From "4Rs and 2Ss" to "Amaka Amasanyufu" (Happy Families): Adapting a U.S.-based Evidence-Based Intervention to the Uganda Context.

In Uganda, one in five children presents mental health challenges, including disruptive behavior disorders (DBDs). DBDs can persist through adulthood and result in negative outcomes. Effective interventions for DBDs have been developed and tested in high-poverty communities in developed countries. Yet, most African countries, such as Uganda, lack such interventions. This paper describes the adaptation process of an evidence-based intervention of U.S. origin to optimize fit to context with intervention fidelity, as part of a randomized trial conducted with youth that exhibit behavioral challenges and their caregivers in 30 schools in Uganda. The process involved: initial meetings with headteachers and teachers to introduce the study and the main concepts of the intervention; initial manual review focusing on 4Rs and 2Ss content by the Uganda team; engagement of community stakeholders for additional feedback on content and cultural relevance; final revision of the manual; and collection of children's drawings for the illustration of the manual. This paper describes both similarities and differences between the original and adapted intervention content and methods of delivery. The findings also highlight the importance of involving community stakeholders in the adaptation process.

En Uganda, uno de cada cinco niños presenta problemas de salud mental, incluidos los trastornos del comportamiento disruptivo (TCD). Los TCD pueden continuar hasta la adultez y tener consecuencias negativas. Se han desarrollado intervenciones eficaces para los TCD, las cuales se han evaluado en comunidades con altos índices de pobreza en países desarrollados. Sin embargo, la mayoría de los países africanos, como Uganda, carecen de dichas intervenciones. Este artículo describe el proceso de adaptación de una intervención factual de origen estadounidense para optimizar su adaptación al contexto con la fidelidad de la intervención como parte de un ensayo aleatorizado realizado con jóvenes que presentan problemas conductuales y sus cuidadores en 30 escuelas de Uganda. El proceso consistió en reuniones iniciales con directores y maestros para presentar el estudio y los conceptos principales de la intervención; una revisión inicial del manual centrada en el contenido de la intervención "4Rs and 2 Ss" por parte del equipo de Uganda; la participación de partes interesadas de la comunidad para obtener comentarios adicionales sobre el contenido y la relevancia cultural; la revisión final del manual; y la recopilación de dibujos de los niños para la ilustración del manual. Este artículo describe tanto las similitudes como las diferencias entre el contenido de la intervención original y la adaptada y los métodos de implementación. Los resultados también destacan la importancia de hacer participar a las partes interesadas en el proceso de adaptación.

Parenting Stress and Depressive Symptoms Among Chinese Parents of Children With and Without Oppositional Defiant Disorder: A Three-Wave Longitudinal Study.

Parents of children with oppositional defiant disorder (ODD) experience greater stress in parenting and more parental depressive symptoms. The study examined the longitudinal and bidirectional associations between three dimensions of parenting stress (i.e., parental distress, parent-child dysfunctional interaction, and difficult child) and parental depressive symptoms from a sample of Chinese parents of children with or without ODD. The sample included 256 parents of children with ODD and 265 parents of children without ODD, along with children's teachers. Using a three wave, cross-lagged design, results showed that parents of children with ODD suffered higher levels of parenting stress across three dimensions. For both groups, the links between parental depressive symptoms and subsequent parental distress and difficult child were unidirectional, whereas the relation between parental depressive symptoms and parent-child dysfunctional interaction was bidirectional. Multi-group analysis found that there was no significant difference in the relations between parenting stress and depressive symptoms between the ODD and non-ODD groups. The findings indicated that children with ODD require comprehensive services to address the stress of their parents. The study also provided support for the dynamic and longitudinal relations between specific dimensions of parenting stress and depressive symptoms among parents of children with or without ODD.

Associations of serotonin transporter gene promoter polymorphisms and monoamine oxidase A gene polymorphisms with oppositional defiant disorder in a Chinese Han population.

