Case study: behavioral treatment of obsessive-compulsive disorder in a boy with comorbid disruptive behavior problems.

Comorbid psychiatric conditions often complicate the treatment of childhood obsessive-compulsive disorder (OCD). Behavioral treatment of OCD using exposure plus response prevention for a boy with disruptive behavior disorders and two previous unsuccessful medication trials is described. Treatment was adapted to his developmental level, his mother was highly involved in treatment, and a contingency management program contained his disruptive behavior so that he could participate in therapy. Posttreatment and 2- and 6-month follow-up measures indicated marked improvement in OCD symptoms. The possibility of successful behavioral treatment of OCD in medication-free children with disruptive behavior problems is highlighted.

Infant and toddler pathways leading to early externalizing disorders.

OBJECTIVE: To examine pathways leading to specific types of early externalizing disorders. METHOD: Longitudinal data were collected on 310 low-income, male subjects followed from infancy until age 6 years. RESULTS: Support across informants was found for the importance of the caregiving environment during infancy in relation to the development of externalizing disorders at school entry. Support was also found for the significance of early child factors, but this was limited to child behavior at home. CONCLUSIONS: The results are consistent with social learning and attachment models, which suggest that severe conduct problems in early childhood are the result of deficits in the caregiving environment. Support was also found for Moffitt's hypothesis that children with the comorbid attention-deficit/hyperactivity disorder-oppositional defiant disorder/conduct disorder pattern experience multiple child and psychosocial risk factors that begin during infancy.

Young children's adjustment to chronic family adversity: a longitudinal study of low-income families.

OBJECTIVE: To test the relation between multiple family stressors and young children's adjustment problems. METHOD: Longitudinal data were collected on 300 low-income, ethnically diverse, male subjects beginning during infancy and followed until age 31/2. RESULTS: General support was found for the family stressor hypothesis. Stressor groups at 18 and 24 months predicted Child Behavior Checklist Externalizing and Internalizing factors at 24 and 42 months, including clinically elevated problems. CONCLUSIONS: The results confirm and extend previous investigation of the family stressor hypothesis. They suggest that psychological evaluations of young children need to be ecologically based, including intra- and extrafamilial factors that appear to cumulatively increase risk of behavior problems.

Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment.

OBJECTIVES: To develop a categorical outcome measure related to clinical decisions and to perform secondary analyses to supplement the primary analyses of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA). METHOD: End-of-treatment status was summarized by averaging the parent and teacher ratings of attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms on the Swanson, Nolan, and Pelham, version IV (SNAP-IV) scale, and low symptom-severity ("Just a Little") on this continuous measure was set as a clinical cutoff to form a categorical outcome measure reflecting successful treatment. Three orthogonal comparisons of the treatment groups (combined treatment [Comb], medication management [MedMgt], behavioral treatment [Beh], and community comparison [CC]) evaluated hypotheses about the MTA medication algorithm ("Comb + MedMgt versus Beh + CC"), multimodality superiority ("Comb versus MedMgt"), and psychosocial substitution ("Beh versus CC"). RESULTS: The summary of SNAP-IV ratings across sources and domains increased the precision of measurement by 30%. The secondary analyses of group differences in success rates (Comb = 68%; MedMgt = 56%; Beh = 34%; CC = 25%) confirmed the large effect of the MTA medication algorithm and a smaller effect of multimodality superiority, which was now statistically significant (p < .05). The psychosocial substitution effect remained negligible and nonsignificant. CONCLUSION: These secondary analyses confirm the primary findings and clarify clinical decisions about the choice between multimodal and unimodal treatment with medication.

A longitudinal study of interparental conflict, emotional and behavioral reactivity, and preschoolers' adjustment problems among low-income families.

Researchers have begun to develop models that explain the processes by which interparental conflict impacts children's adjustment. The present study tested a model based on emotional security theory. The longitudinal relations among interparental conflict, boys' reactions to conflict, and internalizing and externalizing problems were examined in a sample of 129 mother-son dyads from low-income, 2-parent families from the time sons were age 2 to 5. Results indicated that children exposed to interparental conflict were more likely to have concurrent and later behavior problems and that patterns of interparental conflict across time made unique contributions in predicting later problems. Children's emotional reactivity in response to conflict had no direct relation to interparental conflict and only modest relations to behavior problems. However, interparental conflict and reactivity factors interacted to predict behavior problems at ages 3 1/2 and 5. Thus, some support was demonstrated for emotional reactivity as a moderator in the development of young children's behavior problems.

The development of early externalizing problems among children from low-income families: a transformational perspective.

The present study examined pathways leading to early externalizing problems from age 1 to 3 1/2 in a design that took advantage of our knowledge of normative progression and normative socialization as well as findings from research on risk. A sample of 130 low-income participants was followed longitudinally from 12 to 42 months using observational measures of developmentally salient parenting and child disruptive behavior to predict early externalizing problems. Results are best accommodated by concepts such as transformation and transaction from developmental psychology. For boys, both child and parent variables predicted later externalizing. For girls and boys, the interaction between child noncompliance and maternal rejection was significant.

Family processes and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment.

To elucidate processes underlying therapeutic change in a large-scale randomized clinical trial, we examined whether alterations in self-reported parenting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavior, social skills, internalizing symptoms) in children with attention-deficit hyperactivity disorder (ADHD). Participants were 579 children with Combined-type ADHD, aged 7-9.9 years, in the Multimodal Treatment Study of Children with ADHD (MTA). We uncovered 2 second-order factors of parenting practices, entitled Positive Involvement and Negative/Ineffective Discipline. Although Positive Involvement was not associated with amelioration of the school-based outcome measures, reductions in Negative/Ineffective Discipline mediated improvement in children's social skills at school. For families showing the greatest reductions in Negative/Ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation to regular community care. Furthermore, only in combination treatment (and not in behavioral treatment alone) was decreased Negative/Ineffective Discipline associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears related to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process-outcome linkages and the means by which multimodal treatment may be mediated by psychosocial processes related to parenting.

Attachment stability and emotional and behavioral regulation from infancy to preschool age.

Relations between attachment and child emotional and behavioral regulation were studied longitudinally in a sample of 223 children from urban, low-income families. Attachment in the Strange Situation at 12 and 18 months was scored using the infant classification system and at 24 months was scored using a preschool classification system. Only modest stability was found in attachment whether within or across classification systems, with the percentage of insecure attachments consistently increasing over time. Results indicated both concurrent and predictive associations with indices of child regulation based on observer ratings or maternal report. However, only the 24-month classification predicted maternal report of externalizing and internalizing behavior problems at age 3.5 years. with additional variance accounted for by selected measures of child emotional and behavior regulation from the same assessment. Attachment security (B) and atypical attachment classifications (D, A/C, and AD) appear to provide the most consistently useful information about child functioning. Results are discussed in terms of continuity and change from the perspective of developmental psychopathology.