The long and winding road: Pathways from basic research to implementation and evaluation.

In this article, we celebrate Dante Cicchetti's extensive contributions to the discipline of developmental psychopathology. In his seminal article, he articulated why developmental psychopathology was imperative to create research portfolios that could inform the causes, consequences, and trajectories for adults often initiated by early lived experiences (Cicchetti, 1984). In this three-part article, we share our transdisciplinary efforts to use developmental psychopathology as a foundational theory from which to develop, implement, and evaluate interventions for populations who experienced early adversity or who were at risk for child abuse and neglect. After describing interventions conducted at Mt. Hope Family Center that spanned over three decades, we highlight the criticality of disseminating results and address policy implications of this work. We conclude by discussing future directions to facilitate work in developmental psychopathology. Currently, one of three national National Institute of Child Health and Human Development-funded child abuse and neglect centers, we look forward to continuing to build upon Dante's efforts to disseminate this important work to improve society for our children, our nation's often most vulnerable and forgotten citizens.

Pilot examination of independent and interactive effects of maltreatment and neighborhood risk on child attachment.

Elucidating the influence of microsystem and exosystem factors on development is an important goal of developmental psychopathology. This study examined the effects of maltreatment and neighborhood risk on child-caregiver attachment. Maltreatment records, neighborhood risk indices, and Strange Situation data were collected from a diverse sample of 170 four-year-old children and their caregivers. Relative contributions of maltreatment, neighborhood risk, and their interaction on attachment insecurity and disorganization were explored via latent moderation. Maltreated children demonstrated higher rates of insecure attachment, but not attachment disorganization, independent of neighborhood risk. Controlling for maltreatment, preliminary results suggested no effects of neighborhood risk on attachment. Findings support prior research that has identified maltreatment as a salient risk to the formation of secure attachment relationships. However, results add heterogeneity to the limited research investigating effects of neighborhood on attachment. Overall, this study highlights the importance of examining multilevel ecological risk in relation to attachment relationship development.

Transforming the paradigm of child welfare.

As a founder of the field of applied developmental psychology, Dr Edward Zigler promoted public policy that translated scientific knowledge into real-world programs to improve the outcomes of high-risk children and families. Many researchers, practitioners, and public policy proponents have sought to carry on his legacy through integration of empirical research, evidence-based prevention and intervention, and advocacy to address a range of challenges facing families with young children. To advance the field of child maltreatment, a multidisciplinary team of investigators from the Universities of Rochester and Minnesota partnered with the Eunice Kennedy Shriver National Institute of Child Health and Human Development to create the Translational Research that Adapts New Science FOR Maltreatment Prevention Center (Transform). Building on state-of-the-art research methodologies and clinical practices, Transform leverages theoretically grounded research and evidence-based interventions to optimize outcomes for individuals across the life span who have experienced, or may be at risk for, maltreatment. Inspired by the work of Dr Zigler, Transform is committed to bridging science and real-world practice. Therefore, in addition to creating new science, Transform's Community Engagement Core provides translational science to a broad audience of investigators, child-serving professionals, and parental and governmental stakeholders. This article describes Transform's purpose, theoretical framework, current activities, and future directions.

Building Healthy Children: A preventive intervention for high-risk young families.

The Building Healthy Children (BHC) home-visiting preventive intervention was designed to provide concrete support and evidence-based intervention to young mothers and their infants who were at heightened risk for child maltreatment and poor developmental outcomes. This paper presents two studies examining the short- and long-term effectiveness of this program at promoting positive parenting and maternal mental health, while preventing child maltreatment and harsh parenting. It also examines the intervention's sustained effect on child symptomatology and self-regulation. At baseline, young mothers and their infants were randomly assigned to receive BHC or Enhanced Community Standard. Families were assessed longitudinally across four time points. Data were also collected from the child's teacher at follow-up. Mothers who received BHC evidenced significant reductions in depressive symptoms at mid-intervention, which was associated with improvements in parenting self-efficacy and stress as well as decreased child internalizing and externalizing symptoms at postintervention. The follow-up study found that BHC mothers exhibited less harsh and inconsistent parenting, and marginally less psychological aggression. BHC children also exhibited less externalizing behavior and self-regulatory difficulties across parent and teacher report. Following the impactful legacy of Dr. Edward Zigler, these findings underline the importance of early, evidence-based prevention to promote well-being in high-risk children and families.

