A Multi-level Longitudinal Model of Risk Factors for Generalized and Separation Anxiety Symptoms in a Community Sample of 6-year-olds.

The current longitudinal study examined the relations between variables in four domains-contextual (SES, family conflict, stress), parent (caretaker depression), parenting (support hostility, autonomy granting), and child (negative affect, effortful control, sensory regulation, attachment)-and both the presence of generalized and separation anxiety symptoms at age 6 in a community sample of 796 children and the change in these anxiety symptoms from ages 4 to 6. Anxiety was highly stable over time. Specific results revealed both direct and indirect pathways between age 4 and age 5 variables, and age 6 anxiety. Caretaker depression and the child variables of attachment, effortful control, negative affect, and sensory regulation were directly related to anxiety symptoms at age 6. Contextual variables (SES) at age 4 were indirectly related to age 6 anxiety through parent depression at age 5. Parent depression was indirectly related to age 6 anxiety through age 5 child negative affect. Child negative affect at age 4 was indirectly related to age 6 anxiety through age 5 effortful control and age 4 effortful control was indirectly related to age 6 anxiety through age 5 negative affect. With the exception of attachment, there was a reduction in the impact of other variables when initial levels of anxiety symptoms were included in the model. Implications of results for early intervention and further study are discussed.

Multidomain risk factors in early childhood and depression symptoms in 6-year-olds: A longitudinal pathway model.

This study examined effects of risk factors in multiple domains measured in preschool and kindergarten on age 6 depression symptoms, and on changes in symptom levels between ages 4 and 6. Two models were examined in a large, diverse (N = 796) community sample of children and parents. Risk variables included SES, stress, conflict, parental depression, parental hostility, support, scaffolding, child negative affect (NA), effortful control (EC), sensory regulation (SR), and attachment security. Model 1 included effects of risk factors at ages 4 and 5 on child depression symptoms at age 6. Model 2 also included depression symptoms at all three ages to examine changes in these symptoms. Model 1 revealed that age 4 and 5 parental depression, NA, EC, and SR predicted age 6 child depression levels, Several age 4 variables had indirect pathways to age 6 depression via age 5 EC. Model 2 revealed that preschool depression was the only age 4 variable, and EC and SR were the only age 5 variables that significantly predicted increases in age 6 depression. These findings highlight the role of self-regulation in child depression and suggest that targeting self-regulation may be an effective prevention and intervention strategy.

Age 4 Predictors of Oppositional Defiant Disorder in Early Grammar School.

Our ability to predict which children will exhibit oppositional defiant disorder (ODD) at the time of entry into grammar school at age 6 lags behind our understanding of the risk factors for ODD. This study examined how well a set of multidomain risk factors for ODD assessed in 4-year-old children predicted age 6 ODD diagnostic status. Participants were a diverse sample of 796 4-year-old children (391 boys).The sample was 54% White, non-Hispanic; 16.8% African American, 20.4% Hispanic; 2.4% Asian; and 4.4% Other or mixed race. The classification accuracy of two models of multidomain risk factors, using either a measure of overall ODD symptoms or dimensions of ODD obtained at age 4, were compared to one another, to chance, and to a parsimonious model based solely on parent-reported ODD using Automated Classification Tree Analysis. Effect Strength for Sensitivity (ESS), a measure of classification accuracy, indicated a multidomain model including a general measure of ODD symptoms at age 4 yielded a large effect (56.29%), a 13.7% increase over the ESS for the parsimonious model (ESS = 42.9%). The ESS (51.23%) for a model including two ODD dimensions (behavior and negative affect) was smaller than that for the model including a measure of overall ODD symptoms. The Classification Tree Analysis approach showed a small but distinct advantage that would be useful in screening for which children would most likely meet criteria for age 6 ODD.

A multidomain cascade model of early childhood risk factors associated with oppositional defiant disorder symptoms in a community sample of 6-year-olds.

The present study examined a cascade model of age 4 and 5 contextual, parent, parenting, and child factors on symptoms of oppositional defiant disorder (ODD) at age 6 in a diverse community sample of 796 children. Contextual factors include socioeconomic status, family stress, and conflict; parent factors included parental depression; parenting factors included parental hostility, support, and scaffolding skills; child factors included child effortful control (EC), negative affect (NA), and sensory regulation. Direct effects of age 5 conflict, hostility, scaffolding, EC, and NA were found. Significant indirect, cascading effects on age 6 ODD symptom levels were noted for age 4 socioeconomic status via age 5 conflict and scaffolding skills; age 4 parental depression via age 5 child NA; age 4 parental hostility and support via age 5 EC; age 4 support via age 5 EC; and age 4 attachment via age 5 EC. Parenting contributed to EC, and the age 5 EC effects on subsequent ODD symptom levels were distinct from age 5 parental contributions. Scaffolding and ODD symptoms may have a reciprocal relationship. These results highlight the importance of using a multidomain model to examine factors associated with ODD symptoms early in the child's grammar school years.

