Recruitment and retention of participants in prevention trials involving family-based interventions.

Family-based preventive intervention trials in the area of child conduct problems face serious challenges regarding the recruitment and subsequent retention of participants. This article focuses on the problems and strategies pertinent to recruitment and retention in prevention research. The issues are discussed first with respect to initiating and maintaining a longitudinal sample, and then engaging and sustaining families in a preventive intervention. General principles are illustrated by EARLY ALLIANCE, a recently launched preventive intervention trial aimed at reducing children's risk for conduct disorder, substance abuse, and school failure. Recommendations for enhancing recruitment and retention are offered.

Promoting intervention fidelity. Conceptual issues, methods, and preliminary results from the EARLY ALLIANCE prevention trial.

Fidelity refers to the demonstration that an experimental manipulation is conducted as planned. In outcome research, an intervention can be said to satisfy fidelity requirements if it can be shown that each of its components is delivered in a comparable manner to all participants and is true to the theory and goals underlying the research. Demonstrating the fidelity of an intervention is a key methodologic requirement of any sound prevention trial. This paper summarizes key conceptual and methodologic issues associated with intervention fidelity, and describes the steps taken to promote fidelity in EARLY ALLIANCE, a large-scale prevention trial currently testing the effectiveness of family, peer, and school interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure. The paper presents preliminary results (Trial Year 1) that demonstrate content and process fidelity for two of these interventions, and discusses how the EARLY ALLIANCE methodology may be generalized to address fidelity issues in other prevention studies.

The EARLY ALLIANCE prevention trial: a dual design to test reduction of risk for conduct problems, substance abuse, and school failure in childhood.

This paper describes a preventive intervention trial called EARLY ALLIANCE which is aimed at reducing risk for three adverse outcomes in childhood and adolescence: conduct problems, substance abuse, and school failure. The structure of the prevention trial is unique because two linked designs are being implemented concurrently. The primary design focuses on children at elevated risk for adverse outcomes, and compares a targeted, multicontextual preventive intervention with family, classroom, peer relational, and academic components to a universal, schoolwide preventive intervention that emphasizes peaceful conflict management and serves as a "usual care" control condition. The secondary design focuses on children at lower risk for adverse outcomes and compares a universally administered classroom program to the control condition. The paper describes the theoretical foundation for EARLY ALLIANCE, the goals of the prevention trial, the rationale for design choices, and the methods employed.

Children who murder: a review.

Despite considerable research on juvenile homicide, pre-adolescent homicide offenders have received less attention. This paper reviews the existing literature on preteen murderers in order to characterize the current state of research knowledge about this population, and draws on some of the work on adolescent homicide as well. The analysis of this literature considers historical context, methodological issues, previous attempts to classify youthful homicide offenders, and predictors of preteen homicidal behavior. While there is a high degree of heterogeneity within this population, several developmental similarities emerged across cases that were associated with the perpetration of homicide by preteens. A high percentage of preteen homicide offenders come from homes characterized by physical abuse, domestic violence, poor or absent parenting, and overall instability. Gun availability may have been a facilitating factor. Support for different etiologies of preteen versus adolescent homicide is weak. Recommendations for future research directions are offered.

Engagement in child and adolescent treatment: the role of parental cognitions and attributions.

Parental engagement in the treatment process is influenced by parents' beliefs about the cause of their children's problems, perceptions about their ability to handle such problems, and expectations about the ability of therapy to help them. This paper examines the role of parental cognitions related to attributions and expectations in relation to engagement in child mental health treatment. Reviewed studies indicate that parental attributions and expectations influence three aspects of treatment: help seeking, engagement and retention, and outcome. This paper integrates findings from developmental and clinical research, highlights gaps in the literature, presents the beginnings of a model regarding the parental attributional process as it relates to engagement in treatment, recommends future research directions, and discusses clinical implications.

The EARLY ALLIANCE prevention trial: an integrated set of interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure.