Intimate partner violence as a mechanism underlying the intergenerational transmission of maltreatment among economically disadvantaged mothers and their adolescent daughters.

Child maltreatment represents a pervasive societal problem. Exposure to maltreatment is predictive of maladjustment across development with enduring negative effects found in adulthood. Compelling evidence suggests that some parents with a history of child abuse and neglect are at elevated risk for the maltreatment of their own children. However, a dearth of research currently exists on mediated mechanisms that may underlie this continuity. Ecological and transactional theories of child maltreatment propose that child maltreatment is multiply determined by various risk factors that exist across different ecological systems. Intimate partner violence (IPV) often co-occurs with child maltreatment and may represent a pathway through which risk for child abuse and neglect is transmitted across generations within a family. Informed by theories on the intergenerational transmission of child maltreatment and utilizing a community-based, cross-sectional sample of 245 racially and ethnically diverse, low-income mothers and daughters, the objective of this study was to investigate IPV as a propagating process through which risk of child abuse and neglect is conferred from parent to child. We found evidence suggesting that mothers' history of maltreatment is associated with both their IPV involvement and their adolescent daughters' maltreatment victimization (with exposure to IPV as a maltreatment subtype excluded for clarity). Maternal IPV also partially accounted for the continuity of maltreatment victimization from mother to adolescent. A secondary analysis that included the adolescent's own engagement in dating violence provided compelling but preliminary evidence of the emergence of a similar pattern of relational violence, whereby adolescent girls with maltreatment histories were likewise involved in abusive intimate relationships. Future directions and clinical implications of these findings are discussed.

A multilevel prediction of physiological response to challenge: Interactions among child maltreatment, neighborhood crime, endothelial nitric oxide synthase gene (eNOS), and GABA(A) receptor subunit alpha-6 gene (GABRA6).

Physiological response to stress has been linked to a variety of healthy and pathological conditions. The current study conducted a multilevel examination of interactions among environmental toxins (i.e., neighborhood crime and child maltreatment) and specific genetic polymorphisms of the endothelial nitric oxide synthase gene (eNOS) and GABA(A) receptor subunit alpha-6 gene (GABRA6). One hundred eighty-six children were recruited at age 4. The presence or absence of child maltreatment as well as the amount of crime that occurred in their neighborhood during the previous year were determined at that time. At age 9, the children were brought to the lab, where their physiological response to a cognitive challenge (i.e., change in the amplitude of the respiratory sinus arrhythmia) was assessed and DNA samples were collected for subsequent genotyping. The results confirmed that complex Gene × Gene, Environment × Environment, and Gene × Environment interactions were associated with different patterns of respiratory sinus arrhythmia reactivity. The implications for future research and evidence-based intervention are discussed.

Let's Stop the Pain: A Trauma-Informed Care Approach to Pediatric Vaccination.

Exposure to pain during routine vaccinations and other injections can cause lifelong anxiety for pediatric patients that may persist into adulthood. Teaching pediatric providers and staff to use intentional and humane approaches to pain management, including distraction, positioning, and use of purposeful language can help to mitigate these fears. We share our experience with assessing pre and post changes to pain management in our pediatric outpatient setting caring for underserved patients and implementing a trauma-informed care approach.

Investigating the associations between prenatal exposure to substances and intergenerational maltreatment and symptoms of psychopathology for adolescent girls from families with low income.