Multi-domain Predictors of Attention Deficit/Hyperactivity Disorder Symptoms in Preschool Children: Cross-informant Differences.

Numerous studies indicated that agreement between parent and teacher ratings of symptoms of attention-deficit/hyperactivity disorder in children of all ages is poor, but few studies have examined the factors that may be associated with rater differences. The present study examined the contextual, parent, parenting, and child factors associated with rater differences in a community sample of 4-year-old children. Parents and teachers of 344 4-year-olds recruited from preschools and pediatric practices completed the preschool versions of the Child Symptom Inventory. Measures of socioeconomic status, family stress and conflict, caretaker depression, parental hostility, support-engagement, and scaffolding skills, and child negative affect (NA), sensory regulation (SR), effortful control (EC), inhibitory control, and attachment security were obtained either by parental report or observational measures. χ 2 difference tests indicated that child factors of EC and SR, and contextual factor of stress and conflict, contributed more to parent-ratings of ADHD-I and ADHD-HI than to teacher-ratings of those same types of symptoms. Two factors contributed more to teacher-than to parent-rated ADHD-I, NA and caretaker depression. Results indicate there are differences in factors associated with ADHD symptoms at home and school, and have implications for models of ADHD.

Multi-domain predictors of oppositional defiant disorder symptoms in preschool children: cross-informant differences.

Existing research suggests that parent and teacher reports of children's behavior problems are often discrepant. The current study examined whether contextual (stress and family conflict), parent (depression), parenting (hostility, support, and scaffolding), and child factors (receptive vocabulary; negative affect, NA; effortful control, EC; inhibitory control, IC; attachment; and sensory regulation, SR) are related to parent-teacher reporting discrepancies. Participants included a community sample of 344 4-year-old children. A multi-informant approach was used to assess contextual, parent, parenting, and child factors. Parents and teachers completed the Oppositional Defiant Disorder (ODD) scale of the Child Symptom Inventory. Consistent with previous data, there was poor agreement between parents and teachers (r = .17). After correcting for multiple comparisons, child effortful control, parent hostility, and family conflict were significant predictors of parent-rated symptoms of ODD symptoms but not teacher-rated ODD symptoms. Only family conflict was a significant predictor of discrepancies in parent and teacher ratings.

Implementing trauma-informed care in a special education setting: An initial exploration of a multi-tiered model.

Implementing trauma-informed care in a special education environment serving youth from historically marginalized communities with high levels of exposure to potentially traumatic events (PTEs) requires a systematic tiered approach consistent with public health guidelines. Little is known about the implementation of this framework in special education settings where youth have significant emotional and behavioral difficulties. To address this need, a consultant-community partnership was forged between a hospital providing mental health services and a therapeutic day school that serves a special education cooperative. The current case study explores the design and implementation of a three-tiered model of trauma-informed care in a special education setting. This study will address the specific practices implemented at each tier, discuss successes and challenges, and summarize future directions for research, practice, and policy.

A Precision Mental Health Model for Predicting Stability of 4-year-olds' Attention Deficit/Hyperactivity Disorder Symptoms to Age 6 Diagnostic Status.

OBJECTIVE: Estimates of the stability of a preschooler's diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) into early elementary school vary greatly. Identified factors associated with diagnostic instability provide little guidance about the likelihood a particular child will have ADHD in elementary school. This study examined an approach to predicting age 6 ADHD-any subtype (ADHD-any) from preschoolers' demographics and ADHD symptoms. METHOD: Participants were 796 preschool children (Mage = 4.44; 51% boys; 54% White, non-Hispanic) recruited from primary pediatric care and school settings. Parents completed ADHD Rating Scales at child ages 4 and 5 years, and a structured diagnostic interview (DISC-YC) at ages 4 and 6. Classification tree analyses (CTAs) examined the predictive utility of demographic and symptom variables at ages 4 and 5 years for age 6 ADHD. RESULTS: Over half (52.05%) of preschoolers meeting diagnostic criteria for ADHD-any at age 4 did not meet those criteria at age 6; more than half (52.05%) meeting criteria for ADHD-any at age 6 had not met those criteria at age 4. A CTA conducted at age 4 predicted age 6 ADHD-any diagnosis 65.82% better than chance; an age 5 CTA predicted age 6 ADHD-any 70.60% better than chance. At age 4, likelihood of age 6 ADHD-any diagnosis varied from <5% to >40% across CTA tree branches and from <5% to >78% at age 5. CONCLUSIONS: Parent-reported patterns of preschool-age symptoms may differentially predict ADHD-any at age 6. Psychoeducation regarding these patterns may aid in decision about pursuing multidisciplinary evaluations or initiating treatment.

