Validation of a new emotion regulation self-report questionnaire for children.

OBJECTIVE: To examine and validate the self-report Questionnaire on the Regulation of Unpleasant Moods in Children (FRUST), which is a modified and shortened version of the Questionnaire for the Assessment of Emotion Regulation in Children and Adolescents (FEEL-KJ). METHODS: The data comprised child and parent ratings of a community-screened sample with differing levels of affective dysregulation (AD) (N = 391, age: M = 10.64, SD = 1.33, 56% male). We conducted latent factor analyses to establish a factor structure. Subsequently, we assessed measurement invariance (MI) regarding age, gender, and AD level and evaluated the internal consistencies of the scales. Finally, we examined the convergent and divergent validity of the instrument by calculating differential correlations between the emotion regulation strategy (ERS) scales and self- and parent-report measures of psychopathology. RESULTS: A four-factor model, with one factor representing Dysfunctional Strategies and the three factors Distraction, Problem-Solving and Social Support representing functional strategies provided the best fit to our data and was straightforward to interpret. We found strong MI for age and gender and weak MI for AD level. Differential correlations with child and parent ratings of measures of psychopathology supported the construct validity of the factors. CONCLUSIONS: We established a reliable and valid self-report measure for the assessment of ERS in children. Due to the reduced number of items and the inclusion of highly specific regulatory behaviors, the FRUST might be a valuable contribution to the assessment of ER strategies for diagnostic, therapeutic, and research purposes.

Process Mechanisms in Behavioral Versus Nondirective Guided Self-help for Parents of Children with Externalizing Behavior.

The study examined potential mediating effects of therapist behaviors in the per-protocol sample (n = 108) of a randomized controlled trial comparing a behavioral and a nondirective guided self-help intervention for parents of children with externalizing disorders (4-11 years). Additionally, from an exploratory perspective, we analyzed a sequential model with parental adherence as second mediator following therapist behavior. Outcomes were child symptom severity of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder rated by blinded clinicians, and parent-rated child functional impairment. We found a significant indirect effect on the reduction of ADHD and functional impairment through emotion- and relationship-focused therapist behavior in the nondirective intervention. Additionally, we found limited support for an extended sequential mediation effect through therapist behavior and parental adherence in the models for these outcomes. The study proposes potential mediating mechanisms unique to the nondirective intervention and complements previous findings on mediator processes in favor of the behavioral group. Trial registration ClinicalTrials.gov NCT01350986.

Treatment components in behavioral versus nondirective telephone-assisted self-help interventions for parents of children with externalizing behavior problems.

BACKGROUND: The aim of this study was to analyze treatment differentiation in a behavioral and a nondirective telephone-assisted self-help intervention for parents of children with externalizing behavior problems, including the development and evaluation of a rating scale. METHODS: In a randomized controlled trial, 149 parents of children aged 4-11 years with externalizing behavior problems were allocated to a behavioral or a nondirective guided self-help intervention. Parents in both conditions received eight self-help booklets and ten telephone consultations. To analyze the content of the interventions, we developed the Therapist Intervention Scale (TIS). In order to evaluate the scale and analyze treatment differentiation, parent booklets and recorded telephone consultations were rated. RESULTS: Item selection and scale development were based on predefined psychometric criteria. The subscales Guidance & Structures and Relationship & Emotions were developed based on exploratory factor analyses. Interrater reliability and internal consistency were found to be acceptable to excellent. Analyses of construct validity demonstrated positive correlations for corresponding and negative correlations for non-corresponding subscales of therapist ratings. Therapists and booklets in the behavioral intervention showed higher scores on the subscale Guidance & Structures, while therapists and booklets in the nondirective intervention showed higher scores on the subscale Relationship & Emotions. CONCLUSION: The analyses of the TIS support its reliability and validity. The subscale Guidance & Structures contains mainly cognitive-behavioral treatment components, while the subscale Relationship & Emotions contains mainly nondirective treatment components. The implemented telephone-assisted self-help interventions demonstrated distinct treatment profiles which match their intended therapeutic approaches.

Affective dysregulation in childhood - optimizing prevention and treatment: protocol of three randomized controlled trials in the ADOPT study.