BACKGROUND: Adolescent girls whose families experience poverty are more vulnerable to psychopathology, and it is vital to investigate biopsychosocial factors contributing to mental health functioning. OBJECTIVE: To test associations between prenatal exposure to substances, intergenerational maltreatment, and adolescent mental health symptoms. PARTICIPANTS AND SETTING: Baseline data were used from a randomized controlled trial testing the efficacy of Interpersonal Psychotherapy (IPT-A) for depression among girls with and without maltreatment exposure. Adolescents (Aged 13-16; 63.5 % Black/African-American, 21.0 % White, 15.57 % other racial identity; 12.57 % Latina/x) were recruited from families experiencing financial adversity (income <200 % poverty threshold). METHODS: Adolescent maltreatment status was determined by using multiple sources (child protective service records, parental report, and adolescent report). Mothers reported on prenatal substance exposure, experiences of maltreatment in their own childhood, and rated adolescent internalizing and externalizing symptoms. Latent Class Analysis was used to determine common patterns of prenatal substance exposure (tobacco, alcohol, marijuana, and cocaine). Structural Equation Modeling was used to evaluate associations between maltreatment in two generations, prenatal exposure to substances, and adolescent mental health symptoms. RESULTS: Two profiles of prenatal substance exposure emerged: one typified by low substance exposure (92.8 %), and one with moderate to high substance exposure (7.2 %). Both prenatal substance exposure and maternal history of maltreatment were associated with adolescent maltreatment, which in turn, was associated with greater adolescent externalizing symptoms. Parental history of maltreatment was directly associated with greater adolescent internalizing symptoms. CONCLUSION: Prenatal exposure to substances and intergenerational maltreatment each confer risk for mental health symptoms in adolescent girls.

A Longitudinal Examination of Child Maltreatment Dimensions, Emotion Regulation, and Comorbid Psychopathology.

Childhood maltreatment is a toxic stressor that occurs in the family context and is related to adverse outcomes including elevations in internalizing symptomology and externalizing symptomology. In the present study, we tested the role of threat and deprivation dimensions of child maltreatment in the etiology of comorbid psychopathology in emerging adulthood. Additionally, we investigated emotion regulation and emotion lability/negativity as mechanisms underlying the relationship between child maltreatment dimensions and emerging adult psychopathology. To address these aims, we used a longitudinal sample of emerging adults (N = 413, Mage = 19.67, 78.0% Black, 51.1% female) who had previously participated in research assessments at age 10-12. Using a person-centered approach with latent profile analysis, we identified three classes of emerging adulthood psychopathology characterized by different levels of symptom severity and comorbidity between internalizing and externalizing symptoms. Emerging adults who experienced deprivation only, compared to those who were not maltreated, were more likely to belong to a comorbid and severe psychopathology class versus the other identified psychopathology classes. There was also a significant indirect pathway from experiences of both threat and deprivation to a high externalizing class via emotion lability/negativity. Our results contribute to current models of childhood adversity and psychopathology and have implications for interventions to prevent psychopathology among emerging adults exposed to child maltreatment.

The Association Between Patterns of Trauma Exposure, Family Dysfunction, and Psychopathology Among Adolescent Females With Depressive Symptoms From Low-Income Contexts.

Distinguishing profiles of trauma exposure among low-income adolescent females with depressive symptoms is important for understanding comorbidity, family relationships, and treatment. Specifically, child maltreatment is essential to examine in comparison to other traumas. Participants included 170 adolescent females (65.3% Black; 21.2% White; 13.5% other race; 14.1% Latina/x) with depressive symptoms and their primary caregiver from low-income families. Latent class analysis (LCA) identified three trauma classes. Probabilities of endorsing different subtypes of maltreatment (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse), number of subtypes of maltreatment, and non-maltreatment traumas (accident, experiencing or witnessing physical assault, death or injury of loved one, medical trauma) varied among groups. Higher levels of family dysfunction and traumatic stress symptoms were reported in both classes with maltreatment exposure as compared to the class with only non-maltreatment trauma exposure. Findings have implications for family-focused interventions for maltreated adolescent females with depressive symptoms from low-income contexts.

Psychological maltreatment: An operationalized definition and path toward application.