Gene × environment effects of serotonin transporter, dopamine receptor D4, and monoamine oxidase A genes with contextual and parenting risk factors on symptoms of oppositional defiant disorder, anxiety, and depression in a community sample of 4-year-old children.

Genetic factors can play a key role in the multiple level of analyses approach to understanding the development of child psychopathology. The present study examined gene-environment correlations and gene × environment interactions for polymorphisms of three target genes, the serotonin transporter gene, the D4 dopamine receptor gene, and the monoamine oxidase A gene in relation to symptoms of anxiety, depression, and oppositional behavior. Saliva samples were collected from 175 non-Hispanic White, 4-year-old children. Psychosocial risk factors included socioeconomic status, life stress, caretaker depression, parental support, hostility, and scaffolding skills. In comparison with the short forms (s/s, s/l) of the serotonin transporter linked polymorphic repeat, the long form (l/l) was associated with greater increases in symptoms of oppositional defiant disorder in interaction with family stress and with greater increases in symptoms of child depression and anxiety in interaction with caretaker depression, family conflict, and socioeconomic status. In boys, low-activity monoamine oxidase A gene was associated with increases in child anxiety and depression in interaction with caretaker depression, hostility, family conflict, and family stress. The results highlight the important of gene-environment interplay in the development of symptoms of child psychopathology in young children.

Direct and indirect effects of contextual factors, caregiver depression, and parenting on attachment security in preschoolers.

The aim of this study was to develop a multiple-level-of-analysis model of preschool attachment security and to determine the processes (direct and indirect) whereby factors from different domains (e.g., stress and parenting) are related to attachment during this period. This study examined the direct and indirect effects of stress, family conflict, caregiver depression symptoms, and parenting on attachment security in a large (N = 796) and diverse sample of 4-year-olds. This study used the 3-Boxes Task to assess aspects of parenting critical to sensitivity in the preschool period, labeling this construct sensitivity/scaffolding. Parent-report questionnaires were used to assess stress, conflict, caregiver depressive symptoms, parent support/engagement, and parent hostility/coercion. Direct observation (3-Boxes Task) was used to assess sensitivity/scaffolding and attachment (Attachment Q-Sort) based on a 2½-3 hour home visit. Results of structural equation modeling indicated a good overall fit for the model. Among the parenting variables, sensitivity/scaffolding had the strongest effect on attachment. Depressive symptoms had both direct and indirect effects (mediated by parenting). The effects of stress and family conflict were mediated by caregiver depression symptoms and parenting. These data show that a developmentally appropriate measure of sensitivity plays a significant role in attachment security in preschoolers. Thus, strategies designed to enhance sensitivity/scaffolding may increase child resilience by enhancing attachment security.

The Relationship between Temperamental Negative Affect, Effortful Control, and Sensory Regulation: A New Look.

Temperamental negative affectivity (NA) and effortful control (EC) have long been of interest to psychologists, but sensory regulation (SR) has received less attention. Using confirmatory factor analysis, the present study reexamined the Rothbart model of EC and NA using the Children's Behavior Questionnaire (CBQ; M.K. Rothbart, S.A. Ahadi, K.L. Hershy, & P. Fisher, 2001), along with alternative models of EC, NA, and SR using the CBQ and Short Sensory Profile. The results failed to replicate the Rothbart model of EC and NA, which includes SR within the EC and NA factors. A good fit was found for a three-factor model (EC, NA, and SR) that was replicated in a holdout sample. A three-factor model also showed a good fit when EC, NA, and SR items similar to symptoms of behavior problems were eliminated.

Rheumatology Milestones 2.0: A Roadmap for Competency-Based Medical Training of Rheumatology Fellows in the 21st Century.

