Evaluating Practitioner Training to Improve Competencies and Organizational Practices for Engaging Fathers in Parenting Interventions.

Fathers are consistently underrepresented in parenting interventions and practitioners are an important target for change in interventions to enhance father engagement. This research examined the effects of two practitioner training programs in improving practitioner rated competencies and organizational father-inclusive practices. Two studies were conducted, each with a single group, repeated measures (pre, post and 2-month follow-up) design. Study 1 (N = 233) examined the outcomes of face-to-face training in improving practitioner ratings of competencies in engaging fathers, perceived effectiveness and use of father engagement strategies, organizational practices and rates of father engagement. Study 2 (N = 356) examined online training using the same outcome measures. Practitioners in both training formats improved in their competencies, organizational practices and rates of father engagement over time, yet those in the online format deteriorated in three competencies from post-training to follow-up. The implications for delivering practitioner training programs to enhance competencies and rates of father engagement are discussed.

Examining Practitioner Competencies, Organizational Support and Barriers to Engaging Fathers in Parenting Interventions.

Evidence-based parenting interventions have been developed and evaluated largely with mothers. This study examined practitioner reports of rates of father attendance, barriers to engagement, organizational support for father-inclusive practice, participation in training in father engagement, and competencies in working with fathers. It also explored predictors of practitioner competence and rates of father attendance. Practitioners (N = 210) who delivered parenting interventions completed an online survey. Participants reported high levels of confidence in engaging fathers, but only one in three had participated in training and levels of father attendance in parenting interventions were low. Logistic regressions showed that high levels of practitioner competence were predicted by participation in training. Moderate levels of father attendance (vs. low levels) were predicted by greater number of years of experience while high levels of attendance (vs. low levels) were predicted by greater experience, higher levels of competence and higher levels of organizational support. The implications of the findings to informing policy and practice for enhancing father engagement are discussed.

Mothers, Fathers, and Parental Systems: A Conceptual Model of Parental Engagement in Programmes for Child Mental Health-Connect, Attend, Participate, Enact (CAPE).

Parenting programmes are one of the best researched and most effective interventions for reducing child mental health problems. The success of such programmes, however, is largely dependent on their reach and parental engagement. Rates of parental enrolment and attendance are highly variable, and in many cases very low; this is especially true of father involvement in parenting programmes. This paper proposes a conceptual model of parental engagement in parenting programmes-the CAPE model (Connect, Attend, Participate, Enact) that builds on recent models by elaborating on the interdependent stages of engagement, and its interparental or systemic context. That is, we argue that a comprehensive model of parental engagement will best entail a process from connection to enactment of learned strategies in the child's environment, and involve consideration of individual parents (both mothers and fathers) as well as the dynamics of the parenting team. The model provides a framework for considering parent engagement as well as associated facilitators and mechanisms of parenting change such as parenting skills, self-efficacy, attributions, and the implementation context. Empirical investigation of the CAPE model could be used to further our understanding of parental engagement, its importance for programme outcomes, and mechanisms of change. This will guide future intervention refinement and developments as well as change in clinical practice.

DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents.

OBJECTIVE: The purpose of the field trials for oppositional defiant disorder and conduct disorder was to select valid diagnostic thresholds for these disorders and to compare the psychometric properties of DSM-IV criteria for oppositional defiant disorder and conduct disorder with previous DSM diagnostic formulations. METHOD: Structured diagnostic interviews, standardized clinician's validation diagnoses, and multiple measures of impairment were obtained for 440 clinic-referred children and adolescents aged 4-17 years. RESULTS: A diagnostic threshold of four symptoms of oppositional defiant disorder optimized identification of impaired children, improved agreement somewhat with the clinician's validation diagnosis, and had somewhat better test-retest agreement than DSM-III-R. In the case of conduct disorder, the optimal time window for ascertainment of symptoms was clarified. A diagnostic threshold of three symptoms of conduct disorder maximized accurate identification of impaired children and agreement with the clinician's validation diagnosis and resulted in slightly better test-retest agreement than DSM-III-R. Compared with the DSM-III-R definition, the DSM-IV definition of oppositional defiant disorder was somewhat more prevalent, but the prevalence of conduct disorder was essentially unchanged. CONCLUSIONS: DSM-IV definitions of oppositional defiant disorder and conduct disorder are somewhat better than DSM-III-R definitions in terms of internal consistency and test-retest agreement, and the validity of the DSM-IV definition of oppositional defiant disorder is slightly better than that of DSM-III-R.