BACKGROUND: The terms affective dysregulation (AD) and irritability describe transdiagnostic dimensions and are characterized by an excessive reactivity to negative emotional stimuli with an affective (anger) and a behavioral component (aggression). Due to early onset, high prevalence and persistence, as well as developmental comorbidity, AD in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions. AD is especially prevalent in children in the youth welfare service. Despite continuous research, there remains a substantial need for diagnostic approaches and optimization of individualized treatment strategies in order to improve outcomes and reduce the subjective and economic burden. METHODS: The ADOPT (Affective Dysregulation - Optimizing Prevention and Treatment) Consortium integrates internationally established, highly experienced and interdisciplinary research groups. The work program encompasses (a) epidemiology, including prevalence of symptoms and disorders, (b) development and evaluation of screening and assessment tools, (c) stepped care approaches for clinically useful personalized medicine, (d) evaluation of an easily accessible and cost-effective online intervention as indicated prevention (treatment effects, moderation/mediation analysis), and (e) evaluation of an intensive personalized modular outpatient treatment in a cohort of children with AD who live with their parents and in a cohort of children with AD who live in out-of-home care (treatment effects, moderation/mediation analysis). DISCUSSION: The results will lead to significant recommendations for improving treatment within routine clinical care in two cohorts of children with AD and coexisting conditions, especially oppositional-defiant disorder, conduct disorder and disruptive mood dysregulation disorder. TRIAL REGISTRATION: Trial registration ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963 . Registered 27 June 2018. Trial registration ADOPT Treatment: German Clinical Trials Register (DRKS) DRKS00013317 . Registered 27 September 2018. Trial registration ADOPT Institution: German Clinical Trials Register (DRKS) DRKS00014581 . Registered 04 July 2018.

Assessment of affective dysregulation in children: development and evaluation of a semi-structured interview for parents and for children.

BACKGROUND: Children with affective dysregulation (AD) show an excessive reactivity to emotionally positive or negative stimuli, typically manifesting in chronic irritability, severe temper tantrums, and sudden mood swings. AD shows a large overlap with externalizing and internalizing disorders. Given its transdiagnostic nature, AD cannot be reliably and validly captured only by diagnostic categories such as disruptive mood dysregulation disorder (DMDD). Therefore, this study aimed to evaluate two semi-structured clinical interviews-one for parents and one for children. METHODS: Both interviews were developed based on existing measures that capture particular aspects of AD. We analyzed internal consistencies and interrater agreement to evaluate their reliability. Furthermore, we analyzed factor loadings in an exploratory factor analysis, differences in interview scores between children with and without co-occurring internalizing and externalizing disorders, and associations with other measures of AD and of AD-related constructs. The evaluation was performed in a screened community sample of children aged 8-12 years (n = 445). Interrater reliability was additionally analyzed in an outpatient sample of children aged 8-12 years (n = 27). RESULTS: Overall, internal consistency was acceptable to good. In both samples, we found moderate to excellent interrater reliability on a dimensional level. Interrater agreement for the dichotomous diagnosis DMDD was substantial to perfect. In the exploratory factor analysis, almost all factor loadings were acceptable. Children with a diagnosis of disruptive disorder, attention-deficit/hyperactivity disorder, or any disorder (disruptive disorder, attention-deficit/hyperactivity disorder, and depressive disorder) showed higher scores on the DADYS interviews than children without these disorders. The correlation analyses revealed the strongest associations with other measures of AD and measures of AD-specific functional impairment. Moreover, we found moderate to very large associations with internalizing and externalizing symptoms and moderate to large associations with emotion regulation strategies and health-related quality of life. CONCLUSIONS: The analyses of internal consistency and interrater agreement support the reliability of both clinical interviews. Furthermore, exploratory factor analysis, discriminant analyses, and correlation analyses support the interviews' factorial, discriminant, concurrent, convergent, and divergent validity. The interviews might thus contribute to the reliable and valid identification of children with AD and the assessment of treatment responses. TRIAL REGISTRATION: ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963. Registered 27 June 2018.

Satisfaction with videoconference-delivered CBT provided as part of a blended treatment approach for children and adolescents with mental disorders and their families during the COVID-19 pandemic: A follow-up survey among caregivers and therapists.

INTRODUCTION: Psychotherapy delivered via videoconferencing (teletherapy) was a well-accepted treatment option for children and adolescents during the early phases of the COVID-19 pandemic. Information on the long-term satisfaction with teletherapy in routine clinical practice is missing. METHODS: Caregivers (parents) and psychotherapists of n = 228 patients (4-20 years) treated in a university outpatient clinic completed a follow-up survey on satisfaction with videoconference-delivered cognitive-behavioral treatment (CBT). The follow-up survey (T2) was conducted about 1 year after initial assessment of treatment satisfaction in 2020 (T1). RESULTS: At follow up, therapists reported that 79% of families had received teletherapy as part of a blended treatment approach including in-person and videoconference delivery of CBT. Wilcoxon tests revealed that satisfaction with teletherapy was stable over time. In addition, parent ratings of the impact of teletherapy on treatment satisfaction and the therapeutic relationship did not change over time. Therapists' ratings of the impact of teletherapy on the therapeutic relationship with the caregiver were more negative at T2 compared to T1. Satisfaction with teletherapy was higher for patients with less pandemic-related stress, less externalizing behavior problems, and older age (all r < .35). CONCLUSION: The high level of satisfaction with teletherapy for children and adolescents treated in routine clinical practice reported in 2020 was maintained after social distancing regulations were eased in 2021. Teletherapy provided as part of a blended treatment approach is a well-accepted method of treatment delivery for youths with mental health problems. The study was registered in the German Clinical Trials Register (DRKS00028639).