BACKGROUND: Oppositional defiant disorder (ODD) is a behavioral disorder that mainly refers to a recurrent pattern of disobedient, defiant, negativistic and hostile behaviors toward authority figures. Previous studies have showed associations of serotonin transporter (5-HTT) and monoamine oxidase A (MAOA) with behavioral and psychiatric disorders. The purposes of this study were to investigate the potential association of 5-HTT gene promoter polymorphism (5-HTTLPR) and MAOA gene polymorphism with susceptibility to ODD in a Han Chinese school population. METHODS: The 5-HTTLPR gene polymorphism and the MAOA gene polymorphism were genotyped in a case-control study of 257 Han Chinese children (123 ODD and 134 healthy controls). RESULTS: There was significant difference in the allele distribution of 5-HTTLPR (χ2 = 7.849, P = 0.005) between the ODD and control groups. Further, there were significant differences in genotype (χ2 = 5.168, P = 0.023) and allele distributions (χ2 = 10.336, P = 0.001) of the MAOA gene polymorphism that is variable-number tandem repeat (MAOA-uVNTR) between two groups. Moreover, there were significant differences in genotype (χ2 = 4.624, P = 0.032) and allele distributions (χ2 = 9.248, P = 0.002) of MAOA-uVNTR only in the male ODD and healthy groups. CONCLUSIONS: Our results suggest that 5-HTTLPR and MAOA-uVNTR gene variants may contribute to susceptibility to ODD. Further, MAOA-uVNTR gene polymorphism may play a role in susceptibility to ODD only in male children.

Comparing working memory in bilingual and monolingual Hispanic/Latino preschoolers with disruptive behavior disorders.

The current study examined differences in working memory (WM) between monolingual and bilingual Hispanic/Latino preschoolers with disruptive behavior disorders (DBDs). A total of 149 children (Mage = 5.10 years, SD = 0.53; 76% male) with elevated levels of DBDs, as indicated by their parents or teachers, were recruited to participate in an 8-week summer program prior to the start of kindergarten (Summer Treatment Program for Pre-Kindergarteners). Prior to the start of treatment, parents completed several measures about their children's behavior and executive function, and children were administered two subtests of the Automated Working Memory Assessment to examine their current WM capabilities. After controlling for demographic variables (i.e., age, sex, socioeconomic status, IQ, and diagnostic status), no significant differences were observed between bilingual and monolingual children in verbal WM performance (ß = .03, p > .05). However, children who were bilingual did perform better than monolinguals on spatial WM tasks (ß = .23, p < .01). Finally, parent reports of WM corroborated these findings such that bilingual children were reported as having fewer WM problems by parents (ß = -.19, p < .05) and teachers (ß = -.22, p < .05). Whereas WM deficits are often found among children with DBDs, the current findings suggest that bilingualism may serve as a protective factor for preschoolers with DBDs.

Racial/Ethnic Disparities in Mental Health Service Utilization among Youth Participating in Negative Externalizing Behaviors.

PURPOSES: Racial/ethnic differences in mental health service utilization were examined among youth who reported participating in negative externalizing behaviors. METHODS: The study utilized merged data from the 2007-2010 National Survey on Drug Use and Health (NSDUH) to examine differences in utilization of inpatient or outpatient mental health services not related to substance or alcohol use by White, Black and Hispanic youth who reported engaging in negative externalizing behaviors ("acting out"). Differences in service utilization in these groups were assessed using logistic regression models. RESULTS: Race/ethnicity was a significant predictor of outpatient mental health service use. Black and Hispanic children were less likely to use outpatient services. Inpatient service use decreased with increasing income. Parental presence in the household increased the likelihood of outpatient service use for minorities. CONCLUSION: Racial/ethnic minority youth in the United States continue to use outpatient mental health services at lower rates. This may lead to high prevalence of untreated negative externalizing behaviors among minority adolescent groups and, in turn, lead to use of inpatient services from systems such as juvenile justice and foster care. Such severe treatment alternatives can be prevented if timely and culturally tailored outpatient intervention is provided.

Why do young adolescents bully? Experience in Malaysian schools.

