Transforming Nursing Education Through Interprofessional Collaborative Innovation: A Project Story.

This project story is about transforming nursing education through interprofessional collaborative innovation to develop and use a complement of technology-based portable simulation devices collectively known as the Healthcare Education Simulation Station. This collection of inexpensive, simulated point-of-care instruments controlled wirelessly by an instructor or simulation operator were developed and field tested by an interdisciplinary team to enhance learning experiences in several configurations, including those using standardized patients and those using static and low-, mid-, and high-fidelity manikins. The core feature of this project story is the collaboration of students and faculty from two unrelated disciplines, nursing and engineering. The story includes a description of the development, field testing, and initial deployment of a simulated pulse oximeter, capnograph, automated sphygmomanometer, cardiac monitor, thermometer, and fetal monitor. Underpinning this project story is Rogers' Diffusion of Innovation theory and how the characteristics of the innovation, the personnel, and the environment worked together to enable this project and the innovation's subsequent diffusion into nursing education. The aspiration to improve learning experiences for students in multiple disciplines was paramount. The desire to acquire high-quality, dynamic educational tools for nursing educators, coupled with an environment that encourages collaboration, led to an innovation that can transform nursing preparation and ultimately improve patient care, while minimizing cost.

Domain-specific cognitive impairment in non-demented Parkinson's disease psychosis.

INTRODUCTION: In Parkinson's disease (PD), psychosis is associated with cognitive impairment that may be more profound in particular cognitive domains. Our goal was to determine whether psychosis in non-demented PD participants is associated with domain-specific cognitive impairment on the Mini-Mental State Exam (MMSE). METHODS: The Morris K. Udall Parkinson's Disease Research Center of Excellence Longitudinal Study at Johns Hopkins is a prospective study that was initiated in 1998. Clinical assessments are conducted at two-year intervals at the Johns Hopkins Hospital. We analyzed data from 137 enrolled participants with idiopathic PD. Psychosis diagnoses were established by psychiatrist interview per DSM-IV criteria. An incident dementia diagnosis resulted in exclusion from analysis for that evaluation and any future evaluations in that participant. We used logistic regression with generalized estimated equations (GEE) to model the time-varying relationship between MMSE subscale scores and psychosis, adjusting for potential confounding variables identified through univariable analysis. RESULTS: Thirty-one unique psychosis cases were recorded among non-demented participants. Fifty total evaluations with psychosis present were analyzed. In multivariable regressions, psychosis was associated with lower scores on the orientation (relative odds ratio, rOR: 0.73; 95% CI: 0.58-0.93; p = 0.011), language (rOR: 0.64; 95% CI: 0.48-0.86; p = 0.003), and intersecting pentagon (rOR: 0.43; 95% CI: 0.20-0.92 p = 0.030) subscales of the MMSE. CONCLUSIONS: In PD, executive dysfunction, disorientation, and impaired language comprehension may be associated with psychosis. Our findings suggest that the corresponding MMSE subscales may be useful in identifying participants with a higher likelihood of developing psychosis. Copyright © 2017 John Wiley & Sons, Ltd.

Exploring the Impact of an Integrated Trauma-Informed HIV and Vocational Intervention for Black/African American Women Living with HIV.

Given the increased recognition of the role of social determinants of health on the prevalence of HIV in the United States, interventions that incorporate and address social determinants of HIV are essential. In response to the health disparities facing Black/African American women living with HIV, HIV activists and mental health specialists developed an innovative integrated HIV prevention and vocational development intervention, Common Threads, that underscores and addresses key economic and other social determinants of health experienced by Black/African American women within a trauma-informed care (TIC) framework. This research study applied grounded theory methods to conduct a qualitative study of Common Threads based on interviews with 21 women who participated in the Common Threads intervention. Participants shared several critical aspects of program components that reflected the TIC principles, endorsing a safe environment, trust building, and a sense of belonging. These components also encouraged transparency and promoted autonomy. Additionally, participants shared perceived program outcomes, including changes of knowledge and skills in four considering work domains (i.e., medical, psychosocial financial/legal resources, and vocational) that facilitate health and vocational development.

Uncomfortably high: Testing reveals inflated THC potency on retail Cannabis labels.