Describes the EARLY ALLIANCE interventions, an integrated set of four programs designed to promote competence and reduce risk for early-onset conduct disorder, substance abuse, and school failure. These interventions are evaluated as part of a prevention trial that begins at school entry and targets child functioning and socializing practices across multiple contexts (school, peer group, family) and multiple domains (affective, social, and achievement coping-competence). The paper presents the conceptual foundation of the four interventions, including a synopsis of the risk and protective factors associated with conduct disorder and related outcomes, and of the coping-competence model driving EARLY ALLIANCE. The developmental rationale, intended impact, and procedures are described for each intervention: a universally administered classroom program and indicated, peer, reading-mentoring, and family programs. Interventions are currently being tested in a prevention trial, which is briefly summarized.

Coping and adjustment during childhood and adolescence.

This paper reviews research published within the last 10 years on child and adolescent strategies for coping with commonly occurring stressors in nonclinical populations and the relationship of these strategies to adjustment. Current conceptual and classification schemes for children's coping strategies are analyzed and compared. Studies of child coping are reviewed in three clusters: (a) descriptive and taxonomic studies, (b) age-group comparisons, and (c) evaluations of coping-adjustment relationships. Developmental commonalities and changes are identified across studies and conceptual models. Conceptual models compatible with problem-focused/ emotion-focused and approach/avoidance frameworks have proven to be useful for descriptive purposes. However, it is of concern that categories in the current classification systems do not distinguish coping strategies that promote adjustment from ones that limit adjustment. Future directions for addressing this issue and developmental considerations are suggested, including an alternative model pertaining to coping competence.

Short-term stability of aggression, peer rejection, and depressive symptoms in middle childhood.

This study investigated the short-term stability of teacher-rated aggression, peer-rated rejection, and peer-rated depressive symptoms in 478 elementary school children from 25 classrooms (first to third grades) in two geographical areas. Children who presented specific combinations of aggression, rejection, and depressive symptoms were tracked to determine the stability of these combinations from the beginning (Time 1) to the end (Time 2) of the school year. In addition, aggression, rejection, and depressive symptoms were treated as risk factors, and children were classified as displaying zero, one, two, or three risk factors at Times 1 and 2. Of the three risk factors, aggression appeared to be the most stable. Three-quarters of children who presented aggression at Time 1 (either alone or in combination with the other risk factors) were found to continue to have elevated levels of aggression at Time 2. Although specific combinations of aggression, rejection, and depressive symptoms were not very stable over time, the number of risk factors a child displayed at Time 1 was a good predictor of the number of risk factors the child displayed at Time 2. Stability of risk factors was comparable as a junction of child gender and ethnicity.

Family-based treatment for childhood antisocial behavior: experimental influences on dropout and engagement.

Antisocial behavior in childhood and adolescence is an unquestionably serious problem for society. Family-based treatments are promising but face the challenging obstacle of premature parental dropout. To systematically study dropout, we randomly assigned 147 families with a markedly aggressive child (age 4 to 9 years) to a standard family treatment (SFT) focusing exclusively on parental management or to an enhanced family treatment (EFT) that also promoted frequent discussions of adult issues. EFT produced a significantly lower dropout rate than SFT overall, but particularly for high-adversity families. Dropouts were clearly distinguishable from completers on several dimensions. The results underscore the importance of addressing contextual variables such as family adversity in the treatment of childhood antisocial behavior.

Enhancement of social learning family interventions for childhood conduct disorder.

Social learning family intervention (SLFI) is the treatment of choice for young children exhibiting severe conduct disorder and antisocial behavior. Despite the reported success of this intervention, high levels of resistance, poor engagement, and inadequate maintenance of improvements are observed for a substantial proportion of distressed families. These obstacles have inspired enhancement efforts to improve basic social learning family-intervention models. The present review identifies promising approaches for maximizing treatment gains for the conduct-disordered child. Relevant studies were organized into 3 approaches: enhancements and expansions (a) within a dyadic (parent-child) interaction model, (b) within a broad-based model that acknowledges a wider range of family influences, and (c) through a multisystems model. SLFI enhancements within the dyadic model have centered on either the strengthening of parental skills already included in the SLFI regimen or the adding of new interactional strategies. Some gains, but only partial success, have been achieved with the dyadic model supplements. SLFI expansions from a broad-based model have focused on parental adjustment, parental expectations during treatment, and social-environmental stressors. The multisystems adjuncts to SLFI include cognitive-behavioral interventions to affect peer relations and ecological approaches to sweep across domains. The broad-based and multisystems expansions have produced promising but undertested treatment regimens. Related areas of investigation included therapy process research, medication combined with SLFI, and the involvement of fathers in treatment. Recommendations are offered for improvement of SLFI research. The apparent theoretical crossroads for SLFI treatment of childhood conduct disorder are discussed.