Antisocial behavior, somatization, and sensation-seeking behavior in mothers of clinic-referred children.

OBJECTIVE: The relationship between antisocial behavior and somatization was studied in a sample of mothers of clinic-referred, school-age children. The goal was to overcome some of the methodological limitations of past research in this area and to provide a preliminary test of the theory that these disorders share a common substrate: a tendency toward behavioral disinhibition. METHOD: Structured diagnostic interviews and an objective personality measure were used to assess antisocial behavior and somatization in a sample of 90 biological mothers (mean age 34 years) of children referred to an outpatient mental health clinic. A rating scale measure of sensation-seeking behavior was used as a measure of behavioral disinhibition. Structured interviews were used to assess a history of antisocial behavior in the children and their biological fathers. RESULTS: Results indicated a link between somatization and antisocial behavior both within individuals and across generations. This intergenerational link could not be solely accounted for by assortative mating between women with somatization and antisocial men. Both somatization and antisocial behavior were correlated with scores on the sensation seeking scale. CONCLUSIONS: These findings are consistent with the theory that antisocial behavior and somatization are related syndromes and that behavioral disinhibition may be a common predisposition that underlies both.

Psychopathy and conduct problems in children: II. Implications for subtyping children with conduct problems.

OBJECTIVE: To test whether the presence of callous and unemotional (CU) traits designates a unique subgroup of children with conduct problems that corresponds more closely to adult conceptualizations of psychopathy. METHOD: A clinic-referred sample of 120 children between the ages of 6 and 13 years were assessed using parent and teacher ratings of CU traits, as well as parent and teacher report on a structured interview assessing oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms. RESULTS: A cluster analysis of the ratings of CU traits and ODD/ CD symptoms revealed four clusters of children, two of which had high rates of ODD and CD symptoms. One of these conduct problem clusters also exhibited high levels of CU traits (n = 11). These children had a greater number and variety of conduct problems, a stronger history of police contacts, and a stronger parental history of antisocial personality disorder, despite being of higher intelligence than other children with significant conduct problems (n = 29). CONCLUSION: The presence of CU traits with significant conduct problems seems to designate a unique subgroup of antisocial children who show a very severe pattern of antisocial behavior and who correspond more closely to adult conceptualizations of psychopathy.

Oppositional defiant and conduct disorders: issues to be resolved for DSM-IV.

Oppositional defiant disorder (ODD) and conduct disorder (CD) are reasonably distinct both in terms of statistical covariation among symptoms and ages of onset. The two disorders are related in similar ways to impairment and family history of antisocial behavior, but the association is stronger for CD than ODD. Virtually all clinic-referred youths with prepubertal onset of CD have retained the symptoms of ODD that emerged at earlier ages. Furthermore, a set of serious antisocial behaviors characteristically emerges at later ages in some youths with CD, suggesting further developmental progression within CD. These findings are consistent with a conceptualization of ODD and CD as developmentally staged, hierarchically organized levels of severity of the same disorder, but two findings argue for distinguishing separate disorders in DSM-IV: (1) many youths with ODD never develop CD, and (2) CD that emerges for the first time in adolescence appears to be independent of ODD.

Anxiety, inhibition, and conduct disorder in children: I. Relations to social impairment.

