? Adding teacher characteristics as determinants of discrepant parent-teacher reports

In this study, we explored informant characteristics as determinants of parent-teacher disagreement on preschoolers' psychosocial problems. Teacher characteristics were included in the analyses, in addition to child and parent factors. Psychosocial problems of 732 4-year olds from a Norwegian community sample were assessed by parents and teachers (CBCL-TRF). Furthermore, teachers reported on their education, experience and relationship to the child. Parental stress and psychopathology were also measured. Teachers rated children considerably lower than their parents did, especially on internalizing problems. When teachers rated more child problems, this was strongly associated with conflict in the teacher-child relationship, which predicted disagreement more than other factors. The highest agreement was on boys' externalizing problems. Girls' behavior was rated much lower by teachers than boys' behavior compared to parents' ratings. Possible teacher perception biases are discussed, such as teacher-child conflict, non-identification of internalizing problems, and same-gender child preference.

Twelve-Step attendance trajectories over 7 years among adolescents entering substance use treatment in an integrated health plan

AIMS

This study examines 12-Step attendance trajectories over 7 years, factors associated with the trajectories, and relationships between the trajectories and long-term substance use outcomes among adolescents entering out-patient substance use treatment in a private, non-profit integrated managed-care health plan.

DESIGN

Longitudinal observational study.

SETTING

Four Kaiser Permanente Northern California substance use treatment programs.

PARTICIPANTS

A total of 391 adolescents entering treatment between 2000 and 2002 who completed at least one follow-up interview in year 1, and at least one during years 3-7, after treatment entry.

MEASUREMENTS

Alcohol and drug use, 12-Step meeting attendance and activity involvement and post-treatment medical service utilization.

FINDINGS

Semiparametric group-based modeling identified three distinct 12-Step attendance trajectory groups over 7 years: low/no attendance (60%), early but not continued (26%) and continued (14%). There were lower proportions of males and of adolescents with prior substance use treatment experience in the low/no attendance group (P = 0.019 and P = 0.003, respectively). In addition, those in the low/no attendance group had lower perception on circumstances, motivation and readiness for treatment at baseline (P = 0.023). Multivariate logistic generalized estimating equation analyses found that those in the continued group were more likely to be abstinent from both alcohol and drugs during follow-ups than those in the low/no attendance group [odds ratio (OR) = 2.40, P = 0.003 and OR = 1.96, P = 0.026, respectively]. However, no differences in long-term outcomes were found between those in the other two groups.

CONCLUSION

Robust connection with 12-Step groups appears to be associated with better long-term outcomes among adolescents with substance use disorders.

Maternal serum vitamin D levels during pregnancy and offspring neurocognitive development

OBJECTIVES

To determine the association between maternal serum 25(OH)-vitamin D concentrations during a critical window of fetal neurodevelopment and behavioral, emotional, and language outcomes of offspring.

METHODS

Serum 25(OH)-vitamin D concentrations of 743 Caucasian women in Perth, Western Australia (32°S) were measured at 18 weeks pregnancy and grouped into quartiles. Offspring behavior was measured with the Child Behavior Checklist at 2, 5, 8, 10, 14, and 17 years of age (n range = 412-652). Receptive language was assessed with the Peabody Picture Vocabulary Test-Revised at ages 5 (n = 534) and 10 (n = 474) years. Raw scores were converted to standardized scores, incorporating cutoffs for clinically significant levels of difficulty.

RESULTS

χ(2) analyses revealed no significant associations between maternal 25(OH)-vitamin D serum quartiles and offspring behavioral/emotional problems at any age. In contrast, there were significant linear trends between quartiles of maternal vitamin D levels and language impairment at 5 and 10 years of age. Multivariate regression analyses, incorporating a range of confounding variables, found that the risk of women with vitamin D insufficiency (≤46 nmol/L) during pregnancy having a child with clinically significant language difficulties was increased close to twofold compared with women with vitamin D levels >70 nmol/L.