INTRODUCTION: To determine sociodemographic and psychological factors associated with bullying behavior among young adolescents in Malaysia. METHODS: This is a cross-sectional study of four hundred ten 12-year-old adolescents from seven randomly sampled schools in the Federal Territory of Kuala Lumpur, Malaysia. Sociodemographic features of the adolescents and their parents, bullying behavior (Malaysian Bullying Questionnaire), ADHD symptoms (Conners Rating Scales), and internalizing and externalizing behavior (Child Behaviour Checklist) were obtained from adolescents, parents and teachers, respectively. RESULTS: Only male gender (OR=7.071, p=0.01*, CI=1.642-30.446) was a significant sociodemographic factor among bullies. Predominantly hyperactive (OR=2.285, p=0.00*, CI=1.507-3.467) and inattentive ADHD symptoms reported by teachers (OR=1.829, p=0.03*, CI=1.060-3.154) and parents (OR=1.709, p=0.03*, CI=1.046-2.793) were significant risk factors for bullying behavior while combined symptoms reported by young adolescents (OR=0.729, p=0.01*, CI=0.580-0.915) and teachers (OR=0.643, p=0.02*, CI=0.440-0.938) were protective against bullying behavior despite the influence of conduct behavior (OR=3.160, p=0.00*, CI=1.600-6.241). Internalizing behavior, that is, withdrawn (OR=0.653, p=0.04*, CI=0.436-0.977) and somatic complaints (OR=0.619, p=0.01*, CI=0.430-0.889) significantly protect against bullying behavior. DISCUSSIONS: Recognizing factors associated with bullying behavior, in particular factors distinctive to the local population, facilitates in strategizing effective interventions for school bullying among young adolescents in Malaysian schools.

Children and adolescents with Tourette's disorder in the USA versus Argentina: behavioral differences may reflect cultural factors.

To explore behavioral differences as possible cultural factors in presentation of psychiatric comorbidity in two clinically referred, consecutively ascertained samples of youth with Tourette's disorder (TD) from New York and Buenos Aires. Subjects were evaluated between 2002 and 2010 at the Tics and Tourette's Clinical and Research Program at the New York University Child Study Center in New York and the Interdisciplinary Center for Tourette's, Obsessive Compulsive Disorder (OCD) and Associated Disorders (CITTTA)/Institute of Cognitive Psychology (INECO) in Buenos Aires. Demographic, diagnostic, tic severity (Yale Global Tic Severity Scale; YGTSS), clinical (Child Behavior Check List-Parent version; CBCL), and global functioning (Global Assessment of Functioning; GAF) data were compared using descriptive statistics. The sample included 111 subjects ages 6-17 years, who met DSM-IV-TR diagnostic criteria for TD. Findings revealed that the BA sample (n = 35) was significantly older at initial evaluation at the tic specialty clinic, and had higher frequency of oppositional defiant disorder (ODD), mood and non-OCD anxiety disorders than the NY sample (n = 76). There were no differences in gender distribution, age at tic onset or TD diagnosis, tic severity, proportion with current diagnoses of OCD/OC behavior or attention deficit hyperactivity disorder (ADHD), CBCL internalizing, externalizing, or total problems scores, YGTSS scores, or GAF scores. The observed similarities in demographic features, clinical presentation, rates of ADHD and OCD/OCB, and global impairment may reflect similar phenomenology and illness-related characteristics of TD in these referred youth. Differences in age at initial specialty clinic evaluation and rates of ODD, mood and non-OCD anxiety disorders may need further exploration before they may be considered to reflect cultural factors. Because of these limitations (e.g. small sample size), these results can be regarded only as preliminary.

Differences between immigrant and national students in motivational variables and classroom-motivational-climate perception.

The objective of this study is to see whether Immigrant (IM) and Spanish (National) students (SP) need different kinds of help from teachers due to differences in motivation, family expectancies and interests and classroom-motivational-climate perception. A sample of Secondary Students -242 Spanish and 243 Immigrants- completed questionnaires assessing goal orientations and expectancies, family attitudes towards academic work, perception of classroom motivational climate and of its effects, satisfaction, disruptive behavior and achievement. ANOVAs showed differences in many of the motivational variables assessed as well as in family attitudes. In most cases, Immigrant students scored lower than Spanish students in the relevant variables. Regression analyses showed that personal and family differences were related to student's satisfaction, achievement and disruptive behavior. Finally, multi-group analysis of classroom-motivational-climate (CMC) showed similarities and differences in the motivational value attributed by IM and SP to each specific teaching pattern that configure the CMC. IM lower self-esteem could explain these results, whose implications for teaching and research are discussed.

