Lifestyle intervention in obese pregnancy and cardiac remodelling in 3-year olds: children of the UPBEAT RCT.

BACKGROUND/OBJECTIVES: Obesity in pregnancy has been associated with increased childhood cardiometabolic risk and reduced life expectancy. The UK UPBEAT multicentre randomised control trial was a lifestyle intervention of diet and physical activity in pregnant women with obesity. We hypothesised that the 3-year-old children of women with obesity would have heightened cardiovascular risk compared to children of normal BMI women, and that the UPBEAT intervention would mitigate this risk. SUBJECTS/METHODS: Children were recruited from one UPBEAT trial centre. Cardiovascular measures included blood pressure, echocardiographic assessment of cardiac function and dimensions, carotid intima-media thickness and heart rate variability (HRV) by electrocardiogram. RESULTS: Compared to offspring of normal BMI women (n = 51), children of women with obesity from the trial standard care arm (n = 39) had evidence of cardiac remodelling including increased interventricular septum (IVS; mean difference 0.04 cm; 95% CI: 0.018 to 0.067), posterior wall (PW; 0.03 cm; 0.006 to 0.062) and relative wall thicknesses (RWT; 0.03 cm; 0.01 to 0.05) following adjustment. Randomisation of women with obesity to the intervention arm (n = 31) prevented this cardiac remodelling (intervention effect; mean difference IVS -0.03 cm (-0.05 to -0.008); PW -0.03 cm (-0.05 to -0.01); RWT -0.02 cm (-0.04 to -0.005)). Children of women with obesity (standard care arm) compared to women of normal BMI also had elevated minimum heart rate (7 bpm; 1.41 to 13.34) evidence of early diastolic dysfunction (e prime) and increased sympathetic nerve activity index by HRV analysis. CONCLUSIONS: Maternal obesity was associated with left ventricular concentric remodelling in 3-year-old offspring. Absence of remodelling following the maternal intervention infers in utero origins of cardiac remodelling. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: The UPBEAT trial is registered with Current Controlled Trials, ISRCTN89971375.

Associations between early marriage and preterm delivery: Evidence from lowland Nepal.

OBJECTIVES: Preterm delivery (<37 weeks gestation) is the largest cause of child mortality worldwide. Marriage and pregnancy during adolescence have been associated with an increased risk of preterm delivery. We investigate independent associations of age at marriage and age at first pregnancy with preterm delivery in a cohort of women from rural lowland Nepal. METHODS: We analyzed data from 17 974 women in the Low Birth Weight South Asia Trial. Logistic regression models tested associations of age at marriage and age at first pregnancy with preterm delivery, for primigravida (n = 6 243) and multigravida (n = 11 731) women. Models were adjusted for maternal education, maternal caste, and household asset score. RESULTS: Ninety percent of participants had married at <18 years and 58% had their first pregnancy at <18 years. 20% of participants delivered preterm. Primigravida participants married at ≤14 years had higher odds of preterm delivery than those married ≥18 years, when adjusting for study design (adjusted odds ratio (aOR) 1.45, 95% CI: 1.15-1.83), confounders (aOR 1.28: 1.01-1.62) and confounders + age at pregnancy (aOR 1.29: 1.00-1.68). Associations were insignificant for multigravida women. No significant associations were observed between age at first pregnancy and preterm delivery. DISCUSSION: In this population, early marriage, rather than pregnancy, is a risk factor for preterm delivery. We hypothesize that psychological stress, a driver of preterm delivery which is increased among those marrying young, rather than physiological immaturity, drives this association. Further research into the psychological consequences of child marriage in Nepal is needed.

A systematic review of barriers and facilitators to antenatal screening for HIV, syphilis or hepatitis B in Asia: Perspectives of pregnant women, their relatives and health care providers.