CONCLUSIONS

Maternal vitamin D insufficiency during pregnancy is significantly associated with offspring language impairment. Maternal vitamin D supplementation during pregnancy may reduce the risk of developmental language difficulties among their children.

Oral health-related quality of life in Hong Kong preschool children

OBJECTIVES

To assess the impact of early childhood caries (ECC) on the quality of life in a population of preschool children and their families in Hong Kong.

METHODS

A random sample of 1,296 Chinese preschool children participated in the survey and were subjected to an oral examination for their ECC status by 2 trained examiners. The parents were asked to respond to the Early Childhood Oral Health Impact Scale (ECOHIS) and an extra set of questions concerning their sociodemographic background.

RESULTS

The final data analysis included 1,261 children with a mean (±SD) age of 3.9 ± 0.66 years. The prevalence figures for ECC and severe ECC were 19.9 and 15.2%, respectively. Decayed teeth were found in 34.3% of the children while only 5.2% had filled teeth. The mean (±SD) dmft in this group of children was 1.5 ± 2.98. Higher ECOHIS scores were found in parents with lower education or income level, or with children who were born in mainland China (p < 0.05), or with children who had decayed, missing, or filled teeth (p < 0.001). In multiple regression analyses, decayed teeth and filled teeth in primary dentition were the better predictors (p < 0.001) of the ECOHIS score among the various parent and child characteristics collected in this survey.

CONCLUSIONS

The findings of this study showed that parents of young children with dental caries experience perceived that both the children and other family members had poorer quality of life.

Social competence, externalizing, and internalizing behavioral adjustment from early childhood through early adolescence: developmental cascades

This study used a three-wave longitudinal design to investigate developmental cascades among social competence and externalizing and internalizing behavioral adjustment in a normative sample of 117 children seen at 4, 10, and 14 years. Children, mothers, and teachers provided data. A series of nested path analysis models was used to determine the most parsimonious and plausible cascades across the three constructs over and above their covariation at each age and stability across age. Children with lower social competence at age 4 years exhibited more externalizing and internalizing behaviors at age 10 years and more externalizing behaviors at age 14 years. Children with lower social competence at age 4 years also exhibited more internalizing behaviors at age 10 years and more internalizing behaviors at age 14 years. Children who exhibited more internalizing behaviors at age 4 years exhibited more internalizing behaviors at age 10 years and more externalizing behaviors at age 14 years. These cascades among social competence and behavioral adjustment obtained independent of child intelligence and maternal education and social desirability of responding.

Three-year chemical dependency and mental health treatment outcomes among adolescents: the role of continuing care

BACKGROUND

Few studies have examined the effects of treatment factors, including the types of services [chemical dependency (CD), psychiatric, or both], on long-term outcomes among adolescents following CD treatment, and whether receiving continuing care may contribute to better outcomes. This study examines the effect of the index CD and ongoing CD and psychiatric treatment episodes, 12-step participation, and individual characteristics such as CD and mental health (MH) severity and gender, age, and ethnicity, on 3-year CD and MH outcomes.

METHODS

Participants were 296 adolescents aged 13 to 18 seeking treatment at 4 CD programs of a nonprofit, managed care, integrated health system. We surveyed participants at intake, 1 year, and 3 years, and examined survey and administrative data, and CD and psychiatric utilization.

RESULTS

At 3 years, 29.7% of the sample reported total abstinence from both alcohol and drugs (excluding tobacco). Compared with girls, boys had only half the odds of being abstinent (OR = 0.46, p = 0.0204). Gender also predicted Externalizing severity at 3 years (coefficients 18.42 vs. 14.77, p < 0.01). CD treatment readmission in the second and third follow-up years was related to abstinence at 3 years (OR = 0.24, p = 0.0066 and OR = 3.33, p = 0.0207, respectively). Abstinence at 1 year predicted abstinence at 3 years (OR = 4.11, p < 0.0001). Those who were abstinent at 1 year also had better MH outcomes (both lower Internalizing and Externalizing scores) than those who were not (11.75 vs. 15.55, p = 0.0012 and 15.13 vs. 18.06, p = 0.0179, respectively).