OBJECTIVE: Since 2014, rheumatology fellows have been assessed not only based on their ability to provide patient care and possession of medical knowledge but also on their skill in serving as patient advocates, navigators of health systems, and members of a health care team. Such assessments have been carried out through the use of competency-based milestones from the Accreditation Council of Graduate Medical Education (ACGME). However, a needs assessment has demonstrated interest in more context validity and subspecialty relevance since the development of the ACGME internal medicine (IM) subspecialty reporting milestones. The ACGME thus created a milestones working group, and the present study was undertaken to develop Rheumatology Milestones 2.0 as well as a supplemental guide to assist with implementation. METHODS: The working group, consisting of 7 rheumatology program directors, 2 division directors, a community practice rheumatologist, a rheumatology fellow in training, and a public member who is a rheumatology patient, was overseen by the ACGME vice president for milestones development and met through three 12-hour, in-person meetings to compose the rheumatology specialty milestones and supplemental guide within the ACGME Milestones 2.0 project. RESULTS: Informed by the needs assessment data and stakeholders, the working group revised and adapted the ACGME IM subspecialty reporting milestones to create a rheumatology-specific set of milestones and a supplemental guide for their implementation. CONCLUSION: The Rheumatology Milestones 2.0 provides a specialty-specific, competency-based evaluation tool that can be used by program directors, clinical competency committees, and others to assess the competencies of rheumatology fellows during training and help measure readiness for independent practice.

Is smoking during pregnancy a risk factor for psychopathology in young children? A methodological caveat and report on preschoolers.

OBJECTIVE: While studies of the effects of prenatal smoking on child psychopathology have found positive relationships, most studies (1) failed to control for a range of correlates of maternal smoking that could affect children's behavior; (2) have been conducted with school-age rather than younger children, so it is not clear when such problems emerge; and (3) have not examined the effects on internalizing problems. METHOD: This study examined the effects of prenatal smoke exposure on behaviors associated with externalizing and internalizing behavior problems and negative temperament in a diverse community sample of 679 4-year-olds. RESULTS: After controlling for correlates that include socioeconomic status, life stress, family conflict, maternal depression, maternal scaffolding skills, mother-child attachment, child negative affect and effortful control, smoking during pregnancy was no longer associated with child behavior or emotional problems. CONCLUSIONS: Future studies need to control for a wide range of covariates of maternal smoking.

Evidence-based assessment in clinical settings: Reducing assessment burden for a structured measure of child and adolescent anxiety.

Clinically useful and evidence-based mental health assessment requires the identification of strategies that maximize diagnostic accuracy, inform treatment planning, and make efficient use of clinician and patient time and resources. This study uses classification tree analyses to determine whether parent- and child-report instruments, alone or in combination, can accurately predict diagnoses as measured by the Anxiety Disorders Interview Schedule (ADIS). The ADIS, which is the gold-standard semistructured interview for anxiety disorders in children and adolescents, requires formal training and lengthy administration. Data were collected as part of the standard diagnostic assessment process for 201 patients (ages 5 to 17 years) in an urban outpatient psychiatry specialty clinic. Analyses examined 2 models to determine which predictors reached an acceptable level of diagnostic accuracy for generalized anxiety, social anxiety, and separation anxiety disorders. The first model used scores on a parent- and child-report anxiety measure combined with demographic factors, and the second model incorporated a broad-band measure of child psychopathology and a depression measure into the analysis. Although demographic factors did not emerge as accurate predictors in either model, particular measures, either alone or in combination, were able to predict specific ADIS diagnoses in some cases, allowing for the potential streamlining of ADIS administration. These results suggest that a classification-tree analysis lends itself to the construction of simple algorithms that have high clinical utility and may advance the feasibility and utility of evidence-based assessment strategies in real-world practice settings by balancing cost effectiveness, administration demands, and accuracy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds.

Few studies have examined the epidemiology of preschoolers' psychopathology. This study included 796 4-year-old children recruited from schools and pediatric practices in a diverse, urban area. Psychiatric disorder was assessed by a structured interview adapted for preschool children and by questionnaire. The most common disorders were oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). Generalized anxiety disorder (GAD) and depressive disorders were reported in less than 1% of the sample. Race/ethnicity differences were not significant. Gender differences showed ADHD-inattentive type more common among boys, with no gender differences for GAD, major depressive disorder, dysthymia, separation anxiety disorder, or ODD at any level of impairment. The overall comorbidity rate was 6.4%. Approximately 3% of individuals receiving a diagnosis had received mental health services.

Marital and Parent-Child Relationships during Treatment for Adolescent Depression: Child-Driven and Bidirectional Effects.