BACKGROUND: Despite improvements, the prevalence of HIV, syphilis, and hepatitis B remains high in Asia. These sexually transmitted infections (STIs) can be transmitted from infected mothers to their children. Antenatal screening and treatment are effective interventions to prevent mother-to-child transmission (MTCT), but coverage of antenatal screening remains low. Understanding factors influencing antenatal screening is essential to increase its uptake and design effective interventions. This systematic literature review aims to investigate barriers and facilitators to antenatal screening for HIV, syphilis, and hepatitis B in Asia. METHODS: We conducted a systematic review by searching Ovid (MEDLINE, Embase, PsycINFO), Scopus, Global Index Medicus and Web of Science for published articles between January 2000 and June 2023, and screening abstracts and full articles. Eligible studies include peer-reviewed journal articles of quantitative, qualitative and mixed-method studies that explored factors influencing the use of antenatal screening for HIV, syphilis or hepatitis B in Asia. We extracted key information including study characteristics, sample, aim, identified barriers and facilitators to screening. We conducted a narrative synthesis to summarise the findings and presented barriers and facilitators following Andersen's conceptual model. RESULTS: The literature search revealed 23 articles suitable for inclusion, 19 used quantitative methods, 3 qualitative and one mixed method. We found only three studies on syphilis screening and one on hepatitis B. The analysis demonstrates that antenatal screening for HIV in Asia is influenced by many barriers and facilitators including (1) predisposing characteristics of pregnant women (age, education level, knowledge) (2) enabling factors (wealth, place of residence, husband support, health facilities characteristics, health workers support and training) (3) need factors of pregnant women (risk perception, perceived benefits of screening). CONCLUSION: Knowledge of identified barriers to antenatal screening may support implementation of appropriate interventions to prevent MTCT and help countries achieve Sustainable Development Goals' targets for HIV and STIs.

Cultural adaptations to social-emotional learning programs: A systematic review.

Social-emotional learning (SEL) programs offer critical opportunities to promote the development of students' social and emotional competence and well-being. Yet, the landscape of how adaptations are being made to effectively serve all students is unknown. This systematic review examined cultural adaptations to SEL programs and the extent to which they were associated with positive outcomes. Included studies were (a) peer-reviewed empirical studies or dissertations; (b) conducted in PreKindergarten through 12th grade school settings in the United States; (c) available in English; and (d) included a cultural adaptation to an SEL program. Five electronic databases were searched in January 2023. Included articles were coded to extract information regarding the types, purposes, and associations with student outcomes and cultural adaptations to SEL programs have. A total of 11 studies (eight published studies and three dissertations), including 5,173 students, met the inclusion criteria. Results demonstrated most studies used surface- and deep-level adaptations for adapting SEL programs to a specific racial/ethnic group and/or a geographical region. In general, there were mixed results in terms of effectiveness when examining effect sizes and other statistical analyses of the adaptations on student outcomes. However, most studies found high acceptability and/or feasibility in relation to the adaptations. Implications and directions for future research are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

No "Top of the triangle kids": Toward conceptual clarity of students, behavior, and tiers in MTSS to advance social justice.

Schools have increasingly adopted multitier systems of support to address a variety of educational aims. Despite their grounding in behavioral science and the public health model of prevention, in many settings there has been a shift from a foundational focus on behavioral principles to emphasize categorization and treatment of "top of the triangle" or "Tier 3" students. Herein, we first discuss how such emphasis on situating individuals, rather than behaviors, within the continuum of supports is counter to the principles and goals of MTSS, as well as undermining efforts to support prevention and social justice. Next, we apply a critical lens to review the related literature on problem-solving, labeling, marginalization of disabled students, and discipline disparities to provide a rationale for equity-centered MTSS with corresponding recommendations for practice.

Assessment in action: Toward a more complete and justice-oriented understanding of the social consequences of educational measures.

The studies in this special issue examine the social consequences of educational measures. In this commentary, I reflect on past and contemporary conceptualizations of the consequences of measurement and discuss advancing a more justice-oriented approach. To this end, it is imperative that we engage a critical lens in order to interrogate and act upon structural issues as they manifest in testing, assessment, and measurement. Importantly, we must attend to both the intended and unintended consequences of the use and interpretation of educational measures in order to advance equity and social justice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Interventions for Infection and Inflammation-Induced Preterm Birth: a Preclinical Systematic Review.