Determinants of adjustment for children of divorcing parents.

Family physicians frequently see children and parents when they are adjusting to marital separation. This study examined how well child adjustment at school could be determined from an assessment of interspousal relations, maternal functioning, and child perception variables. Teachers evaluated adaptive functioning, social withdrawal, and aggressive behavior at school for a carefully selected sample of 22 boys and 24 girls (ages 7-12) whose parents had been separated for two to 18 months. Regression analyses indicated that boys' overall school adjustment was associated with better maternal parenting skills, lower child fear of abandonment, less blaming of father for the separation, and positive parental verbal attributions toward the other parent. Girls with better overall school adjustment reported less blaming of their mothers and a higher rate of positive attributions by mother about father. These findings suggest concepts family physicians can use in working with families to minimize the effect of divorce on children.

Marital disturbance and child problems: a cautionary note regarding hyperactive children.

In previous work, investigators have found a relationship between marital discord and childhood conduct problems (aggression) in clinic samples. Given the wide variability of aggression found among hyperactive children, it would follow from previous work that child aggression may be associated with marital discord in a hyperactive population. This hypothesis was tested in a sample of 23 boys (ages 5 to 8) diagnosed as attention deficit with hyperactivity. Aggressive behaviors were tracked by the children's teachers for 12 school days. Parental and teacher ratings of conduct problems were also obtained. Additionally, the auditory version of the laboratory Continuous Performance Test was administered. Marital adjustment, overt hostility, and conflict tactics, as reported by the mothers, were not significantly correlated with any of the measures of aggression or conduct problems. In other words, marital discord in families with a hyperactive boy did not explain differential rates of aggressive behavior despite definite variability in both the marital and child behavioral measures. Marital discord was marginally related to severity of attentional deficit on the Continuous Performance Test. The results underscore the need for caution in attempting to extend findings from a general population (i.e., undifferentiated clinic-referred children) to a specific diagnostic subgroup (i.e., attention-deficit hyperactive children).

Reliability of neurological soft signs in children: reevaluation of the PANESS.

Test-retest reliability and intellectual-behavioral correlates of a revised version of the Physical and Neurological Examination for Soft Signs (PANESS) were evaluated. The WISC-R and PANESS were administered to a heterogeneous clinical sample of 28 6- to 8-year-old children. Test-retest interval for PANESS retest was approximately 28 days with 15 children retested by same testers and the remaining children retested by different testers. Results indicated that PANESS total score is a reliable indicator of overall performance; tester assignment and retest had negligible effects on total score. Grade of subcategory scores proved unreliable across examiners but occurrence/nonoccurrence scores were more robust. Performance on the PANESS was significantly correlated with WISC-R indices sensitive to brain dysfunction, and behavioral factors implicated in the description of minor neurological dysfunction. Further research evaluating discriminant validity of the examination and changes in performance as a result of development is recommended.

Hyperactive and aggressive behaviors in childhood: intertwined dimensions.

The relationship between aggression and hyperactivity is unclear in childhood hyperkinesis. To examine the relationship between the two dimensions, a sample of 109 first-, second-, and third-grade children who were rated as hyperactive were evaluated daily by their teachers for 12 consecutive school days on the Daily Behavior Checklist. Daily recordings were made on a total of 22 specific behaviors, 11 physically or verbally aggressive acts, and 11 acts of a restless or hyperactive nature. The Conners hyperactivity score correlated .47 with daily aggression and .49 with daily hyperactivity. A subgroup of hyperactive children who exhibited both hyperactive and aggressive behaviors at rates greater than 98% of their classmates was selected. These children were rated significantly higher on the Conners scale than on alternate subgroup of hyperactive children who showed high rates of hyperactive but not aggressive behaviors. In view of heavy reliance on teacher ratings with the Conners scale in studies of hyperactivity, careful consideration of the potential confounding of hyperactivity and aggression is recommended. Implications for classification, longitudinal investigation, and evaluation of treatment of hyperactive children were discussed.