Jeffrey A. Gray has proposed a model in which conduct disorder (CD) is viewed as the result of both excessive activity of a behavioral activation system that mediates appetitive and aggressive behavior and deficient activity of a behavioral inhibition system that mediates both anxiety and the inhibition of behavior in the presence of cues signalling impending punishment or frustration. The relation of anxiety to antisocial behavior was examined in 177 clinic-referred boys, aged 7 to 12 years, 68 of whom met DSM-III-R criteria for CD. As predicted by Gray's model, boys with CD and comorbid anxiety disorder were markedly less impaired than boys with CD alone.

Anxiety, inhibition, and conduct disorder in children: II. Relation to salivary cortisol.

The relation of symptoms of conduct disorder (CD) and anxiety to salivary cortisol was explored in 67 clinic-referred boys aged 8 to 13 years. Children with anxiety disorder had higher levels of cortisol, but this main effect was qualified by a significant CD x anxiety disorder interaction. Consistent with Gray's biological model of the behavioral inhibition system (BIS), children with both CD and anxiety disorder had higher levels of salivary cortisol than children with CD without comorbid anxiety disorder. In the absence of CD, however, anxiety disorder was not clearly associated with higher cortisol. This result suggests that cortisol may be a useful biological marker of arousal associated with BIS activity in children with CD.

DSM-IV field trials for the disruptive behavior disorders: symptom utility estimates.

OBJECTIVE: We tested the predictive utility of symptoms for proposed DSM-IV definitions of the disruptive behavior disorders using indices corrected for symptom and diagnosis base rates. METHOD: The field trials sample consisted of 440 clinic-referred youths who were consecutive referrals to a heterogeneous group of mental health clinics. Multiple informants were interviewed to determine the presence of symptoms and diagnoses. RESULTS: Some symptoms which were either not in DSM-III or DSM-III-R, or were modifications of DSM-III-R symptoms, had greater diagnostic efficiency than did several existing symptoms. Symptom utility estimates were generally similar for different ages and genders, although some interesting age and sex trends emerged for a few symptoms. CONCLUSIONS: The results supported the inclusion of more restricted definitions of "lying" and "truancy" to increase their association with a conduct disorder diagnosis and they supported the elimination of "swearing" in the oppositional defiant disorder criteria. In addition to their relevance for developing optimal criteria for DSM-IV, these results can aid DSM-IV users by providing a useful guide to the relative efficiency of individual symptoms based on data from a large heterogeneous clinic population.

Comparison of DSM-III and DSM-III-R diagnoses for prepubertal children: changes in prevalence and validity.

A structured and reliable diagnostic procedure based on a revised version of the Diagnostic Interview Schedule for Children for children, parents, and teachers was used to assign both DSM-III and DSM-III-R diagnoses to 177 outpatient boys aged 7 to 12 years. Compared to their DSM-III counterparts, DSM-III-R oppositional defiant disorder was 25.5% less prevalent, DSM-III-R dysthymia was 37.8% less prevalent, and DSM-III-R conduct disorder (CD) was 44.3% less prevalent. However, DSM-III-R attention deficit hyperactivity disorder was 14.4% more prevalent than DSM-III attention deficit disorder with hyperactivity. The two definitions of CD were compared to exemplify an empirical approach to diagnostic validation. The DSM-III-R diagnosis of CD appears to be more valid as it is more strongly associated with police contacts, school suspensions, and history of antisocial personality disorder in the biological father, but both CD diagnoses are associated with family histories of criminal convictions.

Validity of DSM-IV subtypes of conduct disorder based on age of onset.

OBJECTIVE: To present data from the DSM-IV field trials that led to the distinction between subtypes of conduct disorder (CD) that emerge in childhood or adolescence. In addition, data from a household sample were used to attempt to cross-validate these findings. METHOD: Differences between youths who met criteria for the two subtypes of CD were examined in the field trials sample of 440 youths aged 4 through 17 years and in a household sample of 1,285 youths aged 9 through 17 years. RESULTS: In both samples, there was a steep decline in aggression occurring around an age of onset of 10 years, but the number of nonaggressive behaviors was unrelated to the age of onset of CD. In the field trials sample, youths who met criteria for the adolescent-onset type were more likely to be girls, less likely to meet criteria for oppositional defiant disorder, and less likely to have a family history of antisocial behavior than the childhood-onset type, but these latter findings were not confirmed in the household sample. CONCLUSIONS: The DSM-IV approach to subtyping CD distinguishes subgroups that differ markedly in level of physical aggression. The advantages of a developmental approach to subtyping are discussed.

Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials.

OBJECTIVE: To examine the validity of the DSM-IV requirement of an age of onset of impairment due to symptoms before 7 years of age for the diagnosis of attention-deficit/hyperactivity disorder (ADHD). METHOD: The validity of this criterion was examined in a clinic sample of 380 youths aged 4 through 17 years by comparing youths who met symptom criteria for ADHD and either did or did not display impairment before age 7 years. RESULTS: Nearly all youths who met symptom criteria for the predominantly hyperactive-impulsive subtype also met the age of onset of impairment criterion, but 18% of youths who met symptom criteria for the combined type, and 43% of youths who met symptom criteria for the predominantly inattentive type, did not manifest impairment before 7 years. For the latter two subtypes, requiring impairment before age 7 years reduced the accuracy of identification of currently impaired cases of ADHD and reduced agreement with clinicians' judgments. CONCLUSIONS: These findings raise questions about the validity of the DSM-IV definition of age of onset of ADHD. Marked differences in the ages of onset of both symptoms and impairment for the three subtypes of ADHD support the validity of distinguishing among these subtypes in DSM-IV.

Ineffective parenting and childhood conduct problems: the moderating role of callous-unemotional traits.

A sample of 6- to 13-year-old clinic-referred (n = 136) and volunteer (n = 30) participants was investigated for a potential interaction between the quality of parenting that a child receives and callous-unemotional traits in the child for predicting conduct problems. Ineffective parenting was associated with conduct problems only in children without significant levels of callous (e.g. lack of empathy, manipulativeness) and unemotional (e.g., lack of guilt, emotional constrictedness) traits. In contrast, children high on these traits exhibited a significant number of conduct problems, regardless of the quality of parenting they experienced. Results are interpreted in the context of a model that proposes that callous-unemotional traits designate a group of children with conduct problems who have distinct causal factors involved in the development of their problematic behavior.

Familial risk factors to oppositional defiant disorder and conduct disorder: parental psychopathology and maternal parenting.

In a sample of 177 clinic-referred children aged 7-13, an association was found between a diagnosis of conduct disorder (CD) and several aspects of family functioning: maternal parenting (supervision and persistence in discipline) and parental adjustment (paternal antisocial personality disorder and paternal substance abuse). Children with oppositional defiant disorder (ODD) were intermediate to families of children with CD and clinic control children on all variables, but differed from control children only in having a higher rate of paternal substance abuse and paternal antisocial personality disorder (APD). When both parental APD and deviant maternal parenting were entered into 2 x 2 logit-model analyses predicting CD, only parental APD was significantly associated with CD, and no interactions between parental adjustment and maternal parenting were found. The importance of these findings for understanding the etiology of CD and for disentangling correlated risk factors in future studies is discussed.

Serious conduct problems in the children of adolescent mothers: disentangling confounded correlations.

Early motherhood (less than 20 years of age) was found to be significantly correlated (r = .33) with the number of DSM-III symptoms of conduct disorder in a sample of 253 boys aged 6-13 years who had been referred to outpatient clinics. The following models were compared using path analysis: (a) Teenage motherhood, parental antisocial personality, and SES each contribute uniquely to the prediction of childhood conduct problems; (b) teenage motherhood mediates the association of SES and parental antisocial personality with child conduct problems; and (c) teenage motherhood is spuriously related with child conduct problems because of common associations with SES and parental antisocial personality. Model (c) best fit our data. Similar results were obtained whether maternal age at the birth of the firstborn child or the proband child was used to define maternal age and when teenage motherhood was defined as giving birth at less than 18 years.

