Parent and Child Risk Profiles as Predictors of Response to a Conduct Problem Preventive Intervention.

Current evidence-based prevention programming targeting child externalizing problems demonstrates modest overall effect sizes and is largely ineffective for a sizable proportion of youth who participate. However, our understanding of the youth and family characteristics associated with response to specific programming is quite limited. The current study used child and family risk profiles as predictors of response trajectories to the Early Risers conduct problem preventive intervention. A sample of 240 kindergarten-aged youth displaying elevated school-based aggression were randomized by school to either the Early Risers intervention or a control condition. Using a number of child and family risk variables, a latent profile analysis produced a solution consisting of five unique risk profiles. Three low and mixed risk profiles were associated with a limited response to the intervention. One high-risk profile characterized by maladaptive parenting and elevated child externalizing demonstrated notably improved trajectories of externalizing behavior over a 3-year period relative to the control condition. Another high-risk profile characterized by inconsistent discipline, high parental distress, and elevated child internalizing and externalizing symptoms seemed to have positive developmental trends disrupted by the intervention relative to the control condition, potentially consistent with an iatrogenic effect relative to the control condition. The study results support continued efforts to use broader risk profiles to examine heterogeneity in response to preventive interventions and, with replication, will have implications for intervention tailoring.

Self-Regulatory Profiles and Conduct Problems in Youth Referred to Juvenile Diversion.

The current study utilized a person-centered approach to explore how self-regulatory profiles relate to conduct problems in an ethnically diverse sample of 197 adolescents referred to juvenile diversion programming. Utilizing a multidomain, multimethod battery of self-regulation indicators, three common profiles emerged in a latent profile analysis. The profiles represented an Adaptive group, a Cognitively Inflexible group, and an Emotionally Dysregulated group. Group membership was associated with severity and type of conduct problems as well as callous and unemotional traits. The Adaptive group demonstrated lower severity conduct problems when compared to the other groups. The Emotionally Dysregulated group was more likely to commit violent offenses and demonstrated higher levels of some callous and unemotional traits than youth characterized by cognitive inflexibility.

Moving Toward a Precision-Based, Personalized Framework for Prevention Science: Introduction to the Special Issue.

The goal of this Special Issue is to introduce prevention scientists to an emerging form of healthcare, called precision medicine. This approach integrates investigation of the mechanisms of disease and health-compromising behaviors with prevention, treatment, and cure resolved at the level of the individual. Precision Medicine and its derivative personalized prevention represents a promising paradigm for prevention science as it accounts for response heterogeneity and guides development of targeted interventions that may enhance program effect sizes. If successfully integrated into prevention science research, personalized prevention is an approach that can inform the development of decision support tools (screening measures, prescriptive algorithms) and enhance the utility of mobile health technologies that will enable practitioners to use personalized consumer data to inform decisions about the best type and/or intensity of a prevention strategy for particular individuals or subgroups of individuals. In this special issue, we present conceptual articles that provide a heuristic framework for precision-based, personalization prevention research and empirical studies that address research questions exemplary of a new generation of precision-based personalized preventive interventions focused on children's mental health, behavioral health, and education.

Does Giving Parents Their Choice of Interventions for Child Behavior Problems Improve Child Outcomes?

Empowering consumers to be active decision-makers in their own care is a core tenet of personalized, or precision medicine. Nonetheless, there is a dearth of research on intervention preferences in families seeking interventions for a child with behavior problems. Specifically, the evidence is inconclusive as to whether providing parents with choice of intervention improves child/youth outcomes (i.e., reduces externalizing problems). In this study, 129 families presenting to community mental health clinics for child conduct problems were enrolled in a doubly randomized preference study and initially randomized to choice or no-choice conditions. Families assigned to the choice condition were offered their choice of intervention from among three different formats of the Parent Management Training-Oregon Model/PMTO (group, individual clinic, home based) and services-as-usual (child-focused therapy). Those assigned to the no-choice condition were again randomized, to one of the four intervention conditions. Intent-to-treat analyses revealed partial support for the effect of parental choice on child intervention outcomes. Assignment to the choice condition predicted teacher-reported improved child hyperactivity/inattention outcomes at 6 months post-treatment completion. No main effect of choice on parent reported child outcomes was found. Moderation analyses indicated that among parents who selected PMTO, teacher report of hyperactivity/inattention was significantly improved compared with parents selecting SAU, and compared with those assigned to PMTO within the no-choice condition. Contrary to hypotheses, teacher report of hyperactivity/inattention was also significantly improved for families assigned to SAU within the no-choice condition, indicating that within the no-choice condition, SAU outperformed the parenting interventions. Implications for prevention research are discussed.