Adolescent depression can be a stressor for parents and families. This study evaluated how treating adolescent depression affects marital and parent-child relationships. We examined whether marital adjustment and parent-child conflict improved over the course of active treatment of depressed adolescents (36-week visit) and long-term follow-up (one year after discontinuation of treatment) in a sample of 322 clinically depressed youth participating in the Treatment for Adolescents with Depression Study (TADS). We also explored the bidirectional influences of adolescent depression and family relationships. Results indicated that marital adjustment was stable during active treatment but declined during long-term follow up. A structural equation model (SEM) examining the bidirectional relation between adolescent depression and marital adjustment indicated that higher adolescent depression at the conclusion of maintenance treatment (24-week visit) predicted a deterioration of marital adjustment at the end of active treatment (36-week visit). Parent-child conflict was unchanged during treatment and follow up. SEM analyses examining the bidirectional relationship between youth depression and parent-child conflict revealed that reduced depressive symptoms at the end of the active treatment period predicted improvement in parent-child conflict at subsequent time points. These findings suggest that youth depression and its treatment may influence long-term family functioning.

Predictor and moderator effects in the treatment of oppositional defiant disorder in pediatric primary care.

OBJECTIVE: To examine predictors and moderators of parent-training outcomes for treatment of Oppositional Defiant Disorder (ODD) in pediatric primary care. METHODS: Parents of 117 children with ODD, ages 3-6 years, seen in primary care received either a minimal intervention bibliotherapy treatment (MIT), or a 12-session parenting program led by a nurse or psychologist. RESULTS: More initial total life stress, parenting distress, internalizing problems, functional impairment, and difficult temperament were associated with more improvement, but families scoring lower on those variables had fewer behavior problems at posttreatment and follow-up. Gender was a significant moderator, with more improvement for girls than boys in the nurse-led group but more improvement for boys than girls in the MIT group. Less well-educated mothers treated by psychologists showed the greatest change. CONCLUSIONS: Predictors and moderators may play a role in deciding, which families receive a particular form of treatment for ODD in primary care.

Treating oppositional defiant disorder in primary care: a comparison of three models.

OBJECTIVE: To determine if a nurse-led or psychologist-led parent-training program was more successful than a minimal intervention in treating early childhood Oppositional Defiant Disorder (ODD) in pediatric primary care. METHODS: Twenty-four practices were randomized to conditions in which parents of 117, 3- to 6.11-year-olds with ODD received the 12-session Webster-Stratton Incredible Years program led by primary care nurses or clinical psychologists, or to a minimal intervention group in which parents received only the companion book to the treatment program. RESULTS: There was improvement across posttreatment and 12-month follow-up for all groups, but no overall treatment group effects. There was a dose effect, with a reliable, clinically significant gain after seven sessions on the Eyberg intensity scale, and nine sessions on the Child Behavior Checklist externalizing scale. CONCLUSIONS: There is little advantage to the therapist-led treatment over bibliotherapy unless parents attend a significant number of sessions.

Integrative module-based family therapy: application and training.

The field of marriage and family therapy is currently at a crossroads. The challenge for contemporary therapists is how to incorporate the wisdom of previous models with the accountability that comes from evidence-based practice. The Integrative Module-Based Family Therapy treatment model provides a formalized series of steps that clinicians can use in their case planning and implementation. It is based on nine clinically relevant modules for assessment and intervention that are consistent with current best practices and empirically supported treatments. It thus meets the need for a structured family therapy practice and training approach that is respectful of the "art" of family therapy while still adhering to the principles of the "science" of evidence-based treatment.

Parenting and Anxiety: Bi-directional Relations in Young Children.

Developmental psychopathologists have long posited a reciprocal relation between parenting behaviors and the development of child anxiety symptoms. Yet, little empirical research has utilized a longitudinal design that would allow exploration of this bi-directional influence. The present study examined the reciprocal relations between parental respect for autonomy, parental hostility, and parental support, and the development of childhood anxiety during a critical developmental period-the transition from preschool to kindergarten and then first grade. Study participants included a community sample of 391 male and 405 female socioeconomically, racially and ethnically diverse 4 to 6-7 year olds. 54 % of the sample was White, non-Hispanic, 16.8 % was African American, 20.4 % was Hispanic, 2.4 % were Asian and 4.4 % self-identified as Other or mixed race. Parent report and observational methodology were used. Parenting and anxiety were found to interact reciprocally over time. Higher levels of age 4 anxiety led to reduced respect for child autonomy at age 5. At age 4 higher levels of parental hostility led to small increases in age 5 anxiety, and increased age 5 anxiety led to increased levels of age 6 parent hostility. Parental support at age 5 resulted in decreased anxiety symptoms at age 6-7 while higher age 5 anxiety levels were associated with reductions in age 6-7 parental support. No relations were found between these variables at the younger ages. Although the magnitude of these findings was small, they suggest that early treatment for childhood anxiety should include both parent intervention and direct treatment of the child's anxiety symptoms.