CONCLUSIONS

A CD treatment episode resulting in good 1-year CD outcomes may contribute significantly to both CD and MH outcomes 3 years later. The findings also point to the value of providing a continuing care model of treatment for adolescents.

Twelve-Step affiliation and 3-year substance use outcomes among adolescents: social support and religious service attendance as potential mediators

AIMS

Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship.

DESIGN

We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews.

MEASURES

Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance.

FINDINGS

At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes.

CONCLUSIONS

The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

Assessing injuries with proxies: implications for understanding concurrent relations and behavioral antecedents of pediatric injuries

OBJECTIVE

To examine the implications of using proxies of medically attended injuries (minor injuries and close calls) for understanding concurrent relations among-and behavioral antecedents of-pediatric injuries.

METHODS

Participants were 812 children from the NICHD Study of Early Child Care. Measures of externalizing behavior, maternal depression, SES, and the home environment were examined as prospective predictors of minor injuries, close calls, and medically attended injuries.

RESULTS

Minor injuries and close calls were associated with medically attended injuries concurrently. Regression equations revealed different prospective predictors across the three outcome variables.

CONCLUSIONS

This study was the first to examine concurrent associations among minor injuries, close calls, and medically attended injuries. Prospective antecedents of each injury assessment were also examined. The present findings signify the importance of distinguishing between these different methods of assessing pediatric injury. The study also illustrated that different analytic strategies were needed to represent observed data of each outcome variable.

Finality in the eye of the beholder: Multiple sources, multiple time points, multiple paths

This study explores the coherence between different raters of adolescent psychopathology and examines the coherence of these ratings with earlier and later events associated with the development of psychopathology. In particular, teachers', mothers', and adolescents' ratings of the 13-year-old adolescents are examined. Additionally, the earlier factors of attachment status, environmental stress, and the friendship network are related to the different ratings. Both earlier factors and rater judgments are used to examine subsequent use of psychotherapy. The results show little coherence between raters on the presence of psychopathology in 13-year-olds and little coherence between earlier events and subsequent raters' judgments of psychopathology. However, earlier stress events and teachers' ratings of 13-year-olds' psychopathology are related to subsequent therapy use.

Early behavior problems: Pathways to mental disorders in adolescence

From teachers' rating in kindergarten through third grade, mutually exclusive groups of internalized, externalized, and mixed behavior problems were examined as pathways to three groups of psychiatric diagnosis in later adolescence: depression/anxiety, conduct/oppositional defiant, and other disorders. In looking both forward and backwards, the relation between behavior problems in the early school years, regardless of type, and psychopathology in adolescence, regardless of diagnosis, was very strong. The relations between type of early problems and specific outcomes were weak. The findings provided support for both the constructs of multifinality and equifinality; however the nature of the pathways differed somewhat by disorder. There was a substantial amount of multifinality (dispersion of outcomes) for the early internalizing pathway. There was less multifinality for the externalizing pathway, in that there was greater correspondence between early externalizing and later antisocial outcomes than for the internalizing pathway and depressed/anxious outcomes.

Self-initiated tobacco cessation and substance use outcomes among adolescents entering substance use treatment in a managed care organization

PURPOSE

Adolescents with substance use (SU) problems have high rates of tobacco use, yet SU treatment has historically ignored treatment for tobacco use. Barriers to such efforts include the belief that tobacco cessation could compromise other SU abstinence. This study examines self-initiated tobacco cessation and 12-month alcohol and drug abstinence in adolescents entering SU treatment in a private, managed care organization.

RESULTS

Self-initiated tobacco cessation at 6 months, and at both 6 and 12 months, were related to higher odds of drug abstinence but not alcohol abstinence.

CONCLUSION

Self-initiated tobacco cessation was not related to poor SU outcomes, and may be important to maintaining drug abstinence. Implementing tobacco cessation efforts in SU treatment can be challenging, but comprised SU outcomes may not be a barrier. The positive associations for drug abstinence and lack of associations for alcohol abstinence could be due to differences in motivation, medical conditions, or to the illicit nature of drug use. Tobacco use has serious long-term health consequences, and tobacco cessation efforts in adolescent SU treatment programs need further research.