Legal Cannabis products in the United States are required to report THC potency (total THC % by dry weight) on packaging, however concerns have been raised that reported THC potency values are inaccurate. Multiple studies have demonstrated that THC potency is a primary factor in determining pricing for Cannabis flower, so it has an outsized role in the marketplace. Reports of inflated THC potency and "lab shopping" to obtain higher THC potency results have been circulating for some time, but a side-by-side investigation of the reported potency and flower in the package has not previously been conducted. Using HPLC, we analyzed THC potency in 23 samples from 10 dispensaries throughout the Colorado Front Range and compared the results to the THC potency reported on the packaging. Average observed THC potency was 14.98 +/- 2.23%, which is substantially lower than recent reports summarizing dispensary reported THC potency. The average observed THC potency was 23.1% lower than the lowest label reported values and 35.6% lower than the highest label reported values. Overall, ~70% of the samples were more than 15% lower than the THC potency numbers reported on the label, with three samples having only one half of the reported maximum THC potency. Although the exact source of the discrepancies is difficult to determine, a lack of standardized testing protocols, limited regulatory oversight, and financial incentives to market high THC potency likely play a significant role. Given our results it is urgent that steps are taken to increase label accuracy of Cannabis being sold to the public. The lack of accurate reporting of THC potency can have impacts on medical patients controlling dosage, recreational consumers expecting an effect aligned with price, and trust in the industry as a whole. As the legal cannabis market continues to grow, it is essential that the industry moves toward selling products with more accurate labeling.

A systematic review of strategies that increase the recruitment and retention of African American adults in genetic and genomic studies.

BACKGROUND: The National Institutes of Health mandates the inclusion of ancestrally diverse populations into federally funded biomedical and clinical trials research. However, low participation of ethnic minorities in genetics-genomics research continues to be one of the most difficult aspects of conducting human subjects research. OBJECTIVE: This systematic review was conducted to document effective recruitment strategies that increase participation in genetics-genomics studies. METHODS: Extensive literature search strategies were employed to locate and appraise relevant literature reporting original data in which strategies to recruit African American adults into genetics-genomics research studies had been evaluated. RESULTS: Six studies published up to July, 2011 were included. Informal recruitment strategies for initial contact appeared to have a more positive impact on increasing recruitment and participation numbers than formal mailings of letters and postcards. Another key stratagem identified was participant-recruiter like-ancestry. Other methods such as monetary incentives and support of the research project by community leaders were not as effective. CONCLUSIONS: Some strategies bolstered recruitment rates while others did not. More research is needed to determine the efficacy of recruitment strategies with African Americans.

CO2-formatics: how do proteins bind carbon dioxide?

The rising atmospheric concentration of CO(2) has motivated researchers to seek routes for improved utilization, increased mitigation, and enhanced sequestration of this greenhouse gas. Through a combination of bioinformatics, molecular modeling, and first-principles quantum mechanics the binding of carbon dioxide to proteins is analyzed. It is concluded that acid/base interactions are the principal chemical force by which CO(2) is bound inside proteins. With respect to regular secondary structural elements, beta-sheets show a marked preference for CO(2) binding compared to alpha-helices. The data also support the inference that while either or both oxygens of CO(2) are generally tightly bound in the protein environment, the carbon is much less "sequestered." First principles and more approximate modeling techniques are assessed for quantifying CO(2) binding thermodynamics.

Decisions to participate in fragile X and other genomics-related research: Native American and African American voices.

UNLABELLED: The lack of adequate minority representation, including Native-Americans (NA) and African-Americans (AA), in health related research is well documented. Nowhere is this truer than in the area of genomics-related research, which is especially troubling as NA and AA have some of the highest rates of overall morbidity and mortality due to genetic diseases. OBJECTIVES: The purpose of this study is to explore factors associated with the under representation of NA and AA adults in genetic research including: (1) decision barriers, (2) the influence of health care networks, (3) recruitment preferences, and (4) health conditions. METHODS: Eight focus groups were conducted, each by led by individuals who shared racial/cultural identification with participants. Adherence to tenants of Community Based Participatory Research (CBPR) was maintained. Qualitative data were analyzed using NVIVO program analyses and the constant comparative method. RESULTS: Themes supported the efficacy of CBPR to help demolish barriers while facilitating a willingness to participate in genetics-related research. CONCLUSIONS: Community-based approaches may enhance representation of minorities in genomics-related research crucial to eliminating health disparities.