Spontaneous preterm births (< 37 weeks gestation) are frequently associated with infection. Current treatment options are limited but new therapeutic interventions are being developed in animal models. In this PROSPERO-registered preclinical systematic review, we aimed to summarise promising interventions for infection/inflammation-induced preterm birth. Following PRISMA guidance, we searched PubMed, EMBASE, and Web of Science using the themes: "animal models", "preterm birth", "inflammation", and "therapeutics". We included original quantitative, peer-reviewed, and controlled studies applying prenatal interventions to prevent infection/inflammation-induced preterm birth in animal models. We employed two risk of bias tools. Of 4020 identified studies, 23 studies (24 interventions) met our inclusion criteria. All studies used mouse models. Preterm birth was most commonly induced by lipopolysaccharide (18 studies) or Escherichia coli (4 studies). Models varied according to infectious agent serotype, dose, and route of delivery. Gestational length was significantly prolonged in 20/24 interventions (83%) and markers of maternal inflammation were reduced in 20/23 interventions (87%). Interventions targeting interleukin-1, interleukin-6, and toll-like receptors show particular therapeutic potential. However, due to the heterogeneity of the methodology of the included studies, meta-analysis was impossible. All studies were assigned an unclear risk of bias using the SYRCLE risk of bias tool. Interventions targeting inflammation demonstrate therapeutic potential for the prevention of preterm birth. However, better standardisation of preterm birth models, including the dose, serotype, timing of administration and pathogenicity of infectious agent, and outcome reporting is urgently required to improve the reproducibility of preclinical studies, allow meaningful comparison of intervention efficacy, and aid clinical translation.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia.

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

A roadmap to equitable school mental health screening.

Youth in the United States are experiencing mental health concerns at alarming rates. Considering the nation's legacy of racism and growing recognition of the impact of social determinants of health on educational and mental health inequities, it is imperative to re-envision how we approach mental health screening in schools to center equity. A focus on mental health screening for the sole purpose of identifying individual at-risk students ignores key contextual considerations, is ineffective in addressing health and educational inequities, and has the potential to perpetuate oppressive practices in schools. Equity-focused mental health screening requires a shift from individual- and deficit-focused approaches to systems- and holistic-focused approaches that (a) identify strengths and stressors among individuals, groups, and communities; (b) dismantle structural forms of oppression; and (c) promote positive mental health outcomes for minoritized youth. Integrating recommendations from the educational equity literature and critical school mental health frameworks, this paper identifies core considerations for equitable school mental health screening and provides guiding principles for each phase of the screening process, from screening readiness to execution to follow up. To implement these recommendations and transform school-based mental health care, schools should (a) incorporate multiple perspectives; (b) prioritize student, family, and community voices; and (c) build collaborative partnerships to co-construct a vision for equitable school mental health.

Factors predicting amoxicillin prescribing in primary care among children: a cohort study.

BACKGROUND: Antibiotic prescribing during childhood, most commonly for respiratory tract infections (RTIs), contributes to antimicrobial resistance, which is a major public health concern. AIM: To identify factors associated with amoxicillin prescribing and RTI consultation attendance in young children in primary care. DESIGN AND SETTING: Cohort study in Bradford spanning pregnancy to age 24 months, collected 2007-2013, linked to electronic primary care and air pollution data. METHOD: Amoxicillin prescribing and RTI consultation rates/1000 child-years were calculated. Mixed-effects logistic regression models were fitted with general practice (GP) surgery as the random effect. RESULTS: The amoxicillin prescribing rate among 2493 children was 710/1000 child-years during year 1 (95% confidence interval [CI] = 677 to 744) and 780/1000 (95% CI = 745 to 816) during year 2. During year 1, odds of amoxicillin prescribing were higher for boys (adjusted odds ratio [aOR] 1.36, 95% CI = 1.14 to 1.61), infants from socioeconomically deprived households (aOR 1.36, 95% CI = 1.00 to 1.86), and infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.44, 95% CI = 1.06 to 1.94] and outside [aOR 1.42, 95% CI = 1.07 to 1.90]). During year 2, odds of amoxicillin prescribing were higher for infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.46, 95% CI = 1.10 to 1.94] and outside [aOR 1.56, 95% CI = 1.19 to 2.04]) and those born <39 weeks gestation (aOR 1.20, 95% CI = 1.00 to 1.45). Additional risk factors included caesarean delivery, congenital anomalies, overcrowding, birth season, and childcare attendance, with GP surgery explaining 7%-9% of variation. CONCLUSION: Socioeconomic status and ethnic background were associated with amoxicillin prescribing during childhood. Efforts to reduce RTI spread in household and childcare settings may reduce antibiotic prescribing in primary care.