The DADYS-Screen: Development and Evaluation of a Screening Tool for Affective Dysregulation in Children.

Affective dysregulation (AD) in children is characterized by persistent irritability and severe temper outbursts. This study developed and evaluated a screening questionnaire for AD in children. The development included the generation of an initial item pool from existing instruments, a Delphi rating of experts, focus groups with experts and parents, and psychometric analyses of clinical and population-based samples. Based on data of a large community-based study, the final screening questionnaire was developed (n = 771; 49.7 % female; age M = 10.02 years; SD = 1.34) and evaluated (n = 8,974; 48.7 % female; age M = 10.00 years; SD = 1.38) with methods from classical test theory and item response theory. The developed DADYS-Screen (Diagnostic Tool for Affective Dysregulation in Children-Screening Questionnaire) includes 12 items with good psychometric properties and scale characteristics including a good fit to a one-factorial model in comparison to the baseline model, although only a "mediocre" fit according to the root mean square error of approximation (RMSEA). Results could be confirmed using a second and larger data set. Overall, the DADYS-Screen is able to identify children with AD, although it needs further investigation using clinical data.

The importance of familial risk factors in children with ADHD: direct and indirect effects of family adversity, parental psychopathology and parenting practices on externalizing symptoms.

BACKGROUND: Children experiencing unfavorable family circumstances have an increased risk of developing externalizing symptoms. The present study examines the direct, indirect and total effects of family adversity, parental psychopathology, and positive and negative parenting practices on symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in children with ADHD. METHODS: Data from 555 children (M = 8.9 years old, 80.5% boys) who participated in a multicenter study on the treatment of ADHD (ESCAschool) were analyzed using structural equation modeling (SEM). RESULTS: The SEM analyses revealed that (a) family adversity and parental psychopathology are associated with both child ADHD and ODD symptoms while negative parenting practices are only related to child ODD symptoms; (b) family adversity is only indirectly associated with child ADHD and ODD symptoms, via parental psychopathology and negative parenting practices; (c) the detrimental effect of negative parenting practices on child ADHD and ODD symptoms is stronger in girls than in boys (multi-sample SEM); (d) there are no significant associations between positive parenting practices and child ADHD or ODD symptoms. CONCLUSIONS: Family adversity, parental psychopathology, and negative parenting practices should be routinely assessed by clinicians and considered in treatment planning. Trial registration (18th December 2015): German Clinical Trials Register (DRKS) DRKS00008973.

Disentangling symptoms of externalizing disorders in children using multiple measures and informants.

