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.

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.

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.

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.

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.

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.

Multi-domain models of risk factors for depression and anxiety symptoms in preschoolers: evidence for common and specific factors.

Relatively few studies have examined multiple pathways by which risk factors from different domains are related to symptoms of anxiety and depression in young children; even fewer have assessed risks for these symptoms specifically, rather than for internalizing symptoms in general. We examined a theoretically- and empirically-based model of variables associated with these symptom types in a diverse community sample of 796 4-year-olds (391 boys, 405 girls) that included factors from the following domains: contextual (SES, stress and family conflict); parent characteristics (parental depression); parenting (support/engagement, hostility and scaffolding); and child characteristics including negative affect (NA) effortful control (EC) sensory regulation (SR), inhibitory control (IC) and attachment. We also compared the models to determine which variables contribute to a common correlates of symptoms of anxiety or depression, and which correlates differentiate between those symptom types. In the best-fitting model for these symptom types (a) SES, stress and conflict had indirect effects on both symptom types via long-chain paths; (b) caregiver depression had direct effects and indirect ones (mediated through parenting and child effortful control) on both symptom types; (c) parenting had direct and indirect effects (via temperament and SR); and temperament had direct effects on both symptom types. These data provide evidence of common risk factors, as well as indicate some specific pathways/mediators for the different symptom types. EC was related to anxiety, but not depression symptoms, suggesting that strategies to improve child EC may be particularly effective for treatment of anxiety symptoms in young children.

Can parent reports serve as a proxy for teacher ratings in medication management of attention-deficit hyperactivity disorder?

OBJECTIVE: While American Academy of Pediatrics guidelines recommend obtaining symptom reports from both parents and teachers when treating children with attention-deficit hyperactivity disorder (ADHD), information from parents is easier to obtain and practitioners may prefer to rely solely on parent report when managing medications. There are, however, few empirical data on the relationship between parent and teacher reports during medication management of ADHD. This study examined the relationship between parent and teacher reports of symptoms of ADHD during a clinical trial. METHODS: A study to improve medication management of ADHD was conducted in 24 pediatric practices with 270 children. Children meeting criteria for ADHD were randomized by practice to treatment-as-usual or specialized care groups, with data combined from the groups to examine parent-teacher agreement. Parent and teacher reports on the ADHD Rating Scale-IV were obtained at pretreatment, 4 months, and 12 months follow-up. RESULTS: At each assessment, correlations between parent and teacher ratings were statistically significant, but the magnitudes of the correlations were low, accounting for no more than approximately 17% of the variance between measures. Correlations between change scores on parent and teacher ratings were statistically significant but low for Total and Inattentive scales and not significant for the Hyperactive-Impulsive scale. For agreement on extreme scores, 6 of 9 kappas were statistically significant but all were unacceptably low. CONCLUSIONS: Agreement between parent and teacher ratings of symptoms of ADHD is too low for clinicians to rely on parent reports while managing medications. Teacher reports are still needed to ensure optimal management.

A multi-domain model of risk factors for ODD symptoms in a community sample of 4-year-olds.

Few studies have been designed to assess the pathways by which risk factors are associated with symptoms of psychopathology across multiple domains, including contextual factors, parental depression, parenting, and child characteristics. The present study examines a cross-sectional model of risk factors for symptoms of Oppositional Defiant Disorder (ODD) in a diverse community sample of 796 four-year-old children. In the best-fitting model: (a) SES had indirect effects on contextual factors of stress and conflict, parental depression, and parenting factors including hostility, support, and scaffolding; (b) stress and conflict had both direct effects on ODD symptoms, and indirect effects via parental depression and parenting; (c) parenting had direct effects on ODD symptoms and indirect effects via child effortful control (EC), negative affect (NA) and sensory regulation (SR); (c) NA, EC, and SR had direct effects on symptom frequency, and attachment had indirect effects via EC, and SR. These results highlight the importance of using a multi-domain model to examine risk factors for symptoms of ODD, and also provide information about areas to target in treatment.

Computer-assisted management of attention-deficit/hyperactivity disorder.

OBJECTIVES: Medication management of attention-deficit/hyperactivity disorder (ADHD) is often suboptimal. We examined whether (1) brief physician training plus computer-assisted medication management led to greater reduction in ADHD symptoms and (2) adherence to the recommended titration protocol produced greater symptomatic improvement. METHODS: A randomized medication trial was conducted that included 24 pediatric practices. Children who met criteria for ADHD were randomly assigned by practice to treatment-as-usual or a specialized care group in which physicians received 2 hours of didactic training on medication management of ADHD plus training on a software program to assist in monitoring improvement. Parent and teacher reports were obtained before treatment and 4, 9, and 12 months after starting medication. RESULTS: Children in both specialized care and treatment-as-usual groups improved on the ADHD Rating Scales and SNAP-IV, but there were no group differences in improvement rates. Brief physician training alone did not produce improvements. When recommended titration procedures were followed, however, outcomes were better for total and inattentive ADHD symptoms on both the ADHD Rating Scales and SNAP-IV parent and teacher scales. Results were not attributable to discontinuation because of adverse effects or failure to find an effective medication dose. CONCLUSIONS: Brief physician training alone did not lead to reductions in ADHD symptoms, but adherence to a protocol that involved titration until the child's symptoms were in the average range and had shown a reliable change led to better symptom reduction. Computer-assisted medication management can contribute to better treatment outcomes in primary care medication treatment of ADHD.

Predictors and correlates of completing behavioral parent training for the treatment of oppositional defiant disorder in pediatric primary care.

This study examined the role of pretreatment demographic and clinical predictors of attendance as well as barriers to treatment and consumer satisfaction on attendance at therapist-led parent training with 86 families of children ages 3 to 6 years conducted in pediatric primary care settings. Only socioeconomic status (SES) and minority group membership were significantly associated with not completing treatment. Using optimal data analysis procedures, high SES correctly predicted treatment completion 83.6% of the time. Being from a low SES, minority group family correctly predicted noncompletion of treatment 72.7% of the time, but being from a low SES, white family predicted treatment completion 80% of the time. Since barriers to treatment, such as stressors, obstacles to treatment, and treatment demands were unrelated to attendance in the present study, other factors related to social class and minority status that could contribute to better consumer satisfaction and treatment attendance must be investigated.

Re-examining the epidemiology of sensory regulation dysfunction and comorbid psychopathology.

The aims of this study were threefold: (1) to compare prevalence of sensory regulation dysfunction based on previously established criteria to rates established with a more representative community sample of 796 4-year-olds; (2) to examine ethnic/racial and gender differences in prevalence according to the different criteria; and (3) to examine the co-occurrence of sensory regulation dysfunction and preschool psychiatric disorders. Prevalence rates ranged from 3.4% (current criteria) to 15.6% (previous criteria). In contrast to previous studies with less representative samples, there were no significant ethnic or racial differences using the current criteria. Boys were more likely to have sensory regulation dysfunction than girls according to all criteria. Depending upon impairment criteria used, 33-63% of children meeting criteria for sensory dysregulation also had a psychiatric disorder; 37-67% had only a sensory dysregulation disorder, indicating that sensory regulation dysfunction exists independent of psychiatric disorder, and is also a significant risk factor for disorder.