Impact of maternal obesity on neonatal heart rate and cardiac size.

BACKGROUND: Maternal obesity may increase offspring risk of cardiovascular disease. We assessed the impact of maternal obesity on cardiac structure and function in newborns as a marker of fetal cardiac growth. METHODS: Neonates born to mothers of healthy weight (body mass index (BMI) 20-25 kg/m2, n=56) and to mothers who were obese (BMI ≥30 kg/m2, n=31) underwent 25-minute continuous ECG recording and non-sedated, free-breathing cardiac MRI within 72 hours of birth. RESULTS: Mean (SD) heart rate during sleep was higher in infants born to mothers who were versus were not obese (123 (12.6) vs 114 (9.8) beats/min, p=0.002). Heart rate variability during sleep was lower in infants born to mothers who were versus were not obese (SD of normal-to-normal R-R interval 34.6 (16.8) vs 43.9 (16.5) ms, p=0.05). Similar heart rate changes were seen during wakefulness. Left ventricular end-diastolic volume (2.35 (0.14) vs 2.54 (0.29) mL/kg, p=0.03) and stroke volume (1.50 (0.09) vs 1.60 (0.14), p=0.04) were decreased in infants born to mothers who were versus were not obese. There were no differences in left ventricular end-systolic volume, ejection fraction, output or myocardial mass between the groups. CONCLUSION: Maternal obesity was associated with increased heart rate, decreased heart rate variability and decreased left ventricular volumes in newborns. If persistent, these changes may provide a causal mechanism for the increased cardiovascular risk in adult offspring of mothers with obesity. In turn, modifying antenatal and perinatal maternal health may have the potential to optimise long-term cardiovascular health in offspring.

A call to action for school psychology to address COVID-19 health disparities and advance social justice.

The health, economic, and social challenges associated with coronavirus disease 2019 (COVID-19) present a range of threats to students' well-being, psychoeducational experiences, and outcomes, spurring fears for a "lost generation." In this article, we present COVID-19 as a large-scale multisystemic disaster causing massive disruptions and losses, with adversities moderated by the intersectional nature of systemic inequity. We first synthesize the broad effects of COVID-19 as they relate to equity and social justice, followed by the major implications for students and schools, with a focus on intersectional systemic issues. We then propose foundational considerations and resources intended to usher a paradigm shift in how school psychologists' roles and activities are conceptualized in the years to come, ending with key imperatives for practice and graduate education in school psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

School Psychology reflections on COVID-19, antiracism, and gender and racial disparities in publishing.

School Psychology is an outlet for research on children, youth, educators, and families that has scientific, practice, and policy implications. The novel coronavirus 2019 (COVID-19) pandemic has significantly disrupted K-12 schooling as well as university training, impacting educational attainment and highlighting longstanding inequality. Furthermore, the killing of Breonna Taylor and George Floyd has precipitated worldwide protests against antiblack racism, white supremacy, and police brutality. In this editorial, we highlight the potential impacts to our field, including prioritizing research related to educational equity, identifying new research questions related to technology, and utilizing new research methods. We also consider the impact of gender and racial disparities in publications during this time. Finally, given these events, we discuss how best our editorial team can serve the field. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Classroom management for ethnic-racial minority students: A meta-analysis of single-case design studies.