Being "SMART" About Adolescent Conduct Problems Prevention: Executing a SMART Pilot Study in a Juvenile Diversion Agency.

The development of adaptive treatment strategies (ATS) represents the next step in innovating conduct problems prevention programs within a juvenile diversion context. Toward this goal, we present the theoretical rationale, associated methods, and anticipated challenges for a feasibility pilot study in preparation for implementing a full-scale SMART (i.e., sequential, multiple assignment, randomized trial) for conduct problems prevention. The role of a SMART design in constructing ATS is presented. The SMART feasibility pilot study includes a sample of 100 youth (13-17 years of age) identified by law enforcement as early stage offenders and referred for precourt juvenile diversion programming. Prior data on the sample population detail a high level of ethnic diversity and approximately equal representations of both genders. Within the SMART, youth and their families are first randomly assigned to one of two different brief-type evidence-based prevention programs, featuring parent-focused behavioral management or youth-focused strengths-building components. Youth who do not respond sufficiently to brief first-stage programming will be randomly assigned a second time to either an extended parent- or youth-focused second-stage programming. Measures of proximal intervention response and measures of potential candidate tailoring variables for developing ATS within this sample are detailed. Results of the described pilot study will include information regarding feasibility and acceptability of the SMART design. This information will be used to refine a subsequent full-scale SMART. The use of a SMART to develop ATS for prevention will increase the efficiency and effectiveness of prevention programing for youth with developing conduct problems.

Moderating effects of parental well-being on parenting efficacy outcomes by intervention delivery model of the early risers conduct problems prevention program.

Parent-focused preventive interventions for youth conduct problems are efficacious when offered in different models of delivery (e.g., individual in-home, group center-based). However, we know little about the characteristics of parents associated with a positive response to a particular model of delivery. We randomly assigned the parents of an ethnically diverse sample of kindergarten through second grade students (n = 246) displaying elevated levels of aggression to parent-focused program delivery models emphasizing receiving services in a community center largely with groups (Center; n = 121) or receiving services via an individualized in-home strategy (Outreach; n = 125). In both delivery models, parents received parent skills training and goal setting/case management/referrals over an average of 16 months. Structural equation modeling revealed a significant interaction between parental well-being at baseline and intervention delivery model in predicting parenting efficacy at year 2, while controlling for baseline levels of parenting efficacy. Within the Outreach model, parents with lower levels of well-being as reported at baseline appeared to show greater improvements in parenting efficacy than parents with higher levels of well-being. Within the Center model, parental well-being did not predict parenting efficacy outcomes. The strong response of low well-being parents within the Outreach model suggests that this may be the preferred model for these parents. These findings provide support for further investigation into tailoring delivery model of parent-focused preventive interventions using parental well-being in order to improve parenting outcomes.

A Prospective Examination of the Association of Stimulant Medication History and Drug Use Outcomes among Community Samples of ADHD Youths.