Ethnicity, perceived pubertal timing, externalizing behaviors, and depressive symptoms among black adolescent girls.

An accumulation of research evidence suggests that early pubertal timing plays a significant role in girls' behavioral and emotional problems. If early pubertal timing is a problematic event, then early developing Black girls should manifest evidence of this crisis because they tend to be the earliest to develop compared to other girls from different racial and ethnic groups. Given the inconsistent findings among studies using samples of Black girls, the present study examined the independent influence of perceived pubertal timing and age of menarche on externalizing behaviors and depressive symptoms in a nationally representative sample of Black girls (412 African American and 195 Caribbean Black; M = 15 years). Path analysis results indicated that perceived pubertal timing effects on externalizing behaviors were moderated by ethnic subgroup. Caribbean Black girls' who perceived their development to be early engaged in more externalizing behaviors than Caribbean Black girls' who perceived their development to be either on-time or late. Age of menarche did not significantly predict Black girls' externalizing behaviors and depressive symptoms. The onset of menarche does not appear to be an important predictor of Black girls' symptoms of externalizing behavior and depression. These findings suggest ethnic subgroup and perceived pubertal timing are promising factors for better understanding the adverse effects of early perceived pubertal timing among Black girls.

The social adjustment, academic performance, and creativity of Taiwanese children with Tourette's syndrome.

The purpose was to describe the social adjustment, academic achievement, and creativity of 127 Taiwanese children with Tourette's Syndrome and a control group of 138 Taiwanese children with typical development and reports of the parents of both groups. The Tourette's Syndrome group had significantly more disruptive behaviors than the controls; most parents reported their children with Tourette's Syndrome had high academic achievement although the children scored significantly lower than controls on the Elaboration subtest of Creative Thinking.

School discipline and disruptive classroom behavior: the moderating effects of student perceptions.

This study examines the relationship between school discipline and student classroom behavior. A traditional deterrence framework predicts that more severe discipline will reduce misbehavior. In contrast, normative perspectives suggest that compliance depends upon commitment to rules and authority, including perceptions of fairness and legitimacy. Using school and individual-level data from the National Education Longitudinal Study of 1988 and multilevel regression modeling, the author finds support for the normative perspective. Students who perceive school authority as legitimate and teacher­student relations as positive are rated as less disruptive. While perceptions of fairness also predict lower disruptions, the effects are mediated by positive teacher­student relations. Contrary to the deterrence framework, more school rules and higher perceived strictness predicts more, not less, disruptive behavior. In addition, a significant interaction effect suggests that attending schools with more severe punishments may have the unintended consequence of generating defiance among certain youth.

Dissemination of an evidence-based intervention to parents of children with behavioral problems in a developing country.

This project describes the dissemination of an evidence-based parenting skills intervention by training social and health workers with little or no mental health background so that they themselves train mothers of children with behavioral problems in impoverished communities in a developing country. The Strengths and Difficulties Questionnaire was completed by mothers to screen for children with behavioral problems and was repeated at the end of the intervention. Pre- and post-tests of knowledge and parenting attitudes were administered to mothers. Mental health workers trained social and health workers in social development centers and dispensaries. Each social and health worker trained mothers of children with behavioral problems under supervision utilizing an Arabic adaptation of the treatment manual for externalizing disorders "Helping Challenging Children" developed by the Integrated Services Taskforce of the World Psychiatric Association Child Mental Health Presidential Programme. A total of 20 workers and 87 mothers participated in the training. The proportion of children who obtained an SDQ total difficulties score in the abnormal range decreased from 54.4 to 19.7% after the training. Whereas 40.2% of mothers used severe corporal punishment with their children before the intervention, this decreased to 6.1% post-intervention. Three-fourths of mothers related that the program helped them develop new parenting skills. This pilot project demonstrated the feasibility of dissemination of a manual-based intervention and training of workers who have little background in mental health to offer effective services to families in impoverished communities who otherwise would have not received them. Successful replication in other developing countries would pave the way to incorporating such programs in national policies given their potential sustainability and cost-effectiveness.