Diversification trends of U.S. schools make clear the need for evidence-based practices supporting ethnically-racially diverse students. Yet, there are significant hindrances to readily identifying and summarizing findings generated from diverse classroom contexts. The current meta-analytic review was designed to address this gap in the classroom management literature. This review includes single-case design studies conducted in majority ethnic-racial minority classrooms (≥50%) that included a direct comparison of baseline to treatment for behavior management strategies implemented at the whole class level. A total of 22 studies spanning from 1973 to 2014 met eligibility criteria for this review, including 838 students and 46 K-12 classrooms. Results indicate that classwide management approaches applied in diverse classrooms are heavily behavioral and highly effective in improving student behavior (Mτ = |.92|, MHedges's g = 2.52). Overall, interventions that included an individual or group contingency consistently demonstrated large effects and were the most frequently used strategies. However, other interventions displayed comparably high results but were less frequently studied. Findings further revealed significant gaps in the quality and diversity of research completed to date. Specifically, half of the studies did not include cases that met What Works Clearinghouse design standards for demonstrating methodological rigor. There were also few studies that included minority populations other than African American, and there was limited variation in educational settings and intervention designs. Of some concern was the heightened frequency of response cost procedures included in interventions for diverse classrooms, possibly running counter to recommendations that emphasize reinforcement-based strategies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Sexual Health Recovery For Prostate Cancer Survivors: The Proposed Role Of Acceptance And Mindfulness-Based Interventions.

INTRODUCTION: 1 in every 7 Canadian men is affected by prostate cancer. Given impressive advances in detection, treatment, and survival rates, there is a considerable focus on survivors' supportive care needs. Among the top unmet supportive care needs for prostate cancer survivors are concerns related to sexual health and intimacy. AIM: To provide a rationale for introducing mindfulness- and acceptance-based approaches into the role of psychosexual interventions aimed at improving sexual satisfaction among prostate cancer survivors (and their partners). METHODS: A literature review was performed to examine the prevalence of sexual difficulties after prostate cancer treatment and the efficacy of current pharmacologic and psychological treatment approaches. MAIN OUTCOME MEASURE: The main outcome measure was focused on sexual satisfaction in prostate cancer survivors. RESULTS: Current pharmacologic interventions for sexual difficulties after prostate cancer treatment are not fully meeting the needs of prostate cancer survivors and their partners. Conclusions cannot be drawn from existing psychological interventions because of methodologic inconsistencies. Additionally, the focus on erectile function as a measure of treatment effectiveness is likely to instill a greater sense of hopelessness and loss for prostate cancer survivors, which may exacerbate issues around sexual intimacy and satisfaction. An impressive body of evidence supports the role of mindfulness in improving women's sexual functioning and there is preliminary evidence suggesting the efficacy of this approach for improving men's sexual functioning. CONCLUSION: We propose that psychosexual interventions that prioritize mindfulness and acceptance-based frameworks may help men to tune into sensations while challenging the foci on performance and erections, thereby increasing the potential for improvement to sexual satisfaction among prostate cancer survivors. Bossio JA, Miller F, O'Loughlin JI, et al. Sexual Health Recovery for Prostate Cancer Survivors: The Proposed Role of Acceptance and Mindfulness-Based Interventions. Sex Med Rev 2019;7:627-635.

Examining the stability of social, emotional, and behavioral risk status: Implications for screening frequency.

Responsive service delivery frameworks rely on the use of screening approaches to identify students in need of support and to guide subsequent assessment and intervention efforts. However, limited empirical investigations have been directed to informing how often screening should occur for social, emotional, and behavioral difficulties in school settings. The purpose of the current study was to evaluate the stability of risk status on 3 different screening instruments across 3 administrations across the course of a school year. A total of 1,594 students had complete screening data across 3 time points, corresponding to a total of 187 teachers from 22 different public schools located within the northeastern and midwestern United States. Across measures, we examined patterns of risk across time points and investigated the utility of (a) different screening schedules (fall, winter, and spring) and (b) borderline screening when conducting multiple screenings per year. Results indicated that a large proportion of students exhibited stable risk patterns across time points and suggested that borderline screening may be a viable alternative for schools with limited resources. Implications for practice and future research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Initial development and evaluation of the student intervention matching (SIM) form.