Age and gender differences in behavioral problems in Chinese children: Parent and teacher reports

This study examined age and gender differences in internalizing and externalizing behavioral problems in a large sample of Chinese children aged 6-15 (N=4472). The Chinese Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) were used to assess these problems. Results showed that boys were scored higher than girls on externalizing problems by both parents and teachers, while girls were rated higher than boys on somatic problems by teachers. Parent reported externalizing problems tended to decline with age but there was no age effect on internalizing problems except slight increases with age on somatic problems. Older children tended to have higher scores than younger children on anxious and somatic problems as reported by teachers, while aggressive problems showed quadratic association with age, declining until age 10 and thereafter increasing. Parents and teachers tended to report more consistently with boys on externalizing problems but less consistently with boys on anxious and somatic syndromes. Directions for future research were provided.

Taxonomy and comorbidity of conduct problems: Evidence from empirically based approaches

Many children meet criteria for multiple Diagnostic and Statistical Manual (DSM) categories, such as oppositional defiant disorder (ODD) and conduct disorder (CD). If each disorder has been well validated as a separate entity, statistically significant co-occurrence of different disorders may be highly informative. However, ODD and CD have not been well validated as separate entities. The very high rate of overlap between diagnoses of ODD and CD may therefore arise artifactually from the lack of a valid distinction between them, rather than from potentially informative comorbidity between two different disorders. Empirical research strongly supports a distinction between two syndromes that correspond to subsets of the DSM-III-R criteria for CD. Designated as delinquent behavior and aggressive behavior, these syndromes have been found to differ in biological correlates, heritability, developmental stability, course, response to interventions, and long-term outcomes. At this stage of our knowledge, empirically based assessment and taxonomic methods can be especially useful for distinguishing between syndromes, deriving norms, doing longitudinal studies, and detecting patterns of comorbidity. These methods do not preclude categorical taxa, which can be formed by imposing cutpoints on the distributions of syndrome scores. Categorical taxa can also be formed by cluster analyzing profiles of syndrome scores. Accelerated longitudinal designs can bring multiple analyses to bear on empirically derived syndromes to test complex developmental relations more quickly and powerfully than can traditional longitudinal designs. Follow-ups of high-risk groups can identify variables that predict good versus poor outcomes if standardized baseline and outcome measures are used. Interventions for conduct problems should be designed to counteract the risk factors found to predict poor long-term outcomes.

Continuity of behavioral and emotional problems from pre-school years to pre-adolescence in a developing country

BACKGROUND

All previous longitudinal community studies assessing the continuity of child behavioral/emotional problems were conducted in developed countries.

METHOD

Six hundred and one children randomly selected from a Brazilian birth cohort were evaluated for behavioral/emotional problems through mother interview at 4 and 12 years with the same standard procedure - Child Behavior Checklist (CBCL).

RESULTS

CBCL Total Problem score presented a medium stability (r = .42) with externalizing problems showing higher stability and more homotypic continuity than internalizing problems. Of the children presenting deviant scores at the age of 4, only 31% remained deviant at the age of 12 (p < .001). A deviant CBCL Total Problem score at 12 years old was predicted by Rule-Breaking Behavior [OR = 7.46, 95% CI 2.76-20.19] and Social Problems [OR = 3.56, 95% CI 1.36-9.30] scores at 4 years of age. Either Rule-Breaking or Aggressive Behavior - externalizing syndromes - were part of the predictors for the three broad-band CBCL scores and six out of the eight CBCL syndromes.

CONCLUSIONS

Behavioral/emotional problems in preschool children persist moderately up to pre-adolescence in a community sample. Externalizing problems at the age of 4 comprise the developmental history of most behavioral/emotional problems at pre-adolescence. Our findings concur with findings from developed countries and are quite similar for continuity, stability and predictability.