Psychological maltreatment (PM) of children has been difficult to define and even more challenging to operationalize consistently. This fact contributes to child PM being under-recognized and under-addressed by professionals that interact with children with mental health, behavioral, and developmental issues; and by systems such as child welfare, clinical and judicial systems. In this paper, we propose a definition of child PM that is both overarching and operationalized in a manner that will support consistent, fair, and unbiased application in applied contexts. The operationalized definition delineates the nature of caregiver acts that can amount to PM, as well as the level of experienced and potential impact of said act (s) that constitute PM. We detail our rationale for the definition. We discuss the need for field trials to establish the utility of the definition. We explain the necessary training and systems that would be required for the definition to be consistently and accurately applied. We believe that this definition has the potential to substantially enhance systems' abilities to recognize and address child PM, and thereby enhance children's and families' wellbeing.

The Development of a Mental Health Program for Unaccompanied Minors in the United States.

The unique needs of unaccompanied children (UC) and unaccompanied refugee minors (URM) often make it challenging for them to engage in traditional mental health services. This paper describes the development and implementation of a mental health program for UC and URM using a collaborative approach with key stakeholders. In the Exploration phase, we conducted an assessment of youths' mental health needs, barriers to, and recommendations for care through discussions with community partners. Next, we describe the Preparation phase in which we designed the program around three major domains: 1) training and consultation, 2) cross-sector collaboration, and 3) direct services. Discussion of the Implementation phase includes a description of youth served and program materials. Finally, the Sustainment phase focuses on recommendations for best practice informed by successes and challenges of program implementation. Findings have implications for future mental health programming for UC/URM.

Child maltreatment, recent stressful life events, and suicide ideation: A test of the stress sensitivity hypothesis.

BACKGROUND: Exposure to child maltreatment is a well-known risk factor for suicide ideation among adolescents. Recent stressful life events may also contribute to this risk. However, the association between these risk factors is unclear in the etiology of suicide ideation for adolescents from socio-economically disadvantaged backgrounds. OBJECTIVE: The present study tested the stress generation and stress sensitivity hypotheses in relation to child maltreatment, recent stressful life events (in the past year), and suicide ideation (in the past two weeks). PARTICIPANTS AND SETTING: We utilized a sample of diverse, socioeconomically disadvantaged, depressed adolescent girls (N = 175) who were part of a depression treatment intervention. RESULTS: Child maltreatment was significantly associated with adolescent suicide ideation, ß = .40, p < .001. Results supported the stress sensitivity hypothesis, in that exposure to interpersonal stressors in the past year exacerbated the association between child maltreatment and adolescents' suicide ideation, ß = .18, p < .05. We found evidence for a protective factor, cognitive reappraisal, in the association between stressful life events and suicide ideation, ß = -.15, p < .05. CONCLUSIONS: These findings have several implications for clinical practice and suicide prevention with adolescent girls, and contribute to the extant literature on the role of chronic and acute stress in the etiology of adolescent suicide ideation.

Patterns of dating violence moderate the effect of child maltreatment on suicide risk among disadvantaged minority female adolescents with depressive symptoms.

PURPOSE: Childhood maltreatment is associated with increased suicide risk. However, not all maltreated children report self-injurious thoughts and behaviors, highlighting the presence of other risk factors. Notably, adolescent dating violence (ADV) and child maltreatment are highly comorbid, with ADV also linked to suicide risk among adolescents. Current research further suggests that distinct patterns of ADV involvement are differentially related to adolescent mental health. To date, it is unknown whether differences in ADV patterns moderate changes in suicide risk for adolescents with and without a maltreatment history. This study aims to advance the literature by identifying patterns of ADV in a unique sample of adolescents and by determining the differential association between maltreatment and suicidal ideation and non-suicidal self-harming behaviors based on ADV profiles. METHODS: Participants were racially and ethnically diverse low-income non-treatment-seeking adolescent females with elevated depressive symptoms, ages 13-16 (N=198). RESULTS: Using latent class analysis, we found support for a 3-class model of dating violence: adolescent females without ADV involvement, those in relationships with mutual verbal abuse, and those in romantic relationships with multiple and more severe forms of ADV, such as verbal abuse and physical violence. A series of latent class moderation models indicated that the effect of child maltreatment on suicidal ideation significantly differed based on ADV class membership. CONCLUSION: Results highlight the importance of considering different ADV patterns and maltreatment as interactive risk factors for increased self-injurious thoughts and behaviors. Intervention and prevention approaches relevant to maltreated youths are discussed for families and practitioners.