There is currently a large gap in both research and practice between student identification practices for those at-risk (i.e., universal screening, teacher referral, or extant data as early identification methods) and the selection of appropriate Tier 2 interventions for social, emotional, and behavioral concerns. The purpose of this study was to develop and test the treatment validity of the Student Intervention Matching (SIM) Form, an intervention matching protocol designed for use at Tier 2. To this end, single-case design methodology was employed to systematically evaluate outcomes associated with use of the SIM Form in the intervention selection process. Participants included eight elementary-age students arranged in sets of four student dyads. A multiple baseline design was used in order to examine the relative effectiveness of matched interventions according to the SIM Form, and mismatched interventions according to the SIM Form. Results indicated that interventions matched using the SIM Form were functionally related to improved student outcomes across a variety of dependent variables when compared to mismatched phases. Implications for practice and future research are discussed.

Getting "SMART" about implementing multi-tiered systems of support to promote school mental health.

With the growing adoption and implementation of multi-tiered systems of support (MTSS) in school settings, there is increasing need for rigorous evaluations of adaptive-sequential interventions. That is, MTSS specify universal, selected, and indicated interventions to be delivered at each tier of support, yet few investigations have empirically examined the continuum of supports that are provided to students both within and across tiers. This need is compounded by a variety of prevention approaches that have been developed with distinct theoretical foundations (e.g., Positive Behavioral Interventions and Supports, Social-Emotional Learning) that are available within and across tiers. As evidence-based interventions continue to flourish, school-based practitioners greatly need evaluations regarding optimal treatment sequencing. To this end, we describe adaptive treatment strategies as a natural fit within the MTSS framework. Specifically, sequential multiple assignment randomized trials (SMART) offer a promising empirical approach to rigorously develop and compare adaptive treatment regimens within this framework.

Methods matter: A multi-trait multi-method analysis of student behavior.

Reliable and valid data form the foundation for evidence-based practices, yet surprisingly few studies on school-based behavioral assessments have been conducted which implemented one of the most fundamental approaches to construct validation, the multitrait-multimethod matrix (MTMM). To this end, the current study examined the reliability and validity of data derived from three commonly utilized school-based behavioral assessment methods: Direct Behavior Rating - Single Item Scales, systematic direct observations, and behavior rating scales on three common constructs of interest: academically engaged, disruptive, and respectful behavior. Further, this study included data from different sources including student self-report, teacher report, and external observers. A total of 831 students in grades 3-8 and 129 teachers served as participants. Data were analyzed using bivariate correlations of the MTMM, as well as single and multi-level structural equation modeling. Results suggested the presence of strong methods effects for all the assessment methods utilized, as well as significant relations between constructs of interest. Implications for practice and future research are discussed.

Test order in teacher-rated behavior assessments: Is counterbalancing necessary?

Counterbalancing treatment order in experimental research design is well established as an option to reduce threats to internal validity, but in educational and psychological research, the effect of varying the order of multiple tests to a single rater has not been examined and is rarely adhered to in practice. The current study examines the effect of test order on measures of student behavior by teachers as raters utilizing data from a behavior measure validation study. Using multilevel modeling to control for students nested within teachers, the effect of rating an earlier measure on the intercept or slope of a later behavior assessment was statistically significant in 22% of predictor main effects for the spring test period. Test order effects had potential for high stakes consequences with differences large enough to change risk classification. Results suggest that researchers and practitioners in classroom settings using multiple measures evaluate the potential impact of test order. Where possible, they should counterbalance when the risk of an order effect exists and report justification for the decision to not counterbalance. (PsycINFO Database Record