A continuing debate in the child psychopathology literature is the extent to which pharmacotherapy for children with attention-deficit/hyperactivity disorder (ADHD), in particular stimulant treatment, confers a risk of subsequent drug abuse. If stimulant treatment for ADHD contributes to drug abuse, then the risk versus therapeutic benefits of such treatment is greatly affected. We have prospectively followed an ADHD sample (N = 149; 81% males) for approximately 15 years, beginning at childhood (ages 8 to 10 years) and continuing until the sample has reached young adulthood (ages 22 to 24 years). The sample was originally recruited via an epidemiologically derived community procedure, and all youths were diagnosed with ADHD during childhood. We report on the association of childhood psychostimulant medication and subsequent substance use disorders and tobacco use. The substance use outcomes were based on data collected at three time points when the sample was in late adolescence and young adulthood (age range approximately 18 to 22 years old). We did not find evidence to support that childhood treatment with stimulant medication, including the course of stimulant medication, was associated with any change in risk for adolescent or young adulthood substance use disorders and tobacco use. These results from a community-based sample extend the growing body of literature based on clinically derived samples indicating that stimulant treatment does not create a significant risk for subsequent substance use disorders.

Bidirectional Relations Between Parenting Practices and Child Externalizing Behaviors in Formerly Homeless Families: A Random-Intercept Cross-Lagged Panel Analysis.

OBJECTIVE: This study examined the bidirectional relation between effective parenting practices and externalizing problems in children in homeless families. DESIGN: The sample comprised 223 children (M = 8.12 years) in 137 families living in temporary supportive housing, who participated in the Early Risers conduct problems prevention program lasting 2 years. Video-recorded observations of parent-child interactions were collected and rated by trained observers to assess effective parenting practices. Child externalizing problems were reported by their school teachers. Both variables were assessed at baseline prior to intervention and at 1- and 2-year post-baseline. RESULTS: Child externalizing problems at baseline were negatively associated with effective parenting from baseline to year 1 as well as from year 1 to year 2. Observed effective parenting practices at year 1 were negatively associated with child externalizing problems from year 1 to year 2. CONCLUSIONS: These findings underscore the presence of bidirectional influence processes between parents and children in high-risk families. Implications for intervention programs for high-risk families are discussed.

Drug Use and Psychosocial Functioning of a Community Derived Sample of Adolescents with Childhood ADHD.

We describe the late adolescent psychosocial outcomes from a relatively large, community-identified sample of children with ADHD who have been assessed longitudinally from childhood through late adolescence. A range of outcomes were compared between ADHD (n=119) and normal control (n=93) groups, as well as ADHD subgroups that varied as a function of the course of externalizing, predominantly ODD, problems (persisters, desisters, escalators, and resisters). ADHD youth that did not show externalizing problems during childhood (ADHD-resisters) were associated with drug use outcomes generally comparable to the normal non-affected controls. All other ADHD groups with externalizing problems (ADHD-persisters, ADHD-escalaters, and ADHD-desisters) consistently revealed worse drug use outcomes compared to controls/ADHD-resisters. However, ADHD youth with or without externalizing problems showed worse outcomes compared to the control group on the non-drug, psychosocial functioning variables. The study highlights that ADHD with co-existing disruptiveness, whether the disruptiveness persists or remits before adolescence, is associated with an increased risk for drug involvement and that ADHD, regardless of the comorbid pattern, confers a poorer level of psychosocial functioning.

Incorporating multifaceted mental health prevention services in community sectors-of-care.

This article proposes a framework for embedding prevention services into community sectors-of-care. Community sectors-of-care include both formal and grassroot organizations distributed throughout a community that provide various resources and services to at-risk children and their families. Though the child population served by these organizations is often at elevated risk for mental health problems by virtue of children's exposure to difficult life circumstances (poverty, maltreatment, homelessness, domestic violence, etc.) these children face many barriers to accessing evidence-based prevention or treatment services. We review evidence and propose a framework for integrating prevention services into community sectors-of-care that serve high-risk children and families.

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.

The Early Risers preventive intervention: testing for six-year outcomes and mediational processes.