The relationship between maternal adiposity during pregnancy and fetal kidney development and kidney function in infants: the Gomeroi gaaynggal study.

Maternal obesity during pregnancy has a detrimental impact on offspring renal development and function. This is pertinent to Indigenous Australians as they are twice as likely as non-Indigenous Australians to develop chronic kidney disease (CKD). The aim of this study was to examine whether there was an association between maternal adiposity and fetal kidney growth in late gestation (>28 weeks) and kidney function in infants, <2.5 years of age, from the Gomeroi gaaynggal cohort. Pre-pregnancy body mass index (BMI) was recorded at the first prenatal visit and maternal adiposity indicators (percent body fat and visceral fat area) measured at >28 weeks gestation by bioelectrical impedance analysis. Fetal kidney structure was assessed by ultrasound. Renal function indicators (urinary albumin:creatinine and protein:creatinine) were measured in infants from a spot urine collection from nappies. Multiple linear regression and multi-level mixed effects linear regression models with clustering were used to account for repeated measures of urine. 147 mother-child pairs were examined. Estimated fetal weight (EFW), but not fetal kidney size, was positively associated with maternal adiposity and pre-pregnancy BMI. When adjusted for smoking, combined kidney volume relative to EFW was negatively associated with maternal percentage body fat. Infant kidney function was not influenced by maternal adiposity and pre-pregnancy BMI (n = 84 observations). Current findings show that Indigenous babies born to obese mothers have reduced kidney size relative to EFW. We suggest that these babies are experiencing a degree of glomerular hyperfiltration in utero, and therefore are at risk of developing CKD in later life, especially if their propensity for obesity is maintained. Although no impact on renal function was observed at <2.5 years of age, long-term follow-up of offspring is required to evaluate potential later life impacts.

Checklist assessments of FMR1 gene mutation phenotypes.

BACKGROUND: Fragile X Syndrome (FXS) caused by the mutation of the FMR1 gene, is the most common inherited cause of intellectual disability, autism, and other psychoneurological disorders. Timely identification of young children with social or emotional challenges is urged in that emotional and social problems are often overlooked until problems reach serious magnitudes. Reliable methods of screening children at an earlier age are crucial to early intervention. PURPOSE: The purpose of this article is to illuminate phenotypic characteristics of FXS and the role that the use of screening tools may play to help interdisciplinary health and human development professionals to empower parents as frontline screeners to seek early diagnosis and implement effective early intervention. METHODS: This article reviews what is known about phenotypic characteristics of the FMR1 gene mutation. In addition, eight screening tools in use to screen for the FMR1 gene mutation are compared with the author-developed screening tool, the Biopsychiosocial Screening Inventory for Fragile X Syndrome (BIPSSI-FX). CONCLUSIONS: The BIPSSI-FX, a parent response tool, is a conduit by which the primary caregivers may contribute to an earlier diagnosis. It is the only parent response tool, based on research evidence, designed to tap the wealth of knowledge parents possess about subtle developmental characteristics of very young children with FXS.

Markers of impaired motor and cognitive volition in Parkinson's disease: Correlates of dopamine dysregulation syndrome, impulse control disorder, and dyskinesias.

INTRODUCTION: Dopaminergic therapy in Parkinson's disease (PD) can be associated with both motoric (e.g., dyskinesias) and neuropsychiatric adverse effects. Examples of the latter include Dopamine Dysregulation Syndrome (DDS) and impulse control disorder (ICD), which are separate but related behavioral/psychiatric complications of treatment in PD. Dysregulation of volition characterizes both dyskinesias and DDS/ICD; thus, we analyzed potential disease-related correlates in a large PD cohort. METHODS: We analyzed cross-sectional data from 654 participants collected through the NINDS Parkinson's Disease Biomarkers Program. DDS/ICD symptoms and dyskinesias were assessed using the Movement Disorders Society (revised) Unified Parkinson's Disease Rating Scale. Potential associated variables were selected from PD-validated or PD-specific scales of neuropsychiatric or motoric status. Multivariable models with DDS/ICD or dyskinesia presence outcomes were produced with backward stepwise regression to identify factors independently associated with DDS/ICD and/or dyskinesias. RESULTS: Fifty-three (8.1%) participants endorsed DDS and/or ICD symptoms and 150 (22.9%) were dyskinetic. In multivariable analysis, psychosis was independently associated with both dyskinesias (p = 0.006) and DDS/ICD (p < 0.001). Unpredictable motor fluctuations (p = 0.026) and depression (p = 0.023) were also associated with DDS/ICD; female sex (p = 0.025), low tremor score (p = 0.001) and high akinesia-rigidity score (p < 0.001) were associated with dyskinesias. CONCLUSIONS: Our findings suggest that psychosis may be an important marker of impaired volition across motor and cognitive domains. Unpredictable motor fluctuations, psychosis, and depression may together comprise a phenotypic profile of patients at increased risk for DDS/ICD. Similarly, dyskinetic PD patients should be closely monitored for psychotic symptoms and treated appropriately.