Neuropsychological test performance and the attention deficit disorders: clinical utility of the Luria-Nebraska Neuropsychological Battery-Children's Revision.

The Luria-Nebraska Neuropsychological Battery-Children's Revision (LNNB-CR) was administered to 54 clinic-referred children aged 8-12 years. Children reliably diagnosed as attention deficit disorder with hyperactivity were compared with children diagnosed as attention deficit disorder without hyperactivity and with a clinic control group diagnosed with internalizing disorders. Both attention deficit disorder groups were lower than the control group in verbal and Full Scale IQ scores but did not differ from one another. The groups did not differ significantly on any of the LNNB-CR clinical scales, on the right or left hemisphere scores, or on the pathognomonic score using analyses of variance or analyses of covariance with both Full Scale IQ and age as covariates. These findings failed to support the hypothesis that attention deficit disorder, either with or without hyperactivity, is associated with neuropsychological dysfunction as measured by the LNNB-CR.

Psychopathy and conduct problems in children.

Factor analysis of a measure of psychopathy was conducted in a sample of 95 clinic-referred children between the ages of 6 and 13 years. These analyses revealed 2 dimensions of behavior, one associated with impulsivity and conduct problems (I/CP) and one associated with the interpersonal and motivational aspects of psychopathy (callous/unemotional: CU). In a subset of this sample (n = 64), analyses indicated that scores on the I/CP factor were highly associated with traditional measures of conduct problems. In contrast, scores derived from the CU factor were only moderately associated with measures of conduct problems and exhibited a different pattern of associations on several criteria that have been associated with psychopathy (e.g., sensation seeking) or childhood antisocial behavior (e.g., low intelligence, poor school achievement, and anxiety). These analyses suggest that psychopathic personality features and conduct problems are independent, yet interacting, constructs in children, analogous to findings in the adult literature.

Symptom properties as a function of ADHD type: an argument for continued study of sluggish cognitive tempo.

Inconsistent alertness and orientation (sluggishness, drowsiness, daydreaming) were reported to accompany Attention Deficit Disorder (ADD) without Hyperactivity in DSM-III. Such Sluggish Cognitive Tempo items were tested in the DSM-IV Field Trial for ADHD, but were discarded from the Inattention symptom list because of poor negative predictive power. Using 692 children referred to a pediatric subspecialty clinic for ADHD, Sluggish Tempo items were re-evaluated. When Hyperactivity-Impulsivity was absent (i.e., using only cases of Inattentive Type plus clinic controls), Sluggish Tempo items showed substantially improved utility as symptoms of Inattention. Factor analyses distinguished a Sluggish Tempo factor from an Inattention factor. When DSM-IV ADHD types were compared, Inattentive Type was uniquely elevated on Sluggish Tempo. These findings suggest that (a) Sluggish Tempo items are adequate symptoms for Inattentive Type, or (b) Sluggish Tempo may distinguish two subtypes of Inattentive Type. Either conclusion is incompatible with ADHD nosology in DSM-IV.

Reward dominance: associations with anxiety, conduct problems, and psychopathy in children.

The associations between children's behavior and their performance on a task with a steadily increasing ratio of punished to rewarded responses was investigated in a group of clinic-referred (n = 92) and normal control (n = 40) children between the ages of 6 and 13. Clinic-referred children with an anxiety disorder played significantly fewer trials than clinic-referred children without an anxiety disorder but the response style of the anxious children did not differ from that of a normal control group. Children with severe conduct problems who had no anxiety disorder played more trials than (a) children with severe conduct problems and a comorbid anxiety disorder, (b) nonanxious children with attention-deficit hyperactivity disorder, and (c) children in the normal control group. The strongest evidence for the reward dominant response style was for nonanxious subjects with elevations on a measure of psychopathic features, irrespective of whether they also had conduct problems and irrespective of whether they were clinic-referred.