Longitudinal Outcomes of Child Parent Psychotherapy: Response to Commentaries.

In response to the commentaries provided by Chu et al. (2020), Harmon et al. (2020), and McMahon & Maxwell (2020) on our longitudinal follow-up of Child-Parent Psychotherapy (CPP) with mothers with depression and their children, we focus on two domains: accessibility and scalability of CPP and identifying empirically supported mechanisms of change in attachment intervention research. In considering the accessibility and scalability of CPP, we discuss issues related to attrition, length of intervention, and implementation with caregivers with depression. Our discussion of mechanisms of change in attachment interventions explores active comparison conditions, theorized mediators, intervention modalities, assessment methods, and longitudinal research designs. This conversation is intended to highlight important areas for future research in the field of attachment interventions, with the goal of informing clinical and systems-level policies and practices.

The Moderating Role of Child Maltreatment in Treatment Efficacy for Adolescent Depression.

Adolescent girls are at heightened risk of depression, and because adolescent depression may initiate a negative developmental cascade, intervention early in adolescence has potential for altering a negative developmental trajectory. Identifying risk factors that impact response to intervention may inform decisions about the type of treatment to provide for adolescent girls with depression. Understanding moderators of outcomes in evidence-based treatment is critical to the delivery of timely and effective interventions. Matching patients effectively with optimal intervention will not only expedite the alleviation of patients' distress, but will also reduce unnecessary time and resources spent on less advantageous interventions. The current investigation examines the efficacy of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) in a racially and ethnically diverse sample of 120 low-income adolescent girls age 13-15 with and without histories of child maltreatment. Adolescent and parent report of depressive symptoms were assessed at the beginning and end of treatment and a diagnosis of subsyndromal symptoms of depression or depression were required for purposes of inclusion. Results indicated that among adolescent girls who had experienced two or more subtypes of maltreatment, IPT-A was found to be more efficacious than Enhanced Community Standard (ECS) treatment. Importantly, when the subtype of maltreatment experienced was further probed, among girls with a history of sexual abuse, we found preliminary evidence that IPT-A was significantly more effective than ECS in reducing depressive symptoms, and the effect size was large. Thus, if a history of maltreatment is present, especially including sexual abuse, specifically addressing the interpersonal context associated with depressive symptoms may be necessary.

Child maltreatment and trajectories of personality and behavioral functioning: implications for the development of personality disorder.

This study investigated the longitudinal impact of maltreatment parameters on personality processes and maladjustment and prospective relationships between personality trajectory classes and subsequent maladjustment outcomes. The sample involved maltreated (n = 249) and nonmaltreated (n = 200) children followed longitudinally between ages 6 and 10. Growth mixture modeling indicated multifinality in personality development depending on the risk status (i.e., maltreated vs. nonmaltreated). Two trajectory classes of ego resiliency were identified for maltreated children: those who showed a declining trajectory exhibited greater maladjustment. In contrast, three trajectory classes of ego control were identified for nonmaltreated children; the subgroups showing increases in ego undercontrol or dramatic changes from high ego undercontrol to high ego overcontrol exhibited poor adjustment. Experiencing multiple maltreatment subtypes and physical/sexual abuse were related to higher levels of ego undercontrol and externalizing symptomatology, whereas early onset of maltreatment was associated with the low and decreasing trajectory of ego resiliency and higher levels of internalizing symptomatology. The findings suggest that ego resiliency and ego control, personality processes related to self-regulation, may be important factors in identifying distinct pathways to later personality disorders as well as pathways to resilient functioning.

Mother-Daughter Interpersonal Processes Underlying the Association Between Child Maltreatment and Adolescent Suicide Ideation.