We examined effects of the Early Risers "Skills for Success" early-age-targeted prevention program on serious conduct problems following 5 years of continuous intervention and one year of follow-up. We also examined if intervention effects on proximally-targeted variables found after 3 years mediated intervention effects on conduct problems found after 6 years. Participants included 151 at-risk children (106 males and 45 females) followed from first through sixth-grade, from 23 semi-rural schools in Minnesota. After 6 years, program children showed fewer oppositional defiant disorder (ODD) symptoms than control children. Program children did not significantly differ from controls on number of conduct disorder (CD) symptoms, DSM-IV diagnoses of ODD and CD, or drug use involvement. Results of the mediation analysis indicated that fewer ODD symptoms among program youth after 6 years were partially mediated by social skills and effective discipline. The study provides support for the early-starter model of conduct problems development that provides the framework for the Early Risers intervention. The study's implications for prevention and limitations are discussed.

Stressful life events and perceived parental control in formerly homeless families: Impact on child-internalizing symptoms.

Research has neglected the potential role of perceived parental control as a moderator between stressful life events (SLEs) and child-internalizing symptoms. Using secondary data from the Early Risers "Skills for Success" Program (August, Realmuto, Hektner, & Bloomquist, 2001), this study examined the impact of perceived parental control on the association between SLEs and child internalizing symptoms in formerly homeless families. The sample consisted of 137 families with 223 children between 4 and 12 years of age (M = 8.1, SD = 2.3) living in supportive housing sites in Minneapolis, Minnesota. Participants completed measures assessing the number of SLEs experienced (e.g., unemployment of parent, death of loved one, serious illness, homelessness), perceived parental control, and child-internalizing symptoms. In this sample, 65% of children (n = 144) experienced at least 1 SLE with an average experience of 2 SLEs (M = 2.0, SD = 1.9, range = 0-7). A regression analysis found that experiencing more SLEs and a perceived absence of parental control over child behavior were positively associated with child-internalizing symptoms. A significant interaction between SLEs and perceived absence of parental control over child behavior in predicting child internalizing symptoms was also found. These findings suggest that children of parents who model appropriate control are more likely to experience fewer internalizing symptoms in response to SLEs. (PsycINFO Database Record

Prospective study of adolescent drug use among community samples of ADHD and non-ADHD participants.

OBJECTIVE: To describe the late adolescent drug use outcomes from a relatively large, community-identified sample of children with attention-deficit/hyperactivity disorder (ADHD) who have been assessed longitudinally from childhood through late adolescence. METHOD: Adolescent drug use outcomes were compared between ADHD-only (n = 27), ADHD-externalizing (mostly oppositional defiant disorder) (n = 82), and normal control (n = 91) groups. RESULTS: The ADHD-externalizing group revealed significantly worse drug use outcomes (drug use frequency and substance use disorders) compared to the other two groups, and the ADHD-only group showed outcomes comparable to the community control group. CONCLUSIONS: ADHD without a comorbid externalizing disorder is not associated with an increased risk of drug abuse. ADHD with a comorbid externalizing disorder, primarily oppositional defiant disorder, is associated with an elevated risk of drug use, particularly with respect to marijuana and tobacco involvement.

Application of environmental sensitivity theories in personalized prevention for youth substance abuse: a transdisciplinary translational perspective.

Preventive interventions that target high-risk youth, via one-size-fits-all approaches, have demonstrated modest effects in reducing rates of substance use. Recently, substance use researchers have recommended personalized intervention strategies. Central to these approaches is matching preventatives to characteristics of an individual that have been shown to predict outcomes. One compelling body of literature on person × environment interactions is that of environmental sensitivity theories, including differential susceptibility theory and vantage sensitivity. Recent experimental evidence has demonstrated that environmental sensitivity (ES) factors moderate substance abuse outcomes. We propose that ES factors may augment current personalization strategies such as matching based on risk factors/severity of problem behaviors (risk severity (RS)). Specifically, individuals most sensitive to environmental influence may be those most responsive to intervention in general and thus need only a brief-type or lower-intensity program to show gains, while those least sensitive may require more comprehensive or intensive programming for optimal responsiveness. We provide an example from ongoing research to illustrate how ES factors can be incorporated into prevention trials aimed at high-risk adolescents.

Diagnosing attention deficit disorders with the Behavioral Assessment System for Children and the Child Behavior Checklist: test and construct validity analyses using optimal discriminant classification trees.