Concordance between caregiver and child reports of children's oral health-related quality of life

OBJECTIVE

This study sought to assess child-caregiver concordance regarding children's oral health related quality of life (OHRQoL) using the Child Oral Health Impact Profile (COHIP).

METHODS

The sample comprised treatment-seeking children aged 8-15 with pediatric (n = 141), orthodontic (n = 135), and craniofacial (n = 100) needs and their caregivers. Children and their caregivers were queried concerning the child's Oral health, Functional Well-being, Social/Emotional Well-being, School environment and Self-image. These combined subscales yielded an overall OHRQoL rating. The dyads were distributed at recruitment locations as follows: Montreal (50 pediatric, 13 orthodontic, 15 craniofacial), UMDNJ (45 pediatric, 15 orthodontic, 0 craniofacial), and NYU (46 pediatric, 107 orthodontic, 85 craniofacial). Concordance was assessed with Spearman and intraclass correlations and Kruskal-Wallis testing of categories of agreement.

RESULTS

Low to modest rates of agreement between child and caregiver were found for the sample overall. Rates of concordance between child and caregiver varied between clinical groups-craniofacial patients were more likely to rate OHRQoL higher than they were to agree with their caregivers' ratings. In contrast, pediatric and orthodontic patients were more likely either agree with or rate their OHRQoL lower than their caregivers' ratings.

CONCLUSION

These findings of child-caregiver concordance using the COHIP supported previous work suggesting the usefulness of obtaining both child and caregiver reports of the child's QoL.

ADHD symptoms in children with mild intellectual disability

OBJECTIVES

To determine whether the nature and correlates of attention-deficit/hyperactivity disorder (ADHD) symptoms are different in subjects with mild intellectual disability (ID) compared to subjects with average ability.

METHOD

From a general population sample of 2,726 12- to 15-year-olds, a stratified subsample was selected to enrich for mild ID. A total of 192 subjects were included in the analyses. ADHD symptoms and other emotional/behavioral problems were measured with the parent and teacher Strengths and Difficulties Questionnaire and IQ with the WISC-III-UK), and social communication difficulties were assessed by a short version of the Social Communication Questionnaire and academic attainments by the Wechsler Quicktest.

RESULTS

There was a negative linear relationship between ADHD symptoms and IQ (beta = -.087, p <.001). The relationship could not be explained by inappropriate rater expectations. Neither the profiles of ADHD symptoms nor the comorbidity with emotional/behavioral problems differed according to the presence of ID. When IQ was accounted for, the group difference in attainments was nonsignificant.

CONCLUSIONS

ADHD symptoms are increased in people with ID. We found no evidence that this increase can by explained by inappropriate expectations or by confounding associations with other emotional/behavioral or cognitive problems.

Developmental course of psychopathology in youths with and without intellectual disabilities

BACKGROUND

We aimed to describe similarities and differences in the developmental course of psychopathology between children with and without intellectual disabilities (ID).

METHODS

Multilevel growth curve analysis was used to analyse the developmental course of psychopathology, using the Child Behavior Checklist (CBCL), in two longitudinal multiple-birth-cohort samples of 6- to 18-year-old children with ID (N = 978) and without ID (N = 2,047) using three repeated measurements across a 6-year period.

RESULTS

Children with ID showed a higher level of problem behaviours across all ages compared to children without ID. A significant difference between the samples in the developmental courses was found for Aggressive Behaviour and Attention Problems, where children with ID showed a significantly larger decrease. Gender differences in the development of psychopathology were similar in both samples, except for Social Problems where males with ID showed a larger decrease in problem behaviour across time than females with ID and males and females without ID.

CONCLUSIONS

Results indicate that children with ID continue to show a greater risk for psychopathology compared to typically developing children, although this higher risk is less pronounced at age 18 than it is at age 6 for Aggressive Behaviour. Contrary to our expectations, the developmental course of psychopathology in children with ID was quite similar from age 6 to 18 compared to children without ID. The normative developmental trajectories of psychopathology in children with ID, presented here, can serve as a yardstick against which development of childhood psychopathology can be detected as deviant.