Psychometric properties of the Chinese version of the Swanson, Nolan, and Pelham, Version IV Scale-Teacher Form.

OBJECTIVES: To examine the psychometric properties of the Chinese version of Swanson, Nolan and Pelham IV Scale (SNAP-IV)-Teacher Form. METHODS: The sample included a representative sample of 3,653 first to eighth graders (boys, 52.3%) and 190 children diagnosed with ADHD (aged 6-15). Teachers completed the Chinese versions of the SNAP-IV, and Strengths and Difficulties Questionnaire. RESULTS: The confirmatory factor analysis revealed a four-factor structure (inattention, hyperactivity, impulsivity, and opposition) with an adequate fit (Comparative Fit Index = 0.990; root mean square error of approximation = 0.058). The test-retest reliability (intraclass correlations = 0.60-0.84), internal consistency (alpha = .88-.95), and concurrent validity (Pearson correlations = 0.61-0.84) were satisfactory. Children with both ADHD and oppositional defiant/conduct disorders had the highest scores, followed by children with ADHD only who had intermediate scores and then school-based participants who had the lowest scores. CONCLUSIONS: Our findings suggest that the Chinese SNAP-IV-Teacher Form is a reliable and valid instrument for rating ADHD and oppositional symptoms (ClinicalTrials.Gov number, NCT00491361).

Social information processing, moral reasoning, and emotion attributions: relations with adolescents' reactive and proactive aggression.

Connections between adolescents' social information processing (SIP), moral reasoning, and emotion attributions and their reactive and proactive aggressive tendencies were assessed. One hundred mostly African American and Latino 13- to 18-year-olds from a low-socioeconomic-status (SES) urban community and their high school teachers participated. Reactive aggression was uniquely related to expected ease in enacting aggression, lower verbal abilities, and hostile attributional biases, and most of these connections were mediated by adolescents' attention problems. In contrast, proactive aggression was uniquely related to higher verbal abilities and expectations of more positive emotional and material outcomes resulting from aggression. Discussion focused on the utility of assessing both moral and SIP-related cognitions, and on the potential influence of low-SES, high-risk environments on these findings.

Emotional processing deficits in Italian children with Disruptive Behavior Disorder: The role of callous unemotional traits.

Research suggests that callous unemotional (CU) traits are associated with poor emotion recognition due to impairments in attention to relevant emotional cues. To further investigate the mechanisms that underlie CU traits, this study focused on the relationship between levels of CU and children's attention to, and recognition of, facial emotions. Participants were 7- to 10-year-old Italian boys, 35 with a diagnosis of Disruptive Behavior Disorder (age: M = 8.93, SD = 1.35), and 23 healthy male controls (age: M = 8.86, SD = 1.35). Children viewed standardized emotional faces (happiness, sadness, fear, disgust, anger, and neutral) while eye-tracking technology was used to evaluate scan paths for each area of interest (eyes, face, mouth), and for each emotion. CU traits were assessed using parent and teacher ratings on the Antisocial Process Screening Device. In the whole sample, elevated levels of CU traits were associated with a lower ability to recognize sadness, a lower number of fixations, and a lower average length of each fixation, specifically to the eye area of sad faces. In children with Disruptive Behavior Disorder diagnoses, high levels of CU traits were associated with lower duration of fixations to the eye-region on the eye area of sad faces, which in turns predicted lower levels of sadness recognition. The findings confirm that poor emotion recognition is associated with impairments in attention to critical information about other people's emotions. The clinical implications are discussed.

Onset, Comorbidity, and Predictors of Nicotine, Alcohol, and Marijuana Use Disorders Among North American Indigenous Adolescents.