OBJECTIVE: The aim of the present study was to investigate whether mother-daughter relationship quality and mother-daughter conflict represent mechanisms underlying the association between child maltreatment and adolescent passive or active suicide ideation. METHOD: The sample included 164 socioeconomically disadvantaged depressed adolescent girls and their mothers (adolescents: mean age = 14.00 years; 66.3% African-American, 21.3% white, 14.0% Latina). Structural equation modeling was used to test three simultaneous and distinct mediating pathways linking child maltreatment to adolescent suicide ideation: (1) mother-daughter relationship quality, (2) mother-daughter conflict, and 3) adolescent depressive symptoms. RESULTS: Consistent with the interpersonal-psychological theory of suicide (Joiner, Why people die by suicide, 2005, Harvard University Press, Cambridge, MA), both mother-daughter relationship quality and mother-daughter conflict mediated the effect of child maltreatment on adolescent suicide ideation, over and above the significant depressive symptoms mediational pathway. CONCLUSIONS: These findings advance our understanding of why individuals who experienced child maltreatment are at risk for suicide ideation and highlight the importance of relationship-based interventions for these vulnerable youths.

From Research to Practice: Lessons Learned.

Research has informed practice since the origins of developmental psychology, but only recently has basic science and practice begun to be consistently integrated with one another. In addition, considerable research documents the utility of empirically-supported interventions, yet it has been difficult to implement such interventions outside of the research context. This paper describes two Randomized Clinical Trials (RCTs) for maltreated infants and preschoolers as an example of successful community, funder, and researcher partnerships. Key strengths and challenges involved in designing and conducting the studies are discussed, and the necessity of considering the developmental and cultural appropriateness of empirically-supported interventions is highlighted. Programs designed to provide data on the effectiveness of interventions initially evaluated in RCTs are presented. These initiatives indicate that it is possible to create successful evidence-based interventions, even within the complex world of the child welfare system. These studies provide information on developmental and outcome intervention differences that contribute to the scientific literature and have real-world implications for policy makers, funders, and ultimately, for children.

Assessing psychological and physical abuse from children's perspective: Factor structure and psychometric properties of the picture-based, modularized child-report version of the Parent-Child Conflict Tactics Scale - Revised (CTSPC-R).

Child victims' reports of psychological and physical abuse by caregivers are a fundamental source of information beyond official records and caregiver reports. However, few or no sensitive and age-appropriate child-report instruments exist that have undergone in-depth validity and reliability testing across a broad age-range. Our study addresses this gap by examining psychometric properties of a picture-based, modularized version of the Parent-Child Conflict Tactics Scale (CTSPC-R), encompassing the maltreatment subtypes of psychological and physical abuse. A sample of 904 children and adolescents aged 4-16 years from the community (n = 568), child psychiatric services (n = 159), and from Child Protective Services (CPS; n = 177) completed the CTSPC-R. Measures to test convergent (maltreatment in parent interviews and CPS records) and concurrent validity (psychiatric symptoms) were collected. The CTSPC-R comprises 22 items, arranged in three severity modules by increasing level of psychological and physical abuse by caregivers. Companion picture cards were provided for children aged 4 and 8 years. The best fit to the data was attained with a second-order factor model, assuming three inter-correlated factors corresponding to the three severity modules, and a latent second-order factor representing combined physical and psychological abuse. The three factors showed good internal consistencies. Supporting convergent validity at the global and subtype-level of maltreatment, the CTSPC-R severity scale was associated with lifetime CPS-contact, presence of caregiver-reported emotional maltreatment and physical abuse, and dimensions of chronicity and severity. Discriminant validity was supported by non-significant correlations with caregiver-reported lack of supervision, failure to provide, and sexual abuse. Bolstering concurrent validity, moderate and severe physical abuse predicted caregiver-reported internalizing and externalizing symptoms. These effects were independent of child age, gender or community vs. non-community samples. Our study supports the CTSPC-R as a scientifically and clinically sound tool for ascertaining the child's own perspective on psychological and physical abuse from an early age onwards.