The transition to school: adaptation in young children with and without intellectual disability

BACKGROUND

Previous research has highlighted the importance of the transition to school for young children and their families. A child's successful adaptation to school is likely influenced by a number of factors, including academic, social, emotional, behavioural and cognitive competencies. Children with intellectual disability (ID) may be at heightened risk for early school difficulties, in part due to their deficits in cognitive and adaptive behaviours.

METHODS

Factors associated with the adaptive transition to school in young children with (n = 24) and without (n = 43) ID were examined. Adaptive transitions were defined as having few teacher-reported problem behaviours and positive student-teacher relationships. Child self-regulatory skills and both parent- and teacher-reported social skills were evaluated to determine if they predicted positive adaptation in school for 5- to 6-year-old children. Data were gathered from child assessments, parent reports on standardized measures, direct observations of delay of gratification tasks and teacher reports on standardized measures.

RESULTS

Children with ID had significantly more teacher-reported problem behaviour, poorer overall student-teacher relationships, fewer parent- and teacher-reported social skills and fewer self-regulation skills than typically developing children. Self-regulation at child age 36 months (latency to touch a desired toy) was significantly related to adaptation to school, as were parent and teacher reports of social skills. Social skills significantly predicted adaptation to school, even after accounting for the effects of child IQ and adaptive behaviour.

CONCLUSIONS

Children with ID had less positive early school experiences, as indicated by multiple indices of adaptation to school. Fostering early social skills may be an important target for increasing the positive adaptation to school for young children, especially those with ID.

The use of AAP-recommended disciplinary practice guidelines among African American caregivers of children in Head Start programs

OBJECTIVE

The American Academy of Pediatrics (AAP) recommends that parents not use harsh disciplinary practices. Previous studies have characterized the disciplinary practices of African American parents as harsh, with reliance on more aggressive techniques not currently recommended by the AAP. However, recent research has indicated more disciplinary practice diversity among African Americans. This study describes factors associated with the use of AAP-recommended disciplinary practices among lower-income African American caregivers of children in Head Start.

METHODS

Subjects were caregivers of children at three Head Start sites. Participants were eligible for inclusion if the biological mother, biological father, or target child was identified as African American. Using consensus methods, responses to the Parental Discipline Methods Interview (PDMI) were described as consistent or inconsistent with AAP guidelines regarding use of negative disciplinary practices (e.g., spanking, yelling). Caregivers avoiding any of these inconsistent methods were referred to as "adherent."

RESULTS

"Adherent" caregivers were older (32.5 years vs. 30.4 years) and had more education (86.0% vs. 75.4% high school graduates). They were also less likely to report that their child had behavioral problems (12.9% vs. 25.2%) or deficient social skills (1.7% vs. 8.0%).

CONCLUSIONS

Lower-income African American caregivers were more likely to use disciplinary practices consistent with AAP guidelines if they had higher levels of education and were living in an urban setting. Caregivers describing their child as having fewer behavior problems, better social skills, or themselves as less stressed were also more likely to be "adherent."

Adolescents entering chemical dependency treatment in private managed care: ethnic differences in treatment initiation and retention

PURPOSE

There has been little research on adolescents of different ethnicities in chemical dependency (CD) treatment, despite a focus on ethnic disparities in health care in recent years. In particular, little is known about ethnic differences in utilization of adolescent CD services.

METHODS

We examined treatment initiation and treatment retention in a sample of African American, Native American, Latino, Asian American, and Caucasian adolescents entering CD treatment in a private, managed care health plan (n = 419). Our conceptual framework included ethnicity as the main factor as well as measures of external pressure and internal motivation/readiness for treatment, family environment, psychiatric co-morbidities, and severity of alcohol and drug problems. Logistic and Poisson regression were used to examine differences.

RESULTS

The study found ethnic differences in treatment initiation and treatment retention. Native American adolescents had lower odds of returning after intake to initiate treatment compared with Caucasians (odds ratio [OR] .35, p = .009), and African American youth spent less time in treatment than Caucasians (RR: .49, p < .001).