North American Indigenous (i.e., American Indian and Canadian First Nations) youth experience inequities in rates of substance abuse and dependence. Despite this, few longitudinal studies examine the developmental course of substance use disorders (SUD) among community-based samples of Indigenous youth. The purpose of the study was to examine onset and predictors of nicotine dependence, alcohol use disorders, marijuana use disorders, any SUD, and multiple SUDs across the entire span of adolescence among a longitudinal sample (N = 744) of reservation/reserve Indigenous youth in the upper-Midwest of the United States and Ontario, Canada. Using discrete time survival analysis, the results show that rates of meeting criteria for SUDs by late adolescence were 22% for nicotine, 43% for alcohol, and 35% for marijuana. Peak periods of risk for new nicotine dependence and marijuana use disorder cases occurred around 14 years of age, whereas peak periods of risk for new alcohol use disorder cases emerged slightly later around 16 years of age. We found high rates of SUD comorbidity, and the cumulative probability of developing two or more SUDs during adolescence was 31%. Internalizing disorders increased the odds of nicotine dependence and multiple SUDs, while externalizing disorders increased the odds of all outcomes except nicotine dependence. Gender, age, and per capita family income were inconsistently associated with SUD onset. The findings are embedded within broader substance use patterns identified among Indigenous youth, and prevention, intervention, and treatment implications are discussed.

Developing a brief cross-culturally validated screening tool for externalizing disorders in children.

OBJECTIVE: Most screening instruments for externalizing disorders have been developed and validated in Western children. We developed and validated a brief screening instrument for predicting externalizing disorders in native Dutch children as well as in non-Dutch immigrant children, using predictors that can be easily obtained from teachers. METHOD: Teachers completed the Strengths and Difficulties Questionnaire for an ethnic diverse sample of 2,185 children ages 6 to 10 years. In a stratified subsample, 254 children and their parents were additionally interviewed regarding psychiatric disorders and sociodemographic data. In this group, stepwise logistic regression was used to derive a score from sex and all items of the Hyperactivity and Conduct Problems Scale of the Strengths and Difficulties Questionnaire, for predicting a best-estimate diagnosis of any externalizing disorder. The accuracy of the score was compared between native Dutch and non-Dutch immigrant children. RESULTS: Ninety-one cases of externalizing disorders were identified. An externalizing disorder could be predicted by the items restless, obeys, lies, and concentrates. Sex and ethnicity did not contribute to a prediction of an externalizing disorder. The area under the receiver operating characteristic was 0.84 (95% confidence interval 0.79-0.89), indicating good discriminatory power with no substantial differences between native Dutch and non-Dutch immigrant children. CONCLUSIONS: Externalizing disorders in both native Dutch and non-Dutch immigrant children can be predicted with a scoring rule, based on only four items that can be easily assessed by teachers. Before this internally validated prediction tool can be implemented, external validation in another sample is necessary.

Social functioning and adjustment in Canadian-born children with Chinese and European backgrounds.

The purpose of the study was to examine social functioning and adjustment in peer context in Chinese Canadian and European Canadian children. A sample of elementary school children participated in the study. Data on social functioning, peer acceptance and rejection, and victimization were collected from peer assessments and sociometric nominations. The results indicated that Chinese Canadian children were viewed by peers as less aggressive-disruptive than European Canadian children. Chinese Canadian girls, but not boys, were more shy-sensitive than their European Canadian counterparts. Sociability was associated with peer acceptance, whereas aggression was associated with peer rejection and victimization. Shyness was associated with peer relationship difficulties more evidently in European Canadian children than in Chinese Canadian children. These results indicate the relevance of ethnic background to children's peer social experiences.

Reciprocal relationships between parenting behavior and disruptive psychopathology from childhood through adolescence.

Theoretical models suggest that child behaviors influence parenting behaviors, and specifically that unpleasant child behaviors coerce parents to discontinue engaging in appropriate discipline. This study examined reciprocal relationships between parenting behaviors (supervision, communication, involvement, timid discipline and harsh punishment) and child disruptive disorder symptoms (ADHD, ODD and CD) in a clinic-referred sample of 177 boys. Annual measures, including structured clinical interviews, were obtained from the beginning of the study (when boys were between the ages of 7 to 12) to age 17. Specific reciprocal influence was observed; only timid discipline predicted worsening behavior, namely ODD symptoms, and ODD symptoms predicted increases in timid discipline. Greater influence from child behaviors to parenting practices was found: ODD also predicted poorer communication and decreased involvement, and CD predicted poorer supervision. ADHD was neither predictive of, nor predicted by, parenting behaviors. The results are specifically supportive of a coercive process between child behaviors and parenting behaviors, and generally suggestive of greater influence of child behaviors on parenting behaviors than of parenting behaviors on child behaviors.