The trait impulsivity theory suggests that a single, highly heritable externalizing liability factor, expressed as temperamental trait impulsivity, represents the core vulnerability for externalizing disorders. The present study sought to test the application of latent factor models derived from this theory to a clinical sample of children. Participants were 474 German children (age 6-12 years, 81% male) with symptoms of attention-deficit/hyperactivity disorder and externalizing behavior problems participating in an ongoing multicenter intervention study. Using confirmatory factor analyses (CFA) and exploratory structural equation modeling (ESEM), we evaluated several factor models of externalizing spectrum disorders (unidimensional; first-order correlated factors; higher-order factor; fully symmetrical bifactor; bifactor S-1 model). Furthermore, we assessed our prevailing factor models for measurement invariance across raters (clinicians, parents, teachers) and assessment modes (interview, questionnaires). While both CFA and ESEM approaches provided valuable insights into the multidimensionality, ESEM solutions were generally superior since they showed a substantially better model fit and less biased factor loadings. Among the models tested, the bifactor S-1 CFA/ESEM models, with a general hyperactivity-impulsivity reference factor, displayed a statistically sound factor structure and allowed for straightforward interpretability. Furthermore, these models showed the same organization of factors and loading patterns, but not equivalent item thresholds across raters and assessment modes, highlighting cross-situational variability in child behavior. Our findings are consistent with the assumption of the trait impulsivity theory that a common trait, presented as hyperactivity-impulsivity symptoms, underlies all externalizing disorders. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Individualised stepwise adaptive treatment for 3-6-year-old preschool children impaired by attention-deficit/hyperactivity disorder (ESCApreschool): study protocol of an adaptive intervention study including two randomised controlled trials within the consortium ESCAlife.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a psychosocially impairing and cost-intensive mental disorder, with first symptoms occurring in early childhood. It can usually be diagnosed reliably at preschool age. Early detection of children with ADHD symptoms and an early, age-appropriate treatment are needed in order to reduce symptoms, prevent secondary problems and enable a better school start. Despite existing ADHD treatment research and guideline recommendations for the treatment of ADHD in preschool children, there is still a need to optimise individualised treatment strategies in order to improve outcomes. Therefore, the ESCApreschool study (Evidence-Based, Stepped Care of ADHD in Preschool Children aged 3 years and 0 months to 6 years and 11 months of age (3;0 to 6;11 years) addresses the treatment of 3-6-year-old preschool children with elevated ADHD symptoms within a large multicentre trial. The study aims to investigate the efficacy of an individualised stepwise-intensifying treatment programme. METHODS: The target sample size of ESCApreschool is 200 children (boys and girls) aged 3;0 to 6;11 years with an ADHD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or a diagnosis of oppositional defiant disorder (ODD) plus additional substantial ADHD symptoms. The first step of the adaptive, stepped care design used in ESCApreschool consists of a telephone-assisted self-help (TASH) intervention for parents. Participants are randomised to either the TASH group or a waiting control group. The treatment in step 2 depends on the outcome of step 1: TASH responders without significant residual ADHD/ODD symptoms receive booster sessions of TASH. Partial or non-responders of step 1 are randomised again to either parent management and preschool teacher training or treatment as usual. DISCUSSION: The ESCApreschool trial aims to improve knowledge about individualised treatment strategies for preschool children with ADHD following an adaptive stepped care approach, and to provide a scientific basis for individualised medicine for preschool children with ADHD in routine clinical care. TRIAL REGISTRATION: The trial was registered at the German Clinical Trials Register (DRKS) as a Current Controlled Trial under DRKS00008971 on 1 October 2015. This manuscript is based on protocol version 3 (14 October 2016).

Toward a Dimensional Assessment of Externalizing Disorders in Children: Reliability and Validity of a Semi-Structured Parent Interview.

OBJECTIVE: This study assesses the reliability and validity of the DSM-5-based, semi-structured Clinical Parent Interview for Externalizing Disorders in Children and Adolescents (ILF-EXTERNAL). METHOD: Participant data were drawn from the ongoing ESCAschool intervention study. The ILF-EXTERNAL was evaluated in a clinical sample of 474 children and adolescents (aged 6-12 years, 92 females) with symptoms of attention-deficit/hyperactivity disorder (ADHD). To obtain interrater reliability, the one-way random-effects, absolute agreement models of the intraclass correlation (ICC) for single ICC(1,1) and average measurements ICC(1,3) were computed between the interviewers and two independent raters for 45 randomly selected interviews involving ten interviewers. Overall agreement on DSM-5 diagnoses was assessed using Fleiss' kappa. Further analyses evaluated internal consistencies, item-total correlations as well as correlations between symptom severity and the degree of functional impairment. Additionally, parents completed the German version of the Child Behavior Checklist (CBCL) and two DSM-5-based parent questionnaires for the assessment of ADHD symptoms and symptoms of disruptive behavior disorders (FBB-ADHS; FBB-SSV), which were used to evaluate convergent and divergent validity. RESULTS: ICC coefficients demonstrated very good to excellent interrater reliability on the item and scale level of the ILF-EXTERNAL [scale level: ICC(1,1) = 0.83-0.95; ICC(1,3) = 0.94-0.98]. Overall kappa agreement on DSM-5 diagnoses was substantial to almost perfect for most disorders (0.38 ≤ κ ≤ 0.94). With some exceptions, internal consistencies (0.60 ≤ α ≤ 0.86) and item-total correlations (0.21 ≤ r it ≤ 0.71) were generally satisfactory to good. Furthermore, higher symptom severity was associated with a higher degree of functional impairment. The evaluation of convergent validity revealed positive results regarding clinical judgment and parent ratings (FBB-ADHS; FBB-SSV). Correlations between the ILF-EXTERNAL scales and the CBCL Externalizing Problems were moderate to high. Finally, the ILF-EXTERNAL scales were significantly more strongly associated with the CBCL Externalizing Problems than with the Internalizing Problems, indicating divergent validity. CONCLUSION: In clinically referred, school-age children, the ILF-EXTERNAL demonstrates sound psychometric properties. The ILF-EXTERNAL is a promising clinical interview and contributes to high-quality diagnostics of externalizing disorders in children and adolescents.