CONCLUSIONS

Study findings indicate differences in treatment initiation for Native Americans and in treatment retention for African Americans. Intake and orientation sessions offer an opportunity to intervene with Native American youth. Given their high psychiatric co-morbidity, they may also benefit from the availability of psychiatric services. Even after adjusting for severity, we found shorter treatment retention for African American adolescents and suggest that organizational factors, such as cultural competency, may play an important role.

The Obsessive Compulsive Scale of the Child Behavior Checklist predicts obsessive-compulsive disorder: a receiver operating characteristic curve analysis

BACKGROUND

The purpose of this study was to determine a score on the Obsessive Compulsive Scale (OCS) from the Child Behavior Checklist (CBCL) to screen for obsessive compulsive disorder (OCD) in children and to rigorously test the specificity and sensitivity of a single cutpoint.

METHODS

A receiver operating characteristic (ROC) curve analysis was applied to data from 61 patients with clinically determined OCD, 64 clinical controls and 73 general population controls to determine the best sum score on the CBCL-OCS to predict confirmed OCD in children. Using the ROC-determined cutoff, this score was applied to a national sample of CBCL data from 2460 singleton children ages 4-18 and to 20,016 children ages 7-18 from three large general population twin samples to determine the estimated prevalence in the general population.

RESULTS

Using a CBCL-OCS score of 5 demonstrated an area under the curve (AUC) of .88 with high sensitivity (92%) and moderate specificity (67%) compared to clinical controls. Compared to the general population controls, the AUC was .96 with high sensitivity (92%) and specificity (89%). In the twin samples, the number of participants with CBCL-OCS scores above this cutpoint was 2.3-7.1%.

CONCLUSIONS

These findings suggest that the OCS of the CBCL may provide a highly effective way to screen for childhood OCD, and that the prevalence of childhood OCD may have been underestimated, thus prompting the need for further research into screening children for this condition.

Childhood predictors of externalizing and internalizing problems in adolescence. A prospective follow-up study from age 8 to 16

The aim of this study was to assess the childhood predictors of externalizing and internalizing symptoms in adolescence in an epidemiological sample. Behavior ratings were obtained from 609 children at two time-points, accounting for 71% of the target sample. At age 8, children were evaluated with parental and teacher Rutter scales, and with the Child Depression Inventory (CDI), and at age 16 with the Child Behavior Checklist. Evaluations by all informants had a unique contribution to later outcome. In multivariate analysis, among boys, parental reports of hyperactivity independently predicted externalizing problems and teacher reports of hyperactivity independently predicted internalizing problems. Teacher reports of conduct problems independently predicted externalizing problems among both boys and girls. Furthermore, parent reports of emotional problems independently predicted internalizing problems among both boys and girls. Children's own reports of internalized distress measured with CDI predicted a high level of internalizing problems among girls. Perceived need of treatment was the strongest predictor for outcome among girls. Change in family structure (e. g., divorce or remarriage) during follow-up independently predicted externalizing and internalizing problems among boys. The study supports the findings from earlier studies showing that the stability of behavior problems from childhood to adolescence is substantial. This implies a need for early recognition and initiation of treatment efforts.

Outcomes of Prolonged Parent-Child Embrace Therapy among 102 children with behavioral disorders

A growing body of research in neuroscience points to the impact of variations in maternal nurturing on child development and provides a rationale for interventions that target stress adaptation conditioning through natural family nurturing. This pilot study was collected within the course of private practice to assess the progress of children with severe behavioral disorders who were treated effectively with a multiple family therapy prototype, Prolonged Parent-Child Embrace (PPCE) Therapy. Subjects were a consecutive series of 102 patient children aged 4-18 years and their families. Children and their family members were guided for 16h over two consecutive days through intense PPCE Therapy. Families were instructed to continue PPCE Therapy at home for at least 1 year. Scores were compared statistically using t-tests and analysis of variance. For 96 children scores declined on two written measures by approximately 50% between baseline and follow-up (P<0.001). Results showed that PPCE Therapy resulted in significant and prolonged improvements in symptomatic behavior in a majority of children.