The usefulness of the Behavioral Assessment System for Children (BASC) and Child Behavior Checklist (CBCL) Parent scales was examined with respect to (a) differentiating students with attention deficit-hyperactivity disorder (ADHD) from non-ADHD students and (b) discriminating between the predominantly inattentive-type and combined-type ADHD-afflicted students. For both the BASC and the CBCL, a different optimal discriminant classification tree analysis (CTA) model was developed for each of the 2 diagnostic predictions. For distinguishing ADHD students from non-ADHD students, the BASC model was more parsimonious and accurate than the CBCL model. Toward the goal of differentiating between primarily inattentive and combined types, the CBCL's model was superior for predicting primarily inattentive students. The results demonstrate the diagnostic utility of the BASC and CBCL and describe salient behavioral dimensions associated with subtypes of ADHD.

Gender differences in psychiatric comorbidity among adolescents with substance use disorders.

The authors examined gender differences in rates of comorbid psychiatric disorders among adolescents with I or more psychoactive substance use disorders. Baseline diagnostic data were obtained from 135 adolescents, ages 12 to 19, and their parents-guardians, who participated in a study to develop and efficacy test Integrated Family and Cognitive-Behavioral Therapy. Rates of attention-deficit/hyperactivity disorder and conduct disorder were higher among drug-abusing male adolescents compared with drug-abusing female adolescents. However, high rates of disruptive behavior disorders also characterized drug-abusing female adolescents. Similarly, drug-abusing female adolescents exhibited a higher rate of major depression compared with drug-abusing male adolescents. However, rates of dysthymia, double depression (i.e., major depression and dysthymia), and bipolar disorder were equivalent between genders.

Effects of pairing aggressive and nonaggressive children in strategic peer affiliation.

Examined the behavior of 118 second graders who participated in a 6-week summer school program that incorporated strategic peer affiliation (a "buddy system"). Moderately aggressive children (the targets of the intervention) were paired with nonaggressive peers throughout the program. All participants were observed playing foosball with their buddies and with aggressive and nonaggressive nonbuddies as teammates. Aggressive children had lower levels of disruptive behavior when their teammate was nonaggressive, regardless of whether the teammate was a buddy. Nonaggressive children showed elevated disruptive behavior when playing with an aggressive nonbuddy, but not when playing with an aggressive buddy. The highest level of aggressive behavior was seen in pairs of aggressive teammates who were friends. One year later, no increase in peer-rated aggressive behavior was found in either group. Results suggest that unidirectional peer influence is possible and that strategic peer affiliation can be an effective intervention that does not put nonaggressive children at risk for acquiring undesired behaviors.

Parceling component effects of a multifaceted prevention program for disruptive elementary school children.

This study examined predictors and outcomes of attendance in two standard components of a multifaceted preventive intervention aimed at children with early-onset disruptive behavior after 3 years of intervention. Mean rate of attendance in the Family Program, but not the Summer School Program, differed by level of child disruptiveness (grouping variable). Although predictors of attendance (SES, single-parent status, child IQ) did not differ across high- and low-disruptive groups, predictors of outcome were moderated by level of child disruptiveness for academic achievement and aggression outcomes, but not for social competence. Higher attendance in the Summer Program was associated with higher child social competence at Year 3 for all children. For academic achievement, higher attendance in the Summer Program was associated with higher scores for mild/moderately disruptive children and lower scores for highly disruptive children in Year 3. Higher attendance in the Family Program was associated with lower aggression scores for mild/moderately disruptive children. Findings highlight the importance of matching intervention components to the assessed or expressed needs of client subgroups.

Attention deficit hyperactivity disorder: an epidemiological screening method.

Multistage identification, an epidemiological screening method of diagnostic assessment, was used to identify attention-deficit hyperactivity disorder (ADHD) in 1,490 elementary-school students. Children diagnosed with ADHD exhibited more impairment on adjustment measures and were more likely to have coexisting disruptive behavior disorders than were children diagnosed as subclinical non-ADHD.