Onset and Remission of Psychosis in Parkinson's Disease: Pharmacologic and Motoric Markers.

BACKGROUND: Psychosis is among the most disabling complications of Parkinson's disease (PD). The chronicity of PD psychosis remains understudied and the relative importance of dopaminergic therapy versus the disease process itself in engendering psychosis remains unclear. OBJECTIVES: To examine pharmacologic and motoric correlates of PD psychosis onset and remission in a longitudinally monitored PD cohort. METHODS: We analyzed data from 165 participants enrolled in a longitudinal PD study through the Morris K. Udall Parkinson's Disease Research Center of Excellence at Johns Hopkins University. Evaluations included formal psychiatric assessment and were conducted at two-year intervals. Regression with generalized estimated equations (GEE) was used to produce unadjusted and adjusted estimates for time-varying longitudinal associations between psychosis and putative risk factors. RESULTS: Sixty-two participants (37.6%) were diagnosed with psychosis during at least one evaluation. Of forty-nine participants with psychosis followed over multiple evaluations, 13 (26.5%) demonstrated remission despite significant Hoehn & Yahr stage increase (p=0.009); two of these cases later relapsed. Multivariable regression with GEE identified dementia diagnosis, akinesia-rigidity, anticholinergic usage, and levodopa-carbidopa dose to be significantly associated with psychosis, while disease duration was not. A sub-analysis of 30 incident psychosis cases suggested that dopamine agonist dose was lowered after psychosis onset with a compensatory increase in levodopa-carbidopa dosage. CONCLUSIONS: Our findings suggest that in the context of standard therapy, PD-related psychotic disorder can remit at a frequency of approximately 27%. Additionally, akinetic-rigid motor impairment was more strongly associated with psychosis than disease duration, independent of cognitive impairment and medications.

Assessment of Fetal Kidney Growth and Birth Weight in an Indigenous Australian Cohort.

Introduction: Indigenous Australians experience higher rates of renal disease and hypertension than non-Indigenous Australians. Low birth weight is recognized as a contributing factor in chronic disease and has been shown to increase the risk of renal failure in adulthood. A smaller kidney volume with fewer nephrons places an individual at risk of hypertension and renal failure. Indigenous Australians have fewer nephrons than non-Indigenous Australians. In this study, intrauterine fetal and kidney growth were evaluated in 174 Indigenous Australian babies throughout gestation in order to record and evaluate fetal growth and kidney size, within a population that is at high risk for chronic illness. Methods: Pregnant women that identified as Indigenous, or non-Indigenous women that were pregnant with a partner who identified as an Indigenous Australian were eligible to participate. Maternal history, smoking status, blood and urine samples and fetal ultrasounds were collected throughout pregnancy. Fetal kidney measurements were collected using ultrasound. Statistical analysis was performed using the Stata 14.1 software package. Results: 15.2% of babies were born prematurely. 44% of the mothers reported smoking in pregnancy. The median birth weight of this cohort was 3,240 g. Male fetuses had higher kidney to body weight ratios than female fetuses (P = 0.02). The birth weights of term neonates whose mothers smoked during pregnancy were lower (327 g, P < 0.001) than the birth weights of term babies from non-smoking mothers. The kidney volumes of babies whose mothers smoked were also smaller (P = 0.02), but were in proportion to body weight. Conclusion: In this cohort of Indigenous women smoking was associated with both increased number of preterm births and with a reduction in birth weights, even of term infants. Since kidney volume is a surrogate measure of nephron number and nephrogenesis is complete at birth, babies whose mothers smoked during pregnancy must have fewer nephrons than those from non-smoking mothers. Previous studies have shown that glomerular filtration rate is not related to birth weight, thus infants with smaller kidney volumes are hyperfiltering from birth and therefore are likely to be more susceptible to early onset renal disease in later life.

Cortisol response to family interaction as a predictor for adjustment.

Emerging adult (EA) cortisol response during family interaction predicts change in EA anxious behavior during the transition to college (Johnson & Gans, in press). In the present study, we take an initial step toward integrating family systems research and physiology by including assessment of EA salivary cortisol collected during a triadic (mother-father-EA offspring) family interaction task. Emerging adults (N = 101) between the ages of 17 and 19 were assessed at 3 time points across their first college year: the summer before college, Fall and Spring semesters. Two parents accompanied the emerging adult child to the summer assessment; all family members provided 4 saliva samples each at 20-min intervals. Later assessments of emerging adults included measures of internalizing behaviors. EA's cortisol secretion patterns during family interaction predict observed and self-reported family relatedness, as well as patterns of internalizing behavior during the college transition. Observed family functioning appeared to moderate the relationship between EA cortisol response during family interaction and anxious behavior when adapting to college. Different patterns of results emerged, however, for EA men and women. The approach taken by this study provides a first step toward understanding how interrelationships among elements of physiology and family functioning contribute to later adjustment. (PsycINFO Database Record

Parent cortisol and family relatedness predict anxious behavior in emerging adults.

Emerging-adult cortisol response during family interaction predicts change in emerging-adult anxious behavior during the transition to college (Gans & Johnson, in press). In the present study, we take an additional step toward integrating family systems research and physiology by including assessment of parent physiology. We collect salivary cortisol from parents and emerging adults during triadic family interaction. Emerging adults (N = 101) between the ages of 17 and 19 years were assessed at 3 time points across their first college year: the summer before college and the Fall and Spring semesters. Two parents accompanied the emerging-adult child to the summer assessment; all family members provided 4 saliva samples each at 20-min intervals. Later assessments of emerging adults included measures of internalizing behaviors. Parents' cortisol secretion patterns during family interaction predict their emerging-adult children's cortisol secretion pattern, parent perceptions of the family environment, and emerging-adult children's internalizing behavior during the college transition. Different patterns of results emerged for mothers' and fathers' cortisol response to family interaction and for families with sons or with daughters. The approach taken by this study provides a first step toward understanding how interrelationships among elements of physiology and family functioning contribute to adjustment during major life transitions. (PsycINFO Database Record

Gait function and locus coeruleus Lewy body pathology in 51 Parkinson's disease patients.

INTRODUCTION: Gait impairment in Parkinson's Disease (PD) is often severely disabling, yet frequently remains refractory to treatment. The locus coeruleus (LC) has diffuse noradrenergic projections that are thought to play a role in gait function. Enhancement of norepinephrine transmission may improve gait in some PD patients. We hypothesized that the severity of PD pathology, and more specifically, Lewy bodies and neuronal loss in the LC, would correlate with the severity of gait dysfunction in PD. METHODS: Autopsy data from 51 patients, collected through the Morris K. Udall Parkinson's Disease Research Center, were correlated with clinical gait-related measures, including individual Unified Parkinson's Disease Rating Scale (UPDRS) Part II and III questions, total UPDRS Part III scores, and timed up-and-go speed (TUG). RESULTS: Neither the presence nor degree of Lewy body pathology in the LC on autopsy was associated with a higher UPDRS part III gait score. LC tau deposition and frontal Lewy body deposition were not correlated with any of the assessed gait measures. The degree of Lewy body pathology, independent of Braak stage, was positively associated with the severity of motor symptoms overall (UPDRS Part III total score). CONCLUSION: Neither the degree of Lewy body nor tau pathology in the LC is associated with severity of gait disorders in PD. This finding may have implications for targeted noradrenergic therapies in patients with refractory gait disorders.

Palliative care needs of cancer patients in U.S. nursing homes.

BACKGROUND: Increasingly, nursing homes are the place of care for older Americans with cancer. Yet, few studies has characterized the quality of care for this growing population. OBJECTIVE: Characterize the scope and quality of cancer care in U.S. nursing homes. DESIGN: Secondary analysis of the national repository of the Minimum Data Set (MDS) SETTING AND SUBJECTS: Nursing home residents noted to have cancer diagnosis on the MDS. RESULTS: Of the 190,769 New Hampshire residents (8.8%) with a cancer diagnosis, 1 in 4 had weight loss (23.4%), received intravenous medications (27.7%), or used oxygen (25.4%). Overall, 45.3% had a do-not-resuscitate (DNR) order, with state variations ranging from 17.8% (New Jersey) to 70.5% (Wisconsin). More than 1 in 10 (12.0%) were defined as terminally ill, although only 29.3% of these received hospice services. Among patients with pain, half of those who survived to a second assessment had persistent, severe pain (51.3%), which also varied by state, ranging from 43.3% (Iowa) to 65.8% (Nevada). Active treatment was rare; less than 5% received chemotherapy or radiotherapy. However, 15.5% had parenteral and/or tube feedings for nutrition. Approximately, 1 in 10 New Hampshire residents had advanced cancer. CONCLUSION: Our findings suggest important opportunities to improve the quality of cancer care for older adults.

Acute right atrial strain: regression in normal as well as abnormal P-wave amplitudes with treatment of obstructive pulmonary disease.

OBJECTIVE: To evaluate right atrial (RA) "strain" as reflected by changes in P-wave amplitude and vector in patients with COPD immediately before and immediately after beginning treatment of exacerbations. BACKGROUND: P-pulmonale (frequently temporary, reflecting acute RA strain) occurs under a variety of circumstances, including COPD. Emergency room (ED) ECGs in patients with acute exacerbations of COPD have suggested that P-pulmonale (P waves > or = 2.5 in leads II, III, and aVF) tends to resolve subsequent to acute treatment. RA strain is defined as a response to RA stress (probably transient pressure rise and/or acute RA enlargement) in patients with COPD. Since P-pulmonale occurs in a small minority of patients with COPD, we investigated dynamic changes in size and mean vector (axis) of all frontal plane P waves in the ED vs the immediate subsequent ward ECG in patients with acute exacerbations of COPD. METHODS: We prospectively compared P-wave amplitude in the ED with the first in-patient ECG in 50 consecutive patients with acute exacerbations of COPD and in 20 consecutive nonpulmonary control patients, analyzing only ECGs showing sinus rhythm and in which P waves were clearly recorded. Despite using a calibrated magnifying graticule, it was difficult to interpret a dynamic change if the initial ED ECG had P-wave amplitude < 1.5 mm in leads II and aVF. We selected lead II because it usually has the largest frontal plane P waves and also aVF to reflect the relative verticality of the mean P vector (axis). We performed a matched-pair analysis to compare the equality of means. RESULTS: Of the patients with COPD, only seven patients (14%) had classical P-pulmonale on the ED ECG. Forty-eight of 50 consecutive patients (96%) demonstrated a decrease in P-wave amplitude between ED and subsequent ward ECGs. Two patients showed no change. The mean differences of P-wave amplitude between ED and ward ECGs in lead II was 0.78 mm, and that in lead aVF was 0.8 mm. The difference of the mean P-axis between ED and ward ECGs was - 5.24 degrees (p < 0.0001 for all three measurements). There was no P-wave amplitude change in the control group between ED and ward ECGs. CONCLUSIONS: P-wave amplitude in patients with COPD decreases once an acute exacerbation subsides. Thus, P-wave amplitude and vector are dynamic and could reflect reduced RA strain. We question the traditional (1935) absolute cutoff of 2.5 mm for P-pulmonale as of limited value due to insensitivity, hence inappropriate for what this investigation demonstrates to be a continuous variable.

Linking changes in whole family functioning and children's externalizing behavior across the elementary school years.

This study used observational assessments of 57 2-parent families working and playing together when their eldest child was in kindergarten and again in Grade 4 to identify distinct patterns of family functioning derived from structural family systems theory for (a) cohesive, (b) separate, and (c) triangulated families. Little consistency in family type from early to middle childhood was indicated. No significant mean differences were found in teacher reports of children's externalizing behavior in their Grade 1 classrooms for children in cohesive or triangulated families. Fourth graders in triangulated families were seen as more aggressive at school than were their peers in cohesive or separate families. Changes in observed family functioning across a 4-year period (kindergarten to Grade 4) were also systematically linked to changes in teachers' ratings of children's externalizing behavior from